Dialysis in Undocumented Immigrants During COVID-19: Nephrologists on the Frontlines

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As a graduating nephrology fellow, I am well trained in triaging patients for timely dialysis treatments. Recently, the COVID-19 pandemic has posed a different challenge. Every day we work closely with our colleagues in the emergency department to triage patients. I get multiple calls/pages starting at 6 am. “Hi, this is ER; calling about a patient on emergent dialysis here for shortness of breath with pulmonary edema on his chest x-ray; we’re testing him for COVID-19 as well. I wonder if we can dialyze him today”. 

This is a scenario we currently encounter on a daily basis. 

Waiting in the emergency room at least once or twice a week for dialysis in the setting of COVID-19 pandemic can impact undocumented patients’ mental and physical health tremendously. Fear of losing access to care- in this case dialysis- in the midst of a pandemic is real.

This was becoming a new norm for me until one day I saw one of emergent dialysis patients on his way to the emergency room. He ran towards me and I quickly recognized him. 

“Hey doc, hey doc” He was completely out of breath. Speaking in Spanish alternating with English, he asked me if I can somehow help him to get dialyzed today. He had to stop and catch his breath multiple times while he was talking to me. 

He said each time he starts having shortness of breath, he gets scared that he might have caught the “virus” and “you know doc! I have a family to feed”. I looked into his eyes; I saw fear in them. He is a patient who is undocumented on emergent dialysis who have been sick multiple times hospitalized in the past. He has been sicker but this time I truly saw fear in his eyes. 

This time, something was different. I call it fear of the unknown. 

During the COVID-19 pandemic, we started to become actively involved in taking care of patients with multiple comorbidities who are now affected by a new virus. During this time, many of these asked me if I think they have the “virus” or their shortness of breath is related to their usual pre-dialysis symptoms. Sometimes they will need a longer hospitalization waiting for a dialysis spot to become available while they are waiting for their COVID-19 test results. 

COVID-19 pandemic highlights the vulnerability of patients who require dialysis on a recurrent basis yet have no way to do this in a standard outpatient setting. COVID-19 and volume overload they both can present with shortness of breath and this can complicate their management.

This group of patients are often the first ones who face limitations for their treatments. Not to mention risk being exposed to SARS-CoV-2 by their frequent interaction with an acute care setting and that they could pass it on to their family if they were to become asymptomatic. Since they don’t have an assigned dialysis unit; their dialysis treatments would be affected with whatever hits the hospitals. They are on the frontlines to lose access to their routine care. A treatment that helps them to stay alive. They never know when they can get dialysis next. A treatment that is needed at least three times a week sometimes it happens once in a week or maybe less. As recently suggested; protecting undocumented patients in the setting of COVID-19 pandemic, needs bold movements such as providing outpatient dialysis for undocumented patients in all 50 states.  

Undocumented patients are not vocal; as they are grateful to receive whatever care they can get. Yet, they are fearful more than usual. They are quietly suffering. 

As nephrologists, we see them often. We know them. 

People say after this pandemic, physicians will be affected for a long time. 

I know for a fact, one thing that I will remember from COVID-19; is the fear in the eyes of patients who cannot access care like everyone else in our country. The uncertainty. The fear of leaving a family behind. This fear is real. I saw it in his eyes. 

Sayna Norouzi, MD
Nephrology Fellow, Baylor College of Medicine


  1. Wonderful post.

  2. This is incredibly well written and very moving! Thank you for taking the time to share your experience.

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