He’s a 78-year-old diabetic with acute kidney failure. He’s an amputee — trouser-leg empty below the right knee. He’s COVID-positive.

And after all morning waiting in a small isolation room, in his wheelchair, Lewis Lawson still hasn’t been hooked up to the dialysis machine that three times a week flushes out his blood, scours it, and returns it back to his body.

Because the Wheel-Trans vehicle that has transported Lawson from his long-term care nursing home, Hawthorne Place, where three residents had died from COVID-19 the day previous, five fatalities in all, delivered him three hours early for his regular session at Humber River Hospital.

“I’m scared,’’ says Lawson, through his face mask. “I’m suffering.”

The hospital is not at fault. Its dialysis clinic runs three shifts daily for 630 out-patients. The Wheel-Trans service isn’t at fault either. Where once the shuttles picked up several patients per run, they now transport only one at a time, to contain possible contamination.

Lungs may be Ground Zero for COVID-positive patients in acute distress, but the disease is rampaging furiously through the rest of the body. And now increasingly being linked to kidney failure as a secondary cause of death. In the U.S., early studies and clinical anecdotes indicate that a substantial portion of critically ailing coronavirus patients, those on ventilators in intensive care units, require dialysis machines as well, numbers ranging from 20 to 40 per cent of that subgroup of severely ill positive patients.

At Lawson’s care home, there was just one support worker on the floor this morning. “Nobody to take me out of bed, nobody to bring me breakfast,” says Lawson. “I want to talk to my brother, but nobody has been able to bring me a phone.”

Such a fragile individual, already infected, should not have to go through arduous measures to obtain the dialysis treatment that has been keeping him alive for the last seven years.

Vlad Padure, director of the nephrology program at Humber, is the first to agree.

“What would be critical is for long-term care homes to allow dialysis in their facilities. I could do it tomorrow. We have the machines and clinical staff to support long-term care facilities without impacting on their resources or operations. Unfortunately, we have encountered resistance to that idea, despite the overwhelming benefits to our patient and the health care system.”

Except for a small number of long-term care homes that are associated with hospitals and providing peritoneal dialysis — cleansing fluid circulated through a tube in the abdomen — there has been resistance to the idea of providing hemodialysis in long-term facilities.

There are some 500 long-term care patients in Ontario who require dialysis, says Padure. It would cost less, he asserts, to dialyze patients in the homes, rather than bringing them into hospitals, which further anguishes those patients, especially during this global pandemic. Around the world, there have been reports of dialysis patients, fearful of contracting the virus, ceasing their treatments, just not showing up.

Without dialysis, they die.

There is no alternative for dialysis, except a kidney transplant and those have been sharply curtailed as hospitals focus on treating COVID. Toronto hospitals that perform the procedure have suspended transplants except for those on the Highly Sensitized Patient registry or deemed medically urgent.

“It’s scary for all of us because we’ve all got underlying issues and we’re susceptible to everything,” says Kathi Galle, 62, lying on a bed in the Humber clinic, connected to a dialysis machine. “But the nurses here are wonderful. They make me feel like I haven’t been forgotten.’’

Galle has five stents in her heart, five in her arms, one in each leg. She’s had a heart attack. She’s been on the transplant list for three years. And she was actually a support worker in long-term care homes, herself, for decades before falling ill. She’s been self-isolating at home.

“I haven’t seen my grandchildren in so long and it’s breaking my heart. My son will drive me up sometimes so I can wave at them through the window.’’

Kidneys have become part of the battlefield in COVID patients who’ve never had renal issues before they contracted the coronavirus.

“They’re dehydrated. They haven’t been taking any fluids in or they have a fever. They’re coming in with lung injury,” explains Dr. Gavril Hercz, staff nephrologist at Humber and associate professor of medicine at the University of Toronto. “The tendency is to ‘keep them dry’ in the ICU because the fluids could end up in the lungs. So, the kidney doesn’t like that, not getting adequate fluids.

“It’s still early days, but there might also be the impact of COVID, itself, actually attacking cells, in the same manner it attacks cells in the lungs. Also there is the phenomenon of increased clotting. There may be clotting of blood vessels that are feeding the kidneys as well. The kidney becomes the innocent recipient downstream of all that trauma.”

As a result, a high proportion of critically ill COVID patients are ending up on dialysis.

“There’s hope that once they get off the ventilator, the kidney function will improve,” says Hercz. “But it can take weeks or even months. We don’t have enough of a timeline to have followed it along to see what the incidence of that is. We don’t know whether some of these patients, when they go on dialysis, have had chronic kidney disease and this was the superimposed extra trauma.”

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The driving force behind the rapid downhill trajectory in gravely ill COVID patients, it is suspected, derives from a disastrous overreaction of the immune system, known as a “cytokine storm” — cytokines are the small proteins released by many different cells in the body that coordinate response against infection and trigger inflammation. They’re trying to protect the body; that’s their job. But by bombarding the body, certain cytokines soar far beyond what’s needed and immune cells start to attack healthy tissue, with catastrophic organ failure ensuing.

The body’s own response becomes the illness.

Yet paradoxically doctors have noticed a mystifying anomaly between those who were already on dialysis and those who are put on the dialysis machine after they contract the virus.

Early studies out of Wuhan, China, where the coronavirus emerged, and Italy, where the virus overwhelmed hospitals upon its explosion in March, recorded much lower morbidity rates among COVID patients who were already on dialysis because of kidney failure with seriously compromised immunity.

“It goes against what you would expect,” says Hercz, “because they’re immune-suppressed and they’re a vulnerable population. We’re trying to find ways of explaining that without having all the information yet.

“The first thing that comes to mind is that the severe morbidity that happens with COVID is … the cascade immune response. It’s almost like a storm that the body unleashes that becomes activated. And perhaps, by actually being immune-suppressed, they don’t mount that major immune storm so that in a curious way they’re protected from some of the morbidity seen in other patients.”

It’s all still a matter of robust debate among clinicians, the understanding of a piecemeal nature and heavily anecdotal.

At the Humber dialysis clinic, COVID testing has found only nine positive out-patients. Of course, thorough protocols have been put in place, clinic staff given personal protective gear, temperatures taken of all dialysis recipients before they entire the unit, the positives isolated, the rest maintaining appropriate distance in the waiting room — chairs are blocked out — and recovery area. “Just two out of those nine patients required admission,” says Padure, sounding quite stunned, himself. “And we’re talking here about frail people.”

Great care is taken to assure and soothe these patients who already feel stigmatized by being on dialysis, which often takes a psychological toll.

“A big focus of my career has been the psycho-socio impact of chronic illness,” says Hercz at Humber, who runs a website that provides advice for patients, families and nurses on coping mechanisms.

“There’s coping with the illness and then the emotional impact of the illness and now, with COVID, we’ve entered another traumatic situation, an added intensity. Part of it is the insecurity of the patient: ‘Am I going to have a nurse tomorrow? Is everybody going to be there for me because I’m still dependent for my life.’ ”

In his tiny isolation room, Lewis Lawson is still waiting for his dialysis slot, anxious and frightened, and, yes, mad.

Behind the mask, his face crumples.

“Sometimes I wish that I was dead.’’