After weeks of searching high and low for ventilators, Governor Andrew Cuomo and health care leaders around the state are breathing a little easier—and sending some of the frantically acquired units to New Jersey, where they’re increasingly needed during the coronavirus pandemic.

But now, many hospital workers on the front lines in the metro area have been sounding the alarm that a different piece of life-saving equipment is in short supply and high demand: dialysis machines.

“We only have nine or ten machines, and now we have over 30 patients that need them,” said one physician who manages an intensive care unit in Queens but who wasn’t authorized to speak. “So it becomes a question of who the resource goes to, and these are very difficult decisions.”

COVID-19 sickens people–and kills some–mainly by attacking the lungs. That’s why health officials around the country have focused on finding ventilators and staff members to operate them. But ICU doctors are discovering that up to one-third of their most severely ill patients are developing Acute Kidney Injury, as they call it. These largely are not people with advanced diabetes or chronic renal conditions.

No one anticipated the trend, based on research from the coronavirus outbreaks in Asia or Europe.

“It's created a pretty substantial burden on supplies,” said Dr. Steven Fishbane, head of nephrology at Northwell Health, New Yorks’ largest hospital network. “Everybody is running into shortages at this point.”

Those shortages include ICU dialysis machines–which are different than the ones chronic dialysis patients use—and the unique fluids and filters needed to operate them. Most important of all is the lack of highly specialized dialysis nurses, with many in their already thin ranks now sidelined by Covid.

“Our intensive care unit nurses usually [each] take care of two patients,” Fishbane said. “Now, it's one nurse for four patients.”

Like ventilators, dialysis machines are mechanical substitutes for an incapacitated organ system. Ventilators breathe for you when your lungs can’t, and dialysis machines clean your blood of salts and toxins when your kidneys can’t. Neither machine heals you. They only buy time while your immune system fights off pathogens, perhaps with the help of medication.

Unlike the dialysis machines elsewhere in the hospital or in outpatient treatment centers, ICU machines operate continuously, 24 hours a day—unless you have more patients than machines.

It’s not clear exactly how COVID-19 damages kidneys, limiting their ability to clean blood. Dr. Benjamin Humphreys, from Washington University Hospital, suggested the virus could be infecting kidneys directly, exploiting the same protein receptors they attack in the lungs. Or it could be that the higher tendency to develop blood clots among COVID-19 patients is taking its toll on the blood-vessel-rich organs.

“We don't have any other clues as to what differentiates patients that do develop kidney failure, who are infected with COVID with those that don't,” Humphreys said.

The term "rationing" is triggering for political leaders, health officials, and hospital executives, but the Queens and Brooklyn doctors unauthorized to speak both said they already are, in effect, rationing dialysis care. They and other doctors and nursing supervisors are deciding together who gets a machine and who doesn’t, based on who has the best chance of recovering.

Those physicians are at hospitals that serve minorities and immigrants in poor and working class communities. Other doctors in less adverse environments say their situation isn’t quite so dire—yet.

“We haven't had to ration health care at NYU, at Bellevue, or the V.A.” said Dr. David Goldfarb, who heads nephrology units at all three. ”We’ve had discussions about whether rationing was going to occur, under what circumstances it would occur, how that would go, what person or group of people would make those kinds of choices. We've read the documents that exist providing guidance on this topic. But, fortunately, we haven't quite gotten there.”

Fishbane, from Northwell Health, said at his largely suburban hospital network when patients on ventilators aren’t getting better—perhaps they have other problems like dementia or metastatic cancer, but perhaps they don’t—“that leads to questions about should dialysis be provided,” when their kidneys begin to fail. So care-givers discuss with patients and families what their values are and what the likely medical outcomes will be from dialysis.

“Often in those kind of situations, we're not really adding to the dignity at the ends of life, but rather perhaps even sustaining discomfort that isn't necessary,” Fishbane said.

What Fishbane calls “thoughtful conversations” are the way things are supposed to happen. But his counterparts at busy urban hospitals say that process isn’t possible when you’re overwhelmed. Things move too fast, they say, and they don’t have the time, equipment or staff to have those conversations.

“There are hospital ethics councils. There are palliative care teams,” the Queens ICU chief said. “But the kidney doctors are the ones deciding who needs, you know, who is in the worst failure at a given time. They're doing their best, but the renal failure is probably near a 100 percent mortality rate.”

So, is lack of full-time dialysis actually killing patients in the ICU? Goldfarb says it may be a contributing factor, but it’s hard to say how much.

“Lung failure and kidney failure is a really bad combination—and I'm not even confident that dialysis of any sort will change the mortality of that combination,” he said.” But we want to be able to address that kidney failure with all the techniques that we have.”

In other words: the virus is what’s killing patients, mostly by shutting down their lungs. Doctors say reversing that, once it’s advanced, is an uphill battle, and they need all the help they can get from the kidneys—or the best mechanical substitutes available.