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Patients With ESKD Suffered Severe, Disparate Mortality in Early Phase of Pandemic


The findings illustrate the importance of prioritizing COVID-19 vaccinations for patients on dialysis.

COVID-19 hit patients with end stage kidney disease (ESKD) especially hard in the early stages of pandemic, with the risk of death from all causes 17% higher among those undergoing dialysis and 30% higher among those with a kidney transplant than before the virus struck, according to a new study.

The study also found that the rate of COVID-19 hospitalizations among dialysis patients peaked at 40 times higher than the rate in the general population from March 22 to April 25, 2020, with non-Hispanic Blacks, Hispanics, and Asians hit harder than whites.

The severity of the impact points to the need for prioritizing COVID-19 vaccinations for patients receiving kidney dialysis, according to the authors of the study, published this month in the Journal of the American Society of Nephrology. Last month, the Biden administration announced that dialysis centers will be permitted to administer vaccinations against the virus that causes COVID-19.

“This study suggests that the effect of the initial phase of the pandemic on both dialysis and kidney transplant patients has been profound,” said Eric D. Weinhandl, PhD, MS, who is the study’s lead author and is from the Chronic Disease Research Group, a division of Hennepin Healthcare Research Institute and the Coordinating Center of the United States Renal Data System. “With markedly higher rates of all-cause mortality in both dialysis and kidney transplant patients during the second quarter of 2020, there is now a clear rationale for prioritization of kidney failure patients in COVID-19 vaccination schedules promulgated by states.”

The rate of death from COVID-19 is known to be 20% to 30% among patients with ESKD. This data, from CMS’ Renal Management Information System, cast a light on the initial effect of COVID-19 on these patients at a population level.

Approximately 800,000 people receive treatment for kidney failure in the United States, with Blacks overrepresented in the group (33% vs 13% of the general population).

In the third week of 2020, there were 568,333 patients receiving dialysis and 237,746 with a functioning transplant in the United States.

During weeks 13-27 of 2020, adjusted relative rates (ARRs) of death in 2020 vs 2017-2019 were 1.17 (95% CI, 1.16-1.19) among dialysis patients and 1.30 (95% CI, 1.24-1.36) among patients undergoing dialysis or with a functioning transplant, respectively.

For non-Hispanic whites, the ARR for dialysis patients was only 1.07 (95% CI, 1.05-1.09), compared with 1.35 (95% CI, 1.32-1.39) for non-Hispanic Blacks, 1.27 (95% CI, 1.23-1.32) for Hispanics, and 1.28 (95% CI, 1.20-1.38) for Asians.

For transplant patients, rates were as high as 1.84 for non-Hispanic Blacks (95% CI, 1.67-2.03) and 1.90 for Hispanics (1.67-2.17). It was 1.38 (95% CI, 1.07-1.77) for Asians, but for whites only 1.20 (95% CI, 1.12-1.28).

From March 22 to April 25, all-cause mortality skyrocketed to 29% higher among dialysis patients than during the same 5 weeks in 2017-2019, and 48% higher for transplant patients.

Non-Hispanic Black patients saw hospitalization rates that were 60% to 120% higher than whites, while Hispanic patients were hospitalized at 60% to 220% the rate. The authors, however, found that 60% of non-Hispanic Black patients lived in ZIP codes where non-Hispanic Blacks constitute a median of only 34% of the general population, suggesting that location, as opposed to strictly rate, might be a key risk factor.

The study also found that peritoneal dialysis, which occurs in the home, was associated with a much lower risk of hospitalization than patients on hemodialysis, who receive treatment in a medical center. The authors indicated the statistics pointed to reduced risk for treatment at home.

Excess mortality among patients peaked in the spring for non-Hispanic Black, Hispanic, and Asian patients, but remained relatively higher than in previous years even as deaths declined in June. The net result of the higher death rates was an unprecedented decline in the number of patients with ESKD, with totals dropping by 0.4%, according to the study.

One puzzle was a decline in the non-COVID-19 hospitalization rate of dialysis patients of 24% in 2020 compared to 2017-2019. The authors offered 3 possibilities: a lack of usual access to acute care contributing to excess mortality; greater effort to avoid missed treatments and, thus, being able to stay out of the hospital; and almost all excess mortality being directly due to COVID-19.


Weinhandl ED, Wetmore, JB, Peng Y, et al. Initial effects of COVID-19 on patients with ESKD. J Am Soc Nephrol. Published online April 8, 2021.doi:10.1681/ASN.2021010009

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