All-cause mortality increased among patients on dialysis, transplant recipients in 2020
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In the first half of 2020, patients with end-stage kidney disease had a significant increase in all-cause mortality from previous years and a significantly higher hospitalization rate for COVID-19 than the general population, results show.
“Registry reports in Europe have indicated that the fatality rate of COVID-19 among patients with ESKD is between 20% and 30%, a range corroborated by single-center studies in the United States,” Eric D. Weinhandl, PhD, MS, of the Chronic Disease Research Group, Hennepin Healthcare Research Institute, and the department of pharmaceutical care and health systems at the University of Minnesota, and colleagues wrote. “However, the initial effect of COVID-19 on population-level outcomes in the United States has not yet been assessed.”
According to Weinhandl and colleagues, patients with ESKD have an increased risk for hospitalization and mortality from COVID-19 due to a variety of factors. For patients undergoing dialysis, these include older age and a high prevalence of diabetes, heart failure and chronic obstructive pulmonary disease. In addition, health disparities come into play, with Black individuals being disproportionately affected by kidney disease and more than 20% of patients on dialysis living below the federal poverty line; many patients, the researchers noted, rely on public transportation to get to dialysis treatments, thereby increasing their risk of contracting COVID-19.
“Patients with a kidney transplant, who are less likely to carry noted risk factors, require treatment with immunosuppressants, placing them at higher risk of severe COVID-19,” the researchers wrote.
Using CMS data, Weinhandl and colleagues examined hospitalization rates for patients undergoing dialysis and determined excess all-cause mortality for patients on dialysis and transplant recipients, comparing these occurrences in March to July of 2020 (during the COVID-19 pandemic) with the same timeframe in the preceding years (2017 to 2019).
Hospitalizations
Researchers observed that patients on dialysis experienced a peak in hospitalizations for COVID-19 during the same period of 2020 as the general population (between March 22 and April 25), but that hospitalization rates were significantly higher for these patients.
“The trajectory of the rate of COVID-19 hospitalizations among dialysis patients tracked the corresponding trajectory in the general population, but was roughly 40 times higher in magnitude,” Weinhandl said in a related press release.
Racial and ethnic disparities were evident here, according to the researchers, with “non-Hispanic Black” and Hispanic patients having an increased likelihood of hospitalization compared with “non-Hispanic white” patients during these weeks (adjusted relative rates [ARR] of 1.6 to 2.2 and 1.6 to 3.2, respectively).
“Perhaps most surprisingly, the rate of hospitalization for reasons other than COVID-19 declined sharply among patients undergoing dialysis in the spring — after having been nearly constant since 2013,” the researchers wrote after observing the rate on non-COVID-19 hospitalizations was 17% lower in 2020 compared with the corresponding weeks in 2017 to 2019.
Researchers noted that compared with in-center hemodialysis, patients on peritoneal dialysis were less likely to be hospitalized (ARRs of 0.3 to 0.4).
Mortality
Regarding death, all-cause mortality rates were 29% higher for patients undergoing dialysis and 48% higher for those with a functioning transplant compared with the same 5-week period in the preceding years. Further observations indicated excess mortality was higher among “non-Hispanic Black,” Hispanic and Asian patients (ARRs of 1.07 for “non-Hispanic white” patients compared with 1.35, 1.27 and 1.28, respectively).
“Patients with ESKD were severely affected by COVID-19 during the first half of 2020, to the extent that excess mortality in patients on dialysis and with a transplant led to contraction of the ESKD census,” the researchers concluded. “Racial and ethnic disparities in COVID-19 hospitalization and excess mortality further demonstrated the health inequities that have been widely discussed during 2020. Although data from patients performing PD at home suggest potential risk modification, the dominant aspects of ESKD care today are in-facility HD and transplant-related immunosuppression. Vaccination may be the only intervention that can significantly stem morbidity and mortality.”
Weinhandl provided further comment in the press release.
“This study suggests that the effect of the initial phase of the pandemic on both dialysis and kidney transplant patients has been profound,” he said. “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.”
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