High excess mortality seen during COVID-19 pandemic for US adults with kidney failure
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Excess mortality rates rose between February and August 2020 for the end-stage renal disease population, with patients in New York, New Jersey and Texas having the highest rate of death compared to the rest of the country.
The findings were published in the June 1 edition of the CDC’s Morbidity and Mortality Weekly Report.
“The findings of this report suggest that deaths among ESRD patients during the early phase of the pandemic exceeded those that would have been expected based on previous years’ data,” Robert Ziemba, PhD, of the Health Services Advisory Group Inc. in Tampa, Florida, and colleagues wrote.
However, the authors added, “This observation period coincides with the early months of the COVID-19 pandemic, but the actual cause of death and the relationship to COVID-19 was not determined.”
The published data were obtained from the ESRD National Coordinating Center’s analysis of deaths reported to the Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb).
A comparison of deaths that occurred in the total ESRD population pre-pandemic (between 2016 and 2019) with those that occurred between February and August 2020 showed an estimated 8.7 to 12.9 excess deaths per 1,000 patients occurred in the early months of the pandemic (a total of 6,963 to 10,316 excess deaths).
When patients on dialysis (n = 541,932) were compared with transplant recipients (n = 256,671), results suggested the former experienced greater rates of excess mortality.
More specifically, researchers estimated 10.8 to 16.6 excess deaths occurred per 1,000 patients on dialysis (a total of 5,860 to 9,019 excess deaths) compared with 2.6 to 5.5 excess deaths per 1,000 transplant recipients (a total of 663 to 1,403 excess deaths).
Regional variation was also observed, with New York, New Jersey and Texas having the highest estimated number of excess deaths per 1,000 patients.
Ziemba and colleagues contended that while the reasons behind the higher excess mortality rates in patients with ESRD remain unclear, the inability to access in-person health services throughout the pandemic or SARS-CoV-2 transmission from other patients or health care staff members might play a role.
The authors noted all 18 ESRD Networks across the United States have implemented interventions to prevent the transmission of COVID-19, with prevention messages highlighting CDC recommendations distributed to dialysis facilities and patients.
“Networks identified facilities in regions with the most rapid growth in new cases for targeted interventions, and the ESRD Networks provided more than 4,800 instances of one-on-one technical assistance to those facilities during August [to] November 2020,” Ziemba and colleagues wrote. “Data-driven technical assistance has guided the implementation of processes and education initiatives to mitigate the spread of COVID-19 in dialysis facilities. Further research will be required to determine the impact of the technical assistance on excess deaths in the larger context of patient risk factors and regional variations in the progression of the pandemic.”
Perspective
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By now, it is apparent to everybody in the kidney community that COVID-19 infection and end-stage kidney disease have been an awful – and lethal – combination.
Nevertheless, the analysis by Ziemba and colleagues punctuates the misery by quantifying the range of additional deaths that occurred between February and August 2020, relative to what would have occurred in the absence of a pandemic.
Specifically, somewhere between 7,000 and 10,300 additional deaths occurred during those 7 months, with the majority in the dialysis patient population. As a native of a small town of 3,000 people, I am aggrieved by a fatality count of this magnitude.
My colleagues in the United States Renal Data System (USRDS) and I published similar findings, albeit through only June 2020, in the most recent Annual Data Report (ADR) and in the Journal of the American Society of Nephrology.
Of course, the ADR was published online in November 2020 – weeks before Dec. 11, 2020, when the FDA issued the first emergency use authorization for a COVID-19 vaccine.
When I see data like those reported by Ziemba, I become frustrated by the fact that COVID-19 vaccines were not in the hands of dialysis providers in December 2020. Yes, some states wisely allocated vaccine supply to dialysis providers during the early part of 2021. However, at the federal level, there was a tremendous difference in the apparent urgency of vaccinating people in nursing homes and the apparent urgency of vaccinating patients in dialysis facilities. Why? People in both settings necessarily routinely received health care in a group setting. People in both groups had substantial comorbidity. Importantly, vaccines would have been relatively easy to administer en masse in both settings.
I fail to see substantial differences between the settings.
The final calculus will show that thousands of patients on dialysis and hundreds of patients with kidney transplants died of COVID-19 after Dec. 11, 2020. Some portion of the suffering could have been prevented by rapid deployment of vaccines to dialysis facilities. The federal government surely knew what was occurring in patients with kidney failure – through USRDS reports and through its own analyses – yet chose not to act until March 25, 2021.
For this reason, the question of why dialysis patients were ignored during the first weeks of vaccination should be an area of intense scrutiny by the Congress.
References:
USRDS. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. NIH, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, 2020.
Weinhandl E, et al. J Am Soc Nephrol. 2021;doi:10.1681/ASN.2021010009.
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