COVID-19 trends in patients on home dialysis match in-center population
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Trends in COVID-19 prevalence and mortality were similar among patients on home dialysis and those on in-center dialysis, with changes throughout the pandemic mirroring that of the general population in the United States.
Similar to previous investigations, researchers determined that residence in a long-term care facility was associated with higher COVID-19 infection rates for all patients with end-stage kidney disease, regardless of dialysis modality.
“Although infection rates among patients on dialysis tend to parallel local patterns, this population has a higher rate of COVID-19 compared with the general population; this may be a reflection of increased symptom screening and testing, and a limited ability to achieve physically distancing, particularly given the dependence of most patients on maintenance dialysis in the United States on in-center hemodialysis,” Caroline M. Hsu, MD, of Tufts Medical Center and Tufts University School of Medicine in Boston, and colleagues wrote. “Studies describing COVID-19 in patients receiving home dialysis are lacking but needed, given they share with patients on in-center dialysis similar risk factors for poor outcomes, including possible impaired immunity and high prevalence of comorbid conditions.”
For the study, researchers compared COVID-19 trends in patients receiving home dialysis through one of the home programs of Dialysis Clinic Inc. (DCI) with patients receiving in-center treatments; researchers noted that DCI provides home-based care out of 116 clinics across 27 states.
COVID-19 in home dialysis population
“To reflect the evolving epidemiology of the COVID-19 pandemic, analyses were conducted for two time periods: February 22 to September 30, 2020 (termed ‘phase 1’) and October 1 to December 31, 2020 (termed ‘phase 2’),” Hsu and colleagues explained of the methodology. “For each phase, patients on home dialysis with COVID-19 were mapped to their clinics’ counties, which were then used to identify and compare dialysis patients in both home and incenter programs located within the same counties.”
In phase 1, researchers observed that 4.5% of patients receiving home dialysis were diagnosed with COVID-19; in phase 2, this rose to 6.4%, which the researchers suggested parallels patterns of COVID-19 epidemiology across the country, where testing constraints earlier in the pandemic led to limited diagnoses.
Black race, Hispanic ethnicity and long-term care facility residence were identified as significant risk factors for developing COVID-19, while older age, longer time on dialysis and cardiovascular disease were associated with mortality (13% of patients on home dialysis with COVID-19 died in phase 1 and 12.1% died in phase 2 vs. 7.6% and 8.8% without COVID-19, respectively).
Improvements in COVID-19 testing, management
While phase 1 showed higher rates of COVID-19 for patients on in-center dialysis compared with those on home dialysis, the elimination of this difference by phase 2 may reflect improved infection-control practices among long-term care facility residents, according to Hsu and colleagues. This is supported by the observation that declining COVID-19 rates among these residents was associated with lower COVID-19 prevalence among the in-center population.
“Of note, the mortality rate in patients on home dialysis here was less than that reported by other studies of COVID-19 in the general dialysis population, dominated by patients treated in-center, including an earlier study by this group; this likely reflects the generally better health of patients on home dialysis compared with the overall dialysis population,” Hsu and colleagues wrote. “Mortality decreased from phase 1 to phase 2, falling by half among the incenter population, which likely reflects expanded testing availability enabling diagnosis of milder cases, improvement in COVID-19 management over time, fewer infections in [long-term care facility] LTCF residents, and possibly a reduced inoculum burden with widespread masking.
Nevertheless, the high rate of poor outcomes in this vulnerable population reinforces the need for vaccine prioritization and continued vigilance in treating these patients.”
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