ABSTRACT
Background: The incidence of death among patients with ESKD in the United States has been significantly elevated during the COVID-19 pandemic, relative to recent historical levels. In the general population, individual states have exhibited markedly variable COVID-19 death rates, possibly reflecting policy decisions concerning pandemic management. However, little is known about regional variability in the excess mortality of ESKD patients. We analyzed excess mortality among both prevalent dialysis and kidney transplant (KT) patients between March 15, 2020, and June 30, 2021. Method(s): We analyzed national data extracted from the Centers for Medicare and Medicaid Services (CMS) End Stage Quality Reporting System (EQRS). For each epidemiologic week from week 1 of 2018 to week 26 of 2021, we identified prevalent dialysis and KT patients at the beginning of each week, and the incidence of all-cause death among them during the week. For each combination of state and kidney replacement therapy, we estimated excess mortality during the pandemic (definition: week 12 of 2020 and thereafter), using a logistic regression model of death among patient-weeks, with adjustment for age, sex, race. Result(s): From 732,063 dialysis patients in 50 states, there were 129,095 pandemicera deaths;and from 238,265 KT patients in 41 states, there were 11,256 pandemicera deaths. State-level excess mortality ratios in dialysis patients ranged from 0.96 to 1.34, with 40% of states having ratios significantly greater than 1.1. State-level excess mortality ratios in KT patients ranged from 1.02 to 2.73, with 61% of states having ratios significantly greater than 1.1. Conclusion(s): States exhibited wide variability in excess ESKD patient mortality, with roughly 3-fold wider variability in prevalent KT patients than in dialysis patients.
ABSTRACT
Background: How the COVID-19 pandemic altered aspects of dialysis initiation, such as eGFR at initiation, selection of peritoneal dialysis (PD), and, in patients initiating hemodialysis (HD), use of a central venous catheter (CVC), is not fully understood. Methods: We analyzed the most recently updated quarterly USRDS data available. Using Poisson and logistic regression, we studied weekly changes in eGFR at dialysis initiation, use of PD (versus HD), and use of incident CVCs, overall and by strata of race, during the first half of 2020 compared to a forecast of 2020, had 2017-2019 historical trends continued. Results: Mean eGFR at dialysis initiation decreased by 0.33 mL/min/1.73 m2 in weeks 19-22, compared with historical trends;non-Hispanic Black patients exhibited the largest decrease, at 0.61 mL/min/1.73 m2. The odds of initiating dialysis with eGFR <10 ml/min/ 1.73m2 were highest during weeks 19-22 (May;OR 1.14, 1.05-1.17), corresponding to an absolute increase of 2.9%. Although initiation of both HD and PD fell, PD fell less, such that the odds of initiating PD (versus HD) were 24% higher (OR 1.24, 1.14-1.34) in weeks 11-14. Odds of initiating HD with a CVC increased by 30% (OR 1.30, 1.20-1.41) in weeks 15-18, representing an absolute increase of 3.3%. Conclusions: In the first half of 2020, eGFR at dialysis initiation fell, most prominently in non-Hispanic Blacks. During the initial wave of the pandemic, odds of utilizing PD, compared with HD, increased by nearly 25%, and odds of using a CVC at HD initiation increased by 30%.
ABSTRACT
Background: How the COVID-19 pandemic altered ESKD incidence, dialysis initiation, and preemptive kidney transplantation is unknown. Methods: Using Centers for Medicare & Medicaid Services data, we investigated the incidence of ESKD, dialysis initiation, and preemptive kidney transplantation by week during the first half of 2020. Using Poisson regression, we compared findings in 2020 to a forecast of 2020, had 2017-2019 historical trends continued, overall and by strata of age and race. Results: Mean weekly counts of patients with new ESKD are shown in the Figure. Incidence of ESKD dropped dramatically in 2020 compared with the expected incidence, particularly during epidemiologic weeks 15-18 (April;incidence rate ratio [IRR] 0.75, 95% CI 0.73-0.78), before approaching pre-pandemic levels in weeks 23-26 (June;IRR 0.93, 0.90-0.95). Across age groups, the decrease was most pronounced during weeks 15-18 among individuals aged ≥75 years (IRR 0.69, 0.66-0.73, compared with individuals aged 45-64 years, IRR 0.80, 0.77-0.84). In terms of race, the decrease was least notable among non-Hispanic Blacks (IRR 0.85, 0.81-0.89) and was most pronounced in non-Hispanic Whites (IRR 0.72, 0.69-0.74) and Hispanics (IRR 0.73, 0.69-0.78). Dialysis initiation reached a nadir during weeks 15-18 (IRR 0.76, 0.74-0.78), and preemptive kidney transplantation decreased even more strikingly during this period (IRR 0.56, 0.46-0.67). Conclusions: During the first wave of the COVID-19 pandemic in 2020, the number of patients starting treatment for ESKD fell to a level not observed since 2011. Changes in ESKD incidence and utilization of treatment modalities may reflect differential access to care.
ABSTRACT
Background: The novel coronavirus 2019 (COVID-19) pandemic has resulted in substantial morbidity and mortality among patients undergoing maintenance dialysis. Patients performing home hemodialysis (HHD) or peritoneal dialysis (PD) may be able to minimize exposure to the community, thus lowering risk of COVID-19 infection. We assessed whether HHD and PD were associated with lower risks of COVID-19 infection and hospitalization, compared to in-facility hemodialysis (IHD). Methods: We analyzed Medicare Parts A and B claims accrued during 2020. For each epidemiologic week from week 12 (beginning March 15) to week 37 (September 6), we identified patients with a Medicare-covered outpatient dialysis treatment during the preceding 7 days. We stratified patients into cohorts of IHD, HHD, and PD;we limited the IHD cohort to patients without residency in a skilled nursing facility during the 28 days preceding the epidemiologic week. During each week, we estimated the incidence of COVID-19 infection and COVID-19 hospitalization, per Medicare claims with ICD-10-CM diagnosis code U07.1. Using logistic regression with adjustment for demography, comorbidity, and state, we estimated odds ratios of outcomes during weeks 12-22, 23-33, and 34-37. Results: Incidence of COVID-19 infection (figure) and COVID-19 hospitalization peaked twice: during weeks 14-16 and weeks 29-30. During weeks 12-22, adjusted odds ratios (AORs) of COVID-19 infection for HHD versus IHD and PD versus IHD were 0.55 (95% CI, 0.43-0.71) and 0.52 (0.46-0.58), respectively. During weeks 23-33, corresponding AORs were 0.63 (0.50-0.78) and 0.63 (0.57-0.69). Conclusions: Both home dialysis modalities were associated with similarly lower risks of COVID-19 infection and hospitalization. Nephrologists and dialysis provider should consider counseling patients about potentially lower risk of infectious respiratory disease with home dialysis.
ABSTRACT
Background: Patients with ESKD are at high risk of mortality from COVID-19. The extent to which increased mortality in the ESKD population in 2020 was related to COVID-19 vs other causes in the setting of disruption of healthcare delivery is not clear. Methods: We used the Death Notification Form (CMS-2746) to examine excess allcause and COVID-related mortality in Jan through Aug of 2020 among the whole ESKD population and by race/ethnicity adjusting for age and comorbidity. We further examined causes of non-COVID-related mortality in 2020 compared with 2017-2019. Results: All-cause mortality increased by 13.1% during Jan-Aug 2020 compared with mortality during the same period in 2017-2019. Peak overall and excess mortality occurred during Apr (Figure), when 14.7% of all deaths were attributed to COVID-19. COVID-related deaths declined to a nadir of 6.2% of all deaths in June and then increased again in Jul and Aug. Excess mortality was approximately twice as high among Black and Hispanic patients as among whites. Between Feb and Apr, there was substantial excess non-COVID mortality in addition to COVID mortality, whereas most excess mortality during May to Aug was related to COVID-19. There were 4310 excess deaths during Feb-Apr 2020. 1576 (37%) were due to COVID-19, and 517 (12%) were attributed to pneumonia. Thus, approximately half of the excess mortality was not due to COVID-19, including 1635 excess deaths due to cardiac arrest, cause unknown. Conclusions: Patients with ESKD experienced substantial excess mortality in 2020 relative to prior years that affected Black and Hispanic patients disproportionately. Approximately half of the excess mortality was likely caused by COVID-19. There was also excess mortality in the early phase of the pandemic that was not attributed to COVID-19.
ABSTRACT
Background: Monitoring real-time acceleration, plateaus, and deceleration of infection rates is important for healthcare planning during a pandemic. We implemented methodology to continuously monitor daily cases and changes of COVID-19 case rates among individuals with ESKD receiving care in a large dialysis organization. Methods: We identified patients with ESKD receiving dialysis in a Fresenius Medical Care North America (FMCNA) dialysis facility who tested positive for COVID-19. We fit a loess curve to the daily cumulative number of identified cases and computed the first and second derivative of the fitted curve to assess rate of change and change in rate of change, respectively, over time. We used these visualization techniques to monitor trends in case rates at the national and state levels. Results: By May 15, 2020, there were 5,513 confirmed COVID-19 cases among patients receiving dialysis in an FMCNA facility. Mean age was 63.6 years, 57% were male, and 71% of confirmed cases had diabetes. Nationally, during the peak infection period in early April, new cases routinely exceeded 150 per day and there was a steady acceleration in growth of cases until the second week of April. As of May 15, 2020, among states with sufficient data, 2 states demonstrated continued acceleration, 10 demonstrated deceleration, and 13 plateaued in rate of growth. Conclusions: The timing of the acceleration in growth of COVID-19 cases among individuals with ESKD followed national trends in the general population. Varying patterns of plateauing and deceleration of cases at the state level were observed in the ESKD population. Real-time monitoring of disease rates in high-risk populations, such as individuals with ESKD, is needed to plan for continuously changing healthcare demands during a pandemic.