COVID-19-Related Mortality in Kidney Transplant and Dialysis Patients

Results of the ERACODA Collaboration

Luuk B. Hilbrands; Raphaël Duivenvoorden; Priya Vart; Casper F.M. Franssen; Marc H. Hemmelder; Kitty J. Jager; Lyanne M. Kieneker; Marlies Noordzij; Michelle J. Pena; Hanne de Vries; David Arroyo; Adrian Covic; Marta Crespo; Eric Goffin; Mahmud Islam; Ziad A. Massy; Nuria Montero; João P. Oliveira; Ana Roca Muñoz; J. Emilio Sanchez; Sivakumar Sridharan; Rebecca Winzeler; Ron T. Gansevoort


Nephrol Dial Transplant. 2020;35(11):1973-1983. 

In This Article

Abstract and Introduction


Background: Patients on kidney replacement therapy comprise a vulnerable population and may be at increased risk of death from coronavirus disease 2019 (COVID-19). Currently, only limited data are available on outcomes in this patient population.

Methods: We set up the ERACODA (European Renal Association COVID-19 Database) database, which is specifically designed to prospectively collect detailed data on kidney transplant and dialysis patients with COVID-19. For this analysis, patients were included who presented between 1 February and 1 May 2020 and had complete information available on the primary outcome parameter, 28-day mortality.

Results: Of the 1073 patients enrolled, 305 (28%) were kidney transplant and 768 (72%) dialysis patients with a mean age of 60 ± 13 and 67 ± 14 years, respectively. The 28-day probability of death was 21.3% [95% confidence interval (95% CI) 14.3–30.2%] in kidney transplant and 25.0% (95% CI 20.2–30.0%) in dialysis patients. Mortality was primarily associated with advanced age in kidney transplant patients, and with age and frailty in dialysis patients. After adjusting for sex, age and frailty, in-hospital mortality did not significantly differ between transplant and dialysis patients [hazard ratio (HR) 0.81, 95% CI 0.59–1.10, P = 0.18]. In the subset of dialysis patients who were a candidate for transplantation (n = 148), 8 patients died within 28 days, as compared with 7 deaths in 23 patients who underwent a kidney transplantation <1 year before presentation (HR adjusted for sex, age and frailty 0.20, 95% CI 0.07–0.56, P < 0.01).

Conclusions: The 28-day case-fatality rate is high in patients on kidney replacement therapy with COVID-19 and is primarily driven by the risk factors age and frailty. Furthermore, in the first year after kidney transplantation, patients may be at increased risk of COVID-19-related mortality as compared with dialysis patients on the waiting list for transplantation. This information is important in guiding clinical decision-making, and for informing the public and healthcare authorities on the COVID-19-related mortality risk in kidney transplant and dialysis patients.


Since the start of the outbreak in China in December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread throughout the world at an alarming pace.[1] The severity of coronavirus disease 2019 (COVID-19) symptoms varies from mild complaints to serious life-threatening illness.[2] In the report of the Chinese Center for Disease Control on 44 672 confirmed COVID-19 patients, 19% of patients were found to develop severe symptoms and the case-fatality rate was 2.3%.[2] Reported case-fatality rates vary greatly per region owing to differences in demographics and case ascertainment.[3]

Several studies have indicated that advanced age is the most important risk factor for mortality.[4–8] Patients older than 70 years have an >10-fold increased risk of death when compared with patients under 50 years of age.[8] Across all age groups, male sex was found to be associated with increased risk of mortality.[4–8] Furthermore, a number of underlying comorbidities and conditions have been associated with mortality, including obesity, hypertension, cardiovascular disease, diabetes mellitus, chronic lung disease and cancer.[8–14] Also, chronic kidney disease has been associated with increased risk of mortality.[8,9,13]

Currently, only limited data are available on outcomes in patients treated with kidney replacement therapy.[8,9,15–19] Patients who have a kidney transplant or are on dialysis may be at particularly high risk of mortality as they are generally older and often have chronic underlying conditions such as hypertension, cardiovascular disease and diabetes mellitus.[20] In addition, kidney transplant patients are treated with immunosuppressive drugs, which may increase the risk of contracting SARS-CoV-2 infection and developing severe symptoms.[8,9,15–19] In response to the COVID-19 pandemic, a large European database (ERACODA, the European Renal Association COVID-19 Database) has been constructed to specifically investigate the course and outcome of COVID-19 in patients living with a kidney transplant or on maintenance dialysis therapy. Here we present the 28-day outcome in terms of hospital admission, intensive care unit (ICU) admission and mortality. We furthermore report associations of patient, disease and treatment characteristics with mortality and compare outcome in kidney transplant and dialysis patients where relevant.