Dialysis Patients Should Be Moved Up Vaccine Priority List

Pam Harrison

February 16, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Patients on kidney dialysis are on par with long-term care residents in terms of risk for SARS-CoV-2 infection and COVID-19 death, new research indicates. As such, patients on dialysis should highest priority for vaccination, experts say.

During the first 5 months of the pandemic in 2020, researchers found 1.5% of 12,501 patients undergoing dialysis in the province of Ontario, Canada were diagnosed with SARS-CoV-2 — around five times higher than the infection rate for the general population during the same period.

Of those infected, 62.6% required hospital admission; 19.8% were placed in the intensive care unit (ICU) and 15% received mechanical ventilation.

The overall case fatality rate was 28.3%, almost four times higher than that of the general population for the same period, say Peter Blake, MB, Schulich School of Medicine and Dentistry, Western University, London, Ontario, and coauthors in their article published online in the Canadian Medical Association Journal (CMAJ).

"We are advocating very strongly that a group of patients with a mortality rate in the first wave of over 28% should be counted as the highest priority status for vaccination," Blake said in a podcast interview with CMAJ.

"These mortality rates are very similar to those for long-term care home residents who have gotten COVID, which were running in the same [death rate] range of 20% to 27% in the first wave," he added.

"So we think there is a real indication to give this group of patients high priority as well," Blake reemphasized.

CDC Risk Category Should Be Reassessed for Patients on Dialysis

Right now, according to the US Centers for Disease Control and Prevention (CDC), patients on dialysis fall into category 1c; namely, people between the ages of 16 to 64 with high-risk health conditions.

But according to American Kidney Fund (AKF) President and CEO LaVarne Burton, the AKF is urging federal and state governments to move patients on dialysis up to the highest priority for vaccination, namely group 1a, currently made up of healthcare workers and long-term care residents.

"Patients who dialyze in-center are exposed to others three times a week and are in a similar situation to people in long-term care facilities," Burton told Medscape Medical News in an email.

"We are calling on federal and state governments to pull out all the stops and save lives of this vulnerable population," she emphasized.

The problem of course is not just prioritizing patients on dialysis for vaccination, but ensuring patients can access them, Burton said.

For example, in Washington, DC, there has been a huge disparity in vaccine access between wealthier and lower-income wards, she noted.

"Many people who very much want the vaccine are having logistical challenges getting it," she stressed.

Although individual states can develop their own guidelines — and often delegate this task to the local city or county level — there is no uniform framework for a US vaccination strategy, a fact that the AKF deplores. The AKF believes the federal government must make provision so that individual states can develop more consistent vaccine protocols for their residents.

Meanwhile, a survey conducted by the AKF earlier on in the pandemic revealed patients with kidney disease are extremely concerned and fearful about contracting COVID-19 and are incurring significant personal costs to limit exposure.

"This has been a terrible year for our country and patients on dialysis have paid a particularly high price," Burton said. "We must do everything we can to protect this population — and we can save lives if we get our patients vaccinated," she reaffirmed.

Ontario Analysis

Blake and colleagues reported on all patients receiving long-term dialysis registered in the Ontario Renal Reporting System as of March 31, 2020 and all new patients starting dialysis registered between April 1 and August 20, 2020.

"Among patients undergoing dialysis, 187 were diagnosed with SARS-CoV-2 infection," Blake and colleagues report.

The median age of patients diagnosed with COVID-19 was 68 years, and almost 89% of those who contracted the infection were receiving in-center hemodialysis.

"Overall, 1.8% of the entire in-center hemodialysis population in Ontario had a diagnosed infection compared with 0.3% of the patients undergoing home hemodialysis and 0.8% of the patients undergoing peritoneal dialysis," the authors point out (odds ratio, 2.54; P < .001).

Other factors that increased the risk of COVID-19 in patients on dialysis included:

  • Living in long-term care homes: Such individuals who required dialysis were over seven times more likely to become infected than patients who did not live in long-term care homes (P < .001).

  • Living in the Greater Toronto Area (GTA): GTA residents were over three times as likely to develop COVID-19 as those who lived outside of the region (P < .001).

  • Ethnicity: Black patients were over three times as likely as Whites to become infected (P < .001), as were patients from the Indian subcontinent or other non-White patients, who were each approximately twice as likely to become infected as White patients (P = .04 and P = .001, respectively).

  • Being poor: Those in the lowest two income quintiles were twice as likely to be infected as those in the highest quintile (P = .002).

Toll on Hospitals

As Blake pointed out during the CMAJ interview, as many as 4% of patients on dialysis have been infect with SARS-CoV-2.

"The mortality rate has come down a bit from the first wave, but it's still very high at approximately 20%," he noted.

"And these are the patients who have a high rate of getting into hospital, of getting into the ICU, of getting ventilated — they bring a big load of health care onto the shoulders of the hospital," he emphasized.

On the other hand, patients who attend dialysis units would be easy to vaccinate, Blake suggested. After all, they sit in dialysis chairs for hours at a time, three times a week, so getting the vaccine to them would not take a lot effort.

"We realize that lots of people feel they deserve prioritization [for vaccination] as the COVID-19 pandemic proceeds [but] focused efforts should be made to protect this population from infection including prioritizing patients on long-term dialysis and the staff treating them for...vaccination," Blake and colleagues conclude.

Blake has reported receiving honoraria from Baxter Global for speaking engagements.

CMAJ. Published online February 4, 2021. Abstract

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