Patients With End-Stage Kidney Disease Hit Hard by COVID-19

Maureen Salamon

October 01, 2021

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

Deaths among those waiting for, or receiving, a kidney transplant rose dramatically in 2020, and these patients were especially vulnerable to dying from COVID-19, new US research reveals.

Compared with just a year earlier, overall deaths were 24% higher among waitlisted kidney transplant candidates and 20% higher among kidney transplant recipients.

This first national data analysis of COVID-related deaths in patients with end-stage kidney disease also found that those belonging to racial and ethnic minority groups disproportionately succumbed to the SARS-CoV-2 virus.

"Our data predates the vaccine and this phase of the pandemic, but the bottom line is it seems to suggest patients with end-stage kidney disease would be better off with kidney transplant than remaining on dialysis," said lead author Sumit Mohan, MD, MPH, an associate professor of medicine and epidemiology at Columbia University Irving Medical Center in New York City.

One of the reasons is that those awaiting a transplant were generally continuing to receive in-center dialysis, "which would have precluded complete social distancing," Mohan and colleagues note. "Waitlisted candidates are subject to repeated exposure to a healthcare setting where they may be exposed to COVID-19."

The findings therefore drive home why physicians should strenuously advocate for COVID-19 vaccination among patients with kidney disease, Mohan said.

"If you have the opportunity to get a transplant at this point, you should," he added.

The research was published online September 29 in the Clinical Journal of the American Society of Nephrology.

Racial Disparities in COVID-19 Clear Among Those With Kidney Disease

The researchers combed national registry data from the United Network for Organ Sharing (UNOS) database for waitlisted kidney-only transplant candidates and transplant recipients collected through April 2021.

They reported clinical and demographic factors linked with COVID-19–related deaths in 2020 along with other deaths in 2019 and 2020.

About 11% of the 4774 deaths among waitlisted kidney transplant candidates in 2020 were attributed to COVID-19, and these deaths were more likely among males and those with obesity. About 72% of COVID-19 deaths occurred in Black or Hispanic transplant candidates.  

Meanwhile, about 16% of deaths among kidney transplant recipients in 2020 were due to COVID-19, the study found. These recipients were notably younger and more likely to have obesity and lower education levels. They were also far more likely to belong to racial and ethnic minority groups compared with peers who died of other causes in 2019 and 2020.

The study "confirmed what we suspected: there are clearly racial disparities in COVID-19 and COVID-related mortality in patients with kidney disease," Mohan told Medscape Medical News. "Understanding the source of these disparities is going to be important as we move forward." 

He said lower education levels could also be linked to higher COVID-19–related deaths among patients with kidney disease for several reasons, such as job status.

"You may have less flexibility in terms of being able to work remotely" during the pandemic, such as working as a cashier in a supermarket as opposed to a desk job, so your risk of exposure to...COVID-19 is much higher," he said.

More At-Home Dialysis Would Protect Patients From COVID-19

A nephrologist who wasn't involved in the study said the results confirm what she and her colleagues have noticed in clinical practice. "Our patients are particularly vulnerable to COVID-19," remarked Michal Melamed, MD, MHS, who is a professor of medicine and epidemiology and of population health at Albert Einstein College of Medicine, Montefiore Medical Center in Bronx, New York.

The reasons for the vulnerability are numerous, she told Medscape Medical News. "During lockdown, patients couldn't just stay home because they had to go to dialysis," she said.

"There may be some immune dysfunction that goes along with dialysis and end-stage kidney disease," Melamed continued.

"But one of the biggest messages I see from this particular study is [COVID-19] really seemed to affect...ethnic minorities. I think that has to do with years of structural racism and [the fact that] minorities tend to live more in congregate housing and don't have the ability to self-isolate as much as potentially other people do."

Melamed agreed with Mohan that it's imperative for patients with kidney disease to be vaccinated against COVID-19. The study findings might also sway more patients with end-stage kidney disease to choose vaccination and consider home dialysis, if possible, she added.

"Not everyone is offered home dialysis. Number one, you have to have a home, which unfortunately, some of our patients don't," Melamed said.

"But nephrologists are trying to get more people on home modalities, because some data show, especially with COVID-19, that it may be better for them to stay at home," she added.

Mohan and Melamed also agreed that the study's reliance on national data was one of its primary strengths. But Mohan said the findings might be limited by the "reporting lag" common in UNOS data.

"Our estimate of the mortality rate in these populations is probably lower than it actually is," he added.  

The study received funding from the National Science Foundation. Mohan and Melamed have reported no relevant financial relationships.

Clin J Am Soc Nephrol. Published online September 29, 2021. Abstract

Maureen Salamon is a New Jersey-based freelance medical journalist with credits in The New York Times, The Atlantic,, and other major outlets.

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