The COVID-19 supplement of the 2020 US Renal Data System 2020 Annual Data Report provides important insights into dialysis and chronic kidney disease (CKD) during the COVID-19 pandemic. Key findings include 11,200 COVID-19 hospitalizations among Medicare beneficiaries during the first half of 2020, with the rate of COVID-19 hospitalizations being 3-4 times higher in hemodialysis compared with peritoneal dialysis patients. All-cause mortality was 37% higher during weeks 14-17 of 2020. A particularly important finding was a 20% decline in incident end-stage kidney disease (ESKD) cases, defined as dialysis initiations and preemptive kidney transplantations, during weeks 12-19 of 2020 compared with the corresponding period during 2017-2019.
What could explain a decline in new dialysis starts? Did more patients die at home without receiving dialysis, or perhaps opt for conservative therapy with the possibility of choosing dialysis at a later time point? Or did a decreased frequency of clinic visits result in delayed estimated glomerular filtration rate (eGFR) determinations and a later start of dialysis?
As we attempt to explain the drop in dialysis initiation early in the pandemic, we might consider the possibility that the decline occurred in mildly symptomatic or asymptomatic patients who were not started on dialysis due to lack of eGFR determinations early in the pandemic. Examination of the age groups in which the decline occurred may help to zero in on the cause. It also is important to determine if patients started dialysis at a lower eGFR during this period and how this affected patient survival.
Although early dialysis initiation was not found to be beneficial in the IDEAL study1 published in 2010, nephrologists have likely been slow to adapt these findings to clinical practice, with results from the
USRDS in 2018 showing a median eGFR of 9.2 mL/min/1.73 m2 at the start of dialysis, being only marginally lower than in 2013 at 9.4 mL/min/1.73 m2. A recent propensity score weighted analysis2 of USRDS data revealed a higher mortality risk for patients starting dialysis at higher eGFR values. These investigations suggest that some patients
with late-stage CKD may be starting dialysis too soon.
The COVID-19 pandemic has touched each of us in our personal and professional lives. We have sadly seen many of our patients die from this terrible illness. We have also adapted with telehealth visits, decreased office visits, and decreased laboratory determinations. The effects of these practices could affect our patients and our practices for
months and years to come.
- Cooper BA, Branley P, Bulfone L, et al. A randomized controlled trial of early versus late initiation of
dialysis. N Engl J Med. 2010; 363:609-619.
- Bozorgmehri S, Aboud H, Chamarthi G, et al. Association of early initiation of dialysis with all-cause
and cardiovascular mortality: A propensity score weighted analysis of the United States Renal Data
System. Hemodial Int. 2021;25:188-197.