In April 2020, at the height of the COVID-19 pandemic in the United States, the number of patients initiating treatment for kidney failure dropped approximately 30% compared with before the pandemic, according to new study findings. Racial and ethnic minorities and low income patients particularly experienced declines in necessary care.

“Improving access to care and reducing disparities for people with kidney disease are national priorities, but our findings suggest that the early months of the COVID-19 pandemic were associated with lower rates of treatment initiation for this high-risk population with social risk factors,” Kevin H. Nguyen, PhD, of Brown University School of Public Health in Providence, Rhode Island, and colleagues stated in JAMA Network Open.

The study was based on data from 127,149 patients with incident kidney failure who completed the Renal Management Information System Medical Evidence Form, a national census of all patients with incident kidney failure who start long-term dialysis or undergo preemptive kidney transplantation.

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From 2018-2019 to the height of the COVID-19 pandemic in March to June 2020, the proportion of patients undergoing preemptive kidney transplantation declined from 2.1% to 1.4%, and the proportion of individuals starting hemodialysis with an arteriovenous fistula declined from 15.8% to 13.4%. Use of home dialysis increased from 12.1% to 14.4%. All of these changes were statistically significant.

The mean estimated glomerular filtration rate (eGFR) at treatment initiation significantly declined from 9.6 to 9.5 mL/min/1.73 m2 from the pre- to early pandemic periods. These declines only occurred in socially disadvantaged groups. In Black patients, mean eGFR significantly declined from 8.4 to 8.1 mL/min/1.73 m2, and significantly more Black patients initiated treatment at an eGFR less than 5 mL/min/1.73 m2 (20.4% vs 23.6%). No significant changes in mean eGFR were observed for White or Hispanic patients. The investigators calculated eGFR using a modified Chronic Kidney Disease Epidemiology Collaboration formula excluding the race adjustment. Lower proportions of Black and Hispanic than White patients received predialysis nephrology care both before and during the pandemic.

There were significant decreases in eGFR among patients across all quintiles of neighborhood disadvantage. Among residents of counties with the highest quintile of COVID-19 mortality, mean eGFR at treatment initiation significantly declined from 9.5 to 9.2 mL/min/1.73 m2.

“Although the number of incident patients rebounded during the study period, the number of patients with incident kidney failure still did not reach the estimated level based on historical trends even during the third and fourth months of the pandemic,” Dr Nguyen’s team wrote.

They suggested several possible contributors to reduced treatment initiation, including limited appointment availability, fear of infection, shared patient-provider decisions to defer treatment initiation, and financial barriers to accessing care.

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Nguyen KH, Thorsness R, Hayes S, et al. Evaluation of racial, ethnic, and socioeconomic disparities in initiation of kidney failure treatment during the first 4 months of the COVID-19 pandemic. JAMA Netw Open. Published online October 7, 2021. doi:10.1001/jamanetworkopen.2021.27369