End-stage kidney disease (ESKD) incidence in the United States declined 20% during weeks 12 to 19 of 2020 — when the COVID-19 pandemic was in its early stage — compared with the same period in 2017-2019, according to the US Renal Data System (USRDS).
In a COVID-19 supplement to its 2020 annual data report, USRDS called a disruption of this magnitude in ESKD incidence “unprecedented” in the United States.
“The impact of this disruption is impossible to fully understand, given available data,” the supplement states. “It is possible that mortality in patients with advanced CKD increased, thus resulting in a smaller number of survivors who needed to initiate kidney replacement therapy each week. It is also possible that nephrology providers and patients decided to defer dialysis initiation, thus creating an [ESKD] incidence backlog that will be realized later in 2020; as a result of deferral, some patients may choose to permanently select conservative care.”
Major dialysis providers in the United States confirm the decrease in dialysis starts early in the pandemic.
“We noticed a decline in patients starting dialysis between March and May of 2020, similar to the 2020 USRDS published data,” Jeff Giullian, MD, Chief Medical Officer for DaVita Kidney Care, told Renal & Urology News. “Initiating dialysis is a serious decision between patients and their physician. Our hypothesis is that patients may have been waiting to speak with their physician in person. This is in line with what was reported generally in the healthcare system at that time — outside of COVID-19, utilization temporarily decreased. However, patients with chronic kidney disease experience declining kidney function as time goes on, likely attributing to the rebound we saw in patients starting treatment later in 2020.”
Jeffrey Hymes, MD, Executive Vice President, Global Head of Clinical Affairs, and Chief Medical Officer for Fresenius Kidney Care, noted that his company “observed concerning changes in referral patterns for dialysis at the start of the pandemic.” These changes were likely a result of delays in patients seeking routine care, including visits to their primary care physician or nephrologist. The changes in referral patterns also extended to home dialysis as a result of the challenges many patients faced with access to surgery for a catheter or fistula placement, he said.
“At the same time,” Dr Hymes said, “we observed a higher-than-normal incidence of acute kidney injury and increased need for critical kidney disease care as a result of the impact of COVID-19. We have found that as the year progressed and physicians became more comfortable with treating patients during the pandemic, including virtually, referral patterns recovered.”
The COVID-19 supplement also summarized other effects of the pandemic on patients undergoing dialysis, including hospitalizations. Among Medicare beneficiaries undergoing dialysis, more than 11,200 COVID-19 hospitalizations occurred during the first half of 2020, with a peak of nearly 1300 during week 13 (April 5 to 11). This resulted in a peak rate of 4.2 COVID-19 hospitalizations per 1000 patients per week.
The rate of COVID-19 hospitalizations among patients undergoing hemodialysis was generally between 3 and 4 times higher than among patients performing peritoneal dialysis, according to USRDS.
Moreover, all-cause mortality among all patients receiving dialysis in 2020 was 37% higher during weeks 14-17 and 16% higher during weeks 18-27 compared with the same period in 2017-2019. For patients with a functioning kidney transplant, corresponding estimates of excess mortality were 61% and 26%, respectively.
Hospitalizations for reasons unrelated to COVID-19 were 33% less frequent among Medicare beneficiaries undergoing dialysis during weeks 14-17 of 2020 compared with the same period in 2017-2019, according to USRDS. Rates of hospitalization for myocardial infarction and heart failure were 24% and 30% lower, respectively. “Possibly, patients on dialysis were either unable or unwilling to access necessary acute care, resulting in further complications, including death,” the COVID-19 supplement stated.
United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. COVID-19 supplement.