The COVID-19 pandemic was quickly recognized as a highly contagious, relatively lethal infection that warranted close attention in patients with end-stage kidney disease (ESKD). This is especially so, since diabetes mellitus and hypertension are both highly prevalent in patients with ESKD and significant risk factors for severe COVID-19 infections. What’s more, since the success of such contagions depends on excessive social contact, the risk of COVID-19 is enhanced in outpatient hemodialysis due to patient travel needs and close quartering at units. My colleagues and I believed early detection could save future infections and even lives through prompt isolation and ED referral.
A COVID-19 Surveillance Program
In early March 2020, the regional dialysis organization Atlantic Dialysis Management Services of New York City (NYC) and Long Island initiated a surveillance program to identify patients on presentation to dialysis units for suspected COVID-19 infection. Screening by staff included signs and symptoms, as well as known unprotected exposure to a person with symptoms or confirmed COVID-19 diagnosis. Suspected patients were isolated, sent for testing, and/or sent to the hospital if symptomatic. Other interventions to limit exposure included masks and distancing in waiting areas. In one unit, situated within a hospital with an overwhelmingly high COVID-19 census, all patients were transferred to close-by satellite dialysis units for 2 months, furthering precautions.
As the pandemic accelerated and we witnessed increasing infections and hospitalizations, the importance of examining how the pandemic was affecting dialysis patients became apparent. Our dialysis units being situated throughout the NYC area—the epicenter during March and April—provided opportune sources for assessing these questions. With that, we collected the surveillance program data, inclusive of demographics, and then reviewed outcomes—infections, hospitalizations, and mortality—in order to investigate associations. Our findings were published in the Journal of the American Society of Nephrology.
ESKD & COVID-19-Related Outcomes
We found that when compared with NYC residents in general, patients with ESKD had a fourfold higher rate of community exposure to COVID-19 infection, with a tendency toward older and minority patients (Table). Areas of the city with higher density had increased infection rates. More than one-half of the COVID-19-positive/symptomatic patients were hospitalized, with a mortality rate of 26.8% that was significantly associated with age and duration of ESKD.
Our findings also underscore the importance of socioeconomic determinants of health, which was exemplified by immigration status, and specifically undocumented status, being more significant risk factors for death than ESKD duration, despite immigrants in our study being relatively young. In general, these populations are associated with lower socioeconomic status and lack of education and health insurance—social determinants of poorer health outcomes. These barriers, in addition to fear of discovery by authorities and loss of work in the undocumented, only compound health disparities. We also found that minorities were less likely to be hospitalized than non-Hispanic white patients, possibly resulting in delayed acute care that could explain the also high mortality rate of 28.9% in those not hospitalized.
Though an urban study, some findings apply elsewhere. A contagious infection needs close quarters and contact to continue, both likely existing in dialysis units regardless of locale. This risk may need to be considered during flu seasons as well, possibly in providing mechanisms of in-center dispersion while patients wait and in local monitoring of flu status. Also, regardless of geography, immigrant populations and those with low socioeconomic status are more likely to have large and extended families living under one roof, increasing their infection risks.
The vulnerability of patients on dialysis exceeds their comorbidities and, as this pandemic has shown, is also dependent on social status and dialysis modality. The fear of social interaction that the pandemic has introduced may lead those patients with means to prefer home dialysis modalities, leading to decreased dependency on large outpatient units. Exploring the relationship between social status and other demographic factors with mortality among COVID-19-positive/symptomatic patients continues to be an important avenue of study that may likely be of benefit for future such disasters and possibly in dialysis safety in general.