key: cord-0709695-38uakfhq
authors: Schold, Jesse D.; King, Kristen L.; Husain, S. Ali; Poggio, Emilio D.; Buccini, Laura D.; Mohan, Sumit
title: COVID‐19 mortality among kidney transplant candidates is strongly associated with social determinants of health
date: 2021-04-08
journal: Am J Transplant
DOI: 10.1111/ajt.16578
sha: 67b8e74fc92ddece42209740e8523ca0671286a8
doc_id: 709695
cord_uid: 38uakfhq

The COVID‐19 pandemic has affected all portions of the global population. However, many factors have been shown to be particularly associated with COVID‐19 mortality including demographic characteristics, behavior, comorbidities, and social conditions. Kidney transplant candidates may be particularly vulnerable to COVID‐19 as many are dialysis‐dependent and have comorbid conditions. We examined factors associated with COVID‐19 mortality among kidney transplant candidates from the National Scientific Registry of Transplant Recipients from March 1 to December 1, 2020. We evaluated crude rates and multivariable incident rate ratios (IRR) of COVID‐19 mortality. There were 131 659 candidates during the study period with 3534 all‐cause deaths and 384 denoted a COVID‐19 cause (5.00/1000 person years). Factors associated with increased COVID‐19 mortality included increased age, males, higher body mass index, and diabetes. In addition, Blacks (IRR = 1.96, 95% C.I.: 1.43–2.69) and Hispanics (IRR = 3.38, 95% C.I.: 2.46–4.66) had higher COVID‐19 mortality relative to Whites. Patients with lower educational attainment, high school or less (IRR = 1.93, 95% C.I.: 1.19–3.12, relative to post‐graduate), Medicaid insurance (IRR = 1.73, 95% C.I.: 1.26–2.39, relative to private), residence in most distressed neighborhoods (fifth quintile IRR = 1.93, 95% C.I.: 1.28–2.90, relative to first quintile), and most urban and most rural had higher adjusted rates of COVID‐19 mortality. Among kidney transplant candidates in the United States, social determinants of health in addition to demographic and clinical factors are significantly associated with COVID‐19 mortality.

AJT SCHOLD et aL. resulting in transmission of COVID-19, the pandemic has disproportionally affected certain populations with known disparities in access to health care in the United States. This includes racial and ethnic minorities and patients with increased social risk factors. [5] [6] [7] [8] Patients with end-stage kidney disease (ESKD) are particularly susceptible to the impact of COVID-19 given increased morbidity and increased need to interact with individuals for health care interventions. Kidney transplant candidates are a select portion of the ESKD population, and factors associated with susceptibility and impact of COVID-19 may be unique from the broader ESKD or general population. There are currently more than 90,000 kidney transplant candidates in the United States. 9 The effect of demographic characteristics, clinical factors, and social risks on risks of COVID-19 mortality in the United States has not been comprehensively investigated. Understanding candidates who are at highest risk for the severe effects of COVID-19 may inform care management, identify interventions tailored to attenuate patient risks, and provide evidence for potential mechanisms for the effects of COVID-19.

There are a number of reports detailing risks of transmission and health consequences of COVID-19 among the dialysis and transplant recipient population. However, most studies are limited to single center or regional reports and detail different periods of the COVID-19

pandemic. [10] [11] [12] [13] The risks identified in prior studies may be unique to select regions or during the initial phase of the pandemic. In this study, our primary aims were to identify rates and independent risk factors for COVID-19 mortality among kidney transplant candidates in the United States over the first 9 months of the pandemic. In particular, our aim was to evaluate factors associated with COVID-19 mortality comprising demographic characteristics, clinical history, and social conditions to describe the broad array of risks in the population. The designation of COVID-19 mortality as a cause of death was implemented by the United Network for Organ Sharing denoted "Infection: Viral -COVID-19" on April 1, 2020. The numeric codes associated with these were 3916 (kidney alone) and 7247 (kidneypancreas). We used the code associated with this cause of death as an indication of COVID-19 death throughout the study. As these codes we used retrospectively as well (in the weeks prior to April 1), and our study period was March 1-December 1, 2020. We used this period with consideration for the initiation of the pandemic and documentation of COVID-19 causes of death and follow-up when COVID-19 cases were consistently reported. We considered patients at risk for COVID-19 mortality from March 1, 2020 for prevalent patients (those on the waiting list on that date) or from the time of candidate listing for those placed on the waiting list during the period. Rates were calculated per 1000 patient year follow-up and compared between groups using two-sample t-tests and ANOVA.

We evaluated independent factors associated with COVID-19 mortality rates using multivariable Poisson models with time at risk for death on the waiting list as an offset variable and reported adjusted incident rate ratios (IRR).

In addition to the SRTR data, we used primary candidate residential zip code information to merge other data sources. We merged data with the distressed community index generated from the Economic Innovation Group. 14 These data include an index (0%-100%) of the level of residential distress by zip code in the United States based on residential education, housing vacancy, employment, poverty, income, and changes in business establishments.

For the purpose of these analyses, we used the measured quintile of the residential zip code of candidates to merge with SRTR data.

Candidates without an available zip code were coded as missing level for the purpose of the analyses. We also merged data from the patient years, p < .01). These associations were largely consistent considering COVID-19 deaths as a proportion of all-cause deaths (Table 1) .

COVID-19 deaths comprised 10.9% of all deaths during the study period and this proportion varied significantly by patient characteristics.

The rate of COVID-19 mortality was significantly higher for non-White candidates and increasing age (p-values <.01). The increased rates by race/ethnic group were consistent in each age group with the highest mortality rates among Hispanics mortality rates were also higher among patients with lower educational attainment in each race/ethnic group. In addition, for both

Blacks and Hispanics, COVID-19 mortality rates increased associated with increasing distress index ( Figure 4 ). However, COVID-19 mortality did not increase among Whites by residential distress

index. There was also a modest "U-shaped" pattern of COVID-19 mortality by rural-urban designation. Patients in the most urban counties (>1 million population) and rural counties had the highest COVID-19 mortality rates relative to candidates in mid-size residential communities. However, this pattern appeared to vary by race/ethnic group ( Figure 5 ). In addition, there was significant variation of COVID-19 mortality rates by UNOS region. As displayed in Figure 6 , COVID-19 mortality rates were highest in region 9, and non-Whites generally had higher rates in each region.

The multivariate incident rate ratios for COVID-19 mortality are displayed in Table 2 There was a substantially higher proportion of deaths with increasing age than the distribution of the population and a higher number of deaths among males. In contrast, among the candidate population, there was a lower relative COVID-19 mortality proportion among

Whites and a higher proportion of deaths among Hispanics relative to the distribution in the population. Increasing age was also associated with increased COVID-19 mortality but not as elevated in older groups as in the general population. Males had a higher relative proportion of deaths which was also evident in the general population. 

The primary findings of the study indicate that in the first 9 months of the pandemic, there were a significant number of deaths at- In summary, the study demonstrated significant rates of

United States. COVID-19 mortality was disproportionally represented in the population and patients who were older, diabetic, higher body mass index, and male were significantly more likely to have a COVID-19 death during the study period. In addition, social determinants of health including education, insurance, residential distress, geographic location, and racial/ethnic background were strongly associated COVID-19 mortality. These social factors in conjunction with clinical factors should be strongly considered for risk assessment and care management in the kidney transplant candidate population.

The authors report no conflict of interest for the study. Government.

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

These data may be made available by the Scientific Registry of Transplant Recipients. 

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COVID-19 mortality among kidney transplant candidates is strongly associated with social determinants of health