key: cord-0872968-w27smhke
authors: Perez, Aubriana; Retzloff, Samantha; Browne, Teri; Cruz, Alexandra; Wright, Shannon; Pastan, Stephen O.; Patzer, Rachel E.
title: Dialysis staff-reported impact of COVID-19 on early kidney transplant steps
date: 2022-01-07
journal: Kidney Int Rep
DOI: 10.1016/j.ekir.2022.01.007
sha: c54c14607f07b943e70fb27d11f78d27fb73e5d4
doc_id: 872968
cord_uid: w27smhke

nan

COVID-19 has influenced multiple aspects of kidney transplantation, the preferred treatment for the majority of patients with end-stage kidney disease (ESKD). Patients with ESKD and transplant recipients are vulnerable to severe COVID-19 illness given the high prevalence of comorbidities and immunosuppression in these populations. 1 Vast disruptions to kidney transplant operations were reported early in the pandemic, with 72% of US transplant centers reporting temporary suspension of living donor kidney transplant (LDKT) activity and 84% of centers reporting some or major restrictions to deceased donor kidney transplants (DDKT) in a national survey in March 2020. 2, 3 Further, analyses of Scientific Registry of Transplant Recipients data from March-April 2020 revealed considerable declines in waitlist registrations and expected kidney transplant rates, in addition to higher rates of inactivation on the kidney transplant waiting list. 4 Notably, states with higher per capita confirmed COVID-19 cases witnessed greater declines in waitlist registrations and DDKT rates. 4 Although rates of DDKT had recovered to pre-pandemic estimates by June 2020, a sustained decrease in LDKT volume was observed. 5, 6 Moreover, the impact of this initial delay on patients upstream in the kidney transplant process remain unknown.

For patients with ESKD pursuing kidney transplantation, there is a complex multi-step and multi-system process between ESKD diagnosis and receipt of a kidney transplant. Dialysis facilities are instrumental in facilitating timely access to kidney transplantation, particularly in earlier stages of the transplant process. 7 Critical steps in the transplant process occur in dialysis settings, including transplant education and referral for transplant evaluation. Changes in rates of kidney transplant referrals and evaluations due to COVID-19 are difficult to observe, largely due to the lack of national data collection on these steps. While the impact of COVID-19 on kidney transplantation appears to be significant for transplant centers, the effects of the pandemic on transplant steps occurring at the dialysis facility level are unknown.

Despite the Southeastern United States, including Georgia, North Carolina, and South Carolina, having some of the highest rates of ESKD nationally, rates of kidney transplantation in the Southeast remain lower than the national average. 8 Early in the COVID-19 pandemic, transplant centers in the Southeast responded by restricting or halting organ transplant activities, especially for living donor transplantation. 3 It is unknown whether resulting delays in access to early steps in the kidney transplant process will exacerbate existing disparities in care, especially coupled with lower rates of COVID-19 vaccination in the Southeast. 9 Widespread delays in overall healthcare access in the Southeast region have been previously documented, with one survey describing ~40% of respondents having missed or delayed an appointment since March 2020. S1 Greater perception of personal risk of COVID-19 diagnosis and mortality was associated with missed appointments, which will likely continue to play a role in disruption of care as more transmissible variants emerge throughout the US.

Understanding how dialysis centers shifted their transplant referrals during the early pandemic will inform our knowledge of the extent to which kidney transplant care was similarly interrupted at this time. We analyzed cross-sectional survey data to determine the early impact of the COVID-19 pandemic on kidney transplant access from a dialysis facility perspective in the Southeast, including Georgia, North Carolina, and South Carolina. As the impact of COVID-19 on kidney transplantation rates persists beyond the early stages of the pandemic 3,S2 and the United States experiences a resurgence in COVID-19 in late 2021, S3 these findings can also be helpful as we move forward to help maximize kidney transplantation rates despite the pandemic's lasting impact. Tables 1 and 2 ).

Our findings provide evidence that kidney transplantation has been substantially affected by the COVID-19 pandemic, even upstream in the transplant process at the dialysis facility level.

We report that ~30% of dialysis facilities experienced disruptions in referrals to transplant centers and ~60% of dialysis facilities reported that transplant evaluations were impacted by COVID-19 in three Southeastern states, where kidney transplant rates remain among the lowest in the nation. 8 While other studies have reported the impact of COVID-19 on transplant rates, 4 transplant outcomes, 6, S8-S11 and transplant center organ procurement and patient management practices, S10,S12 the extent to which dialysis facilities have changed referral practices has not been reported. Dialysis staff-reported barriers, and specifically "dependent institution not operating as usual," align with disruptions documented among kidney transplant programs during this time. S13

Results from a survey among living kidney donor transplant programs in the US showed that 66% of surveyed programs placed their surgeries on hold in the early stages of the pandemic. S14

Barriers to surgeries such as concerns for patient safety, restrictions on elective surgeries, and hospital administrative restrictions were also reported. S15 These results may have a long-lasting impact on patient access to transplantation.

Patients with ESKD comprise an especially vulnerable patient population in the COVID-19 pandemic. Our results confirm a high prevalence of underlying conditions that predispose patients to likelihood of severe COVID-19 illness. S14 Furthermore, COVID-19 has revealed the J o u r n a l P r e -p r o o f vast disparities in healthcare access and outcomes between Black populations and other racial/ethnic populations throughout the US. Even after adjustment for age, poverty, comorbidities, and epidemic duration, counties with higher proportions of Black residents (third versus first quartile of percent of Black residents) experienced 24% higher rates of COVID-19 diagnoses. S15 Additionally, Black race has been independently associated with higher rates of hospital admissions during the pandemic, with Black patients having nearly twice the odds of hospitalization for COVID-19 compared to white patients, after adjustment for clinical and socioeconomic variables. S16 Policies surrounding transitions to normal operations among dialysis facilities must take into account the potential for disproportionately poor outcomes among the Black ESKD population, as well as the long-term implications of these disruptions for transplant access.

This study is not without limitations, including a moderate response rate and a small sample size. In addition, staff-reported disruptions to transplant activities may not be reflective of trends in actual kidney transplant referrals and evaluations in the early COVID-19 pandemic.

We were also unable to compare results to regional transplant center closures and capacities. A final limitation is that this study occurred early in the COVID-19 pandemic. However, as COVID-19 cases and hospitalizations rise again in late 2021 in the United States, our findings remain relevant as the impact of the pandemic on kidney transplantation will persist (or new pandemics may occur) and dialysis centers will continue to play an important role in helping patients get transplants.

All authors declared no competing interests.

J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f Other 13 (4.6) *One respondent per facility from 280 facilities.

COVID-19 in patients with kidney disease

Early impact of COVID-19 on transplant center practices and policies in the United States

Navigating the COVID-19 pandemic: Initial impacts and responses of the Organ Procurement and Transplantation Network in the United States

Early national and center-level changes to kidney transplantation in the United States during COVID-19 epidemic

Practicing With Uncertainty: Kidney Transplantation During the COVID-19 Pandemic

Trends in US Kidney Transplantation During the COVID-19 Pandemic. Cureus

Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States

USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases

Changes in COVID-19 vaccination receipt and intention to vaccinate by socioeconomic characteristics and geographic area