key: cord-1021508-3pr2o2ge
authors: Sim, John J.; Huang, Cheng-Wei; Selevan, David C.; Chung, Joanie; Rutkowski, Mark P.; Zhou, Hui
title: COVID-19 and Survival in Maintenance Dialysis
date: 2020-11-24
journal: Kidney Med
DOI: 10.1016/j.xkme.2020.11.005
sha: e0c18777adf414d13475b5b88da28d186a67c35a
doc_id: 1021508
cord_uid: 3pr2o2ge

nan

event occurred or until the end of the observation period (8/10/2020). Information on demographics, medications, laboratory results, co-morbidities, hospitalizations and death within the observation period were extracted from the electronic health records.

Among 7,533 total ESKD patients, 133 (16 peritoneal and 117 hemodialysis) patients were diagnosed with COVID-19 in our observation period. The mean age was 66 years with 38% women, 62% Hispanics, 16% blacks, 11% Asians, and 9% whites (Table   1 ). Overall, 76 (57%) patients required hospitalization with a median length of hospitalization of 10 days. There were 30(23%) patient deaths with a median survival of 16 days. Patients who died were older (68 vs 64) and had more comorbidities including diabetes (93%), heart failure (33%), and ischemic heart disease (57%). Only 2 (7%) of deceased patients were on angiotensin converting enzyme inhibitor (ACEI) compared to 25% among survivors. There appeared to be no differences in mortality by race/ethnicity and socioeconomic status. Inpatient laboratory studies revealed that deceased patients had higher peak levels of lactate dehydrogenase compared to survivors.

We describe the clinical course of all 133 ESKD patients diagnosed with COVID-19 within a large integrated health system. The majority (57%) required hospitalization.

The 23% mortality in our ESKD cohort is significantly greater than 1.3% within KPSC, 1.8% in California, and the 3-4% mortality reported from the Center for Disease Control and the Who Health Organization for people diagnosed COVID-19. The dialysis population is more likely to be identified with COVID-19 given the frequency of screening and care they receive at health facilities as they have low threshold for screening and testing. Tests were routinely performed based on clinical presentation (fever, symptoms) or history of exposure. Beginning early March 2020, individual J o u r n a l P r e -p r o o f dialysis units throughout California instituted strict policies and procedures to screen for SARS COV2 infection to protect patients and personnel throughout these dialysis centers.

Among our COVID-19 ESKD patient population, there appeared to be a greater proportion of Hispanics (62 vs 38%) and lesser proportion of blacks (16 vs 23%) and non-Hispanic whites (9 vs 28%) compared to the overall KPSC ESKD population 9 . The 12% peritoneal dialysis patients with COVID-19 was lower than the 20% prevalent home dialysis/peritoneal dialysis population at KPSC. We observed no apparent differences in survival based on race/ethnicity or socioeconomic status. Patients who died were older and had more comorbidities; specifically, heart failure, ischemic heart disease, and diabetes. Our findings are comparable to a French National ESKD cohort with an overall 21% mortality 3 . Previous observations among hospitalized ESKD patients with COVID-19 have observed mortality rates 30% or higher reported in relatively homogeneous populations 4, 5 .

Strengths of our study include our observation period of >/=30 days to fully capture ESKD patient's clinical course. Information was drawn from a single integrated system which tracks this population using a comprehensive internal registry and thus was able to reliably capture all hospitalizations and deaths. Limitations include the fact that we cannot fully determine that deaths were due to COVID-19 nor whether patients opted for palliative/hospice. The reported death rate while high is an aggregate over a 3-month period. It does not reflect changing rates of mortality which may occur with the evolving care of COVID-19 including more aggressive oxygenation support, screening and monitoring for cytokine storm syndrome, earlier use of steroids, immunosuppression, 

Hemoglobin 10.8 (9.7-11.7) 57 10.5 (9.4-11.6) 76 11.1 (9.9-11.7) 103 10.8 (9.6-11.8) 30 10.7 (9.8-11.4) 0.18 

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

US Renal Data System 2016 Annual Data Report: Epidemiology of Kidney Disease in the United States

*For inpatient laboratory values, we used the highest levels during the hospitalization to capture patients who may have met criteria for cytokine storm syndrome