ESKD increases risk for mortality among patients hospitalized with COVID-19
Among patients with COVID-19 treated at 13 New York hospitals, those with end-stage kidney disease had a higher rate of death compared with those without ESKD, according to a study published in Kidney International.
Black patients with ESKD in the study had a lower risk for in-hospital death than their white counterparts.
“Patients on dialysis have long been known to have a greatly increased risk [for] death compared to the general population,” Jia H. Ng, MD, a member of the Nephrology COVID-19 Research Consortium at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, and colleagues wrote. “The rates of DM [diabetes mellitus], heart disease, vascular disease and other conditions are substantially greater than in the non-dialysis population. Because of this, our finding of a significantly increased risk [for] in-hospital mortality among ESKD patients with COVID-19 compared to non-dialysis patients would appear to be intuitive.
“However, adjusting for comorbidities did not meaningfully change the greater risk observed in the ESKD cohort,” the researchers wrote. “This suggests that other unmeasured characteristics of the ESKD patients accounted for the increased risk, which may be related to host response to infection.”
Ng and colleagues suggested the increased risk for infections likely is related to a dysregulated immune system, “as the uremic milieu has been associated with disturbances in both innate as well as adaptive immunity,” they wrote.
The researchers looked at 10,482 patients with COVID-19 admitted to 13 hospitals in New York from March 1 to April 27. The group included 419 patients with ESKD, the majority of whom (97.4%) were on hemodialysis.
“(COVID-19) has resulted in a large number of hospitalizations and ICU admissions, with now well-described pulmonary, cardiac, vascular and renal complications,” the researchers wrote. “Understanding the outcomes of COVID-19-infected patients with and without ESKD is important because this information would help risk-stratify patients with ESKD to certain therapies for COVID-19 as they arrive at the hospital.”
Patients with ESKD tended to be older and have more comorbid conditions than those without ESKD, and a greater proportion of patients with vs. without ESKD identified as Black (36.3% vs. 19.8%).
In-hospital death served as the study’s primary outcome, with mechanical ventilation and length of stay as secondary outcomes.
The researchers found that patients with ESKD had a significantly higher rate of in-hospital death than those without ESKD (31.7% vs. 25.4%), even after adjusting for demographic and comorbid conditions.
“The odds of length of stay of seven or more days was higher in the group with ESKD compared to the group without ESKD in both the crude and adjusted analysis. There was no difference in the odds of mechanical ventilation between the groups,” researchers wrote.
The researchers speculated that Black race was associated with a significantly reduced risk for death among the hospitalized patients with COVID-19 and ESKD because Black patients have better survival while on dialysis compared with white patients.
“This inherent survival advantage may partly explain our finding of improved hospital survival of Black ESKD patients with COVID-19,” they wrote. “Dialysis dosing, nutritional factors with higher BMI as a protective mechanism, and racial differences in inflammatory responses are some possible hypotheses that may confer the racial difference in improved dialysis survival. Any racial differences in inflammatory or coagulation parameters could be highly relevant in COVID-19 disease.”