COVID-19 in patients undergoing long-term dialysis in Ontario

Effectiveness of Molnupiravir and Nirmatrelvir-Ritonavir in CKD Patients With COVID-19

Introduction

Even with effective vaccines, patients with CKD have a higher risk of hospitalization and death subsequent to COVID-19 infection than those without CKD. Molnupiravir and nirmatrelvir-ritonavir have been approved for emergency use, but their effectiveness for the CKD population is still unknown. This study was conducted to determine the effectiveness of these drugs in reducing mortality and severe COVID-19 in the CKD population.

Methods

This was a target trial emulation study using electronic health databases in Hong Kong. Patients with CKD aged 18 years or older who were hospitalized with COVID-19 were included. The per-protocol average treatment effect among COVID-19 oral antiviral initiators, including all-cause mortality, intensive care unit (ICU) admission, and ventilatory support within 28 days, were compared to noninitiators.

Results

Antivirals have been found to lower the risk of all-cause mortality, with Molnupiravir at a hazard ratio (HR) of 0.85 (95% confidence interval [CI], 0.77 to 0.95] and nirmatrelvir-ritonavir at an HR of 0.78 [95% CI, 0.60 to 1.00]. However, they do not significantly reduce the risk of ICU admission (molnupiravir: HR, 0.88 [95% CI, 0.59 to 1.30]; nirmatrelvir-ritonavir: HR, 0.86 [95% CI, 0.56 to 1.32]) or ventilatory support (molnupiravir: HR, 1.00 [95% CI, 0.76 to 1.33]; nirmatrelvir-ritonavir: HR, 1.01 [95% CI, 0.74 to 1.37]). There was a greater risk reduction in males and those with higher Charlson Comorbidity Index (CCI). The nirmatrelvir-ritonavir trial also showed reduced risk for those who had antiviral treatment and received 3 or more vaccine doses.

Conclusion

Both molnupiravir and nirmatrelvir-ritonavir reduced mortality rates for hospitalized COVID-19 patients with CKD.

S. J, Balasubramanian CM, Devaraju PK, Murugesan V, P. S, Lamech TM, Arumugam V, Gopalakrishnan N. SARS-CoV-2 Antibody Seroprevalence and Humoral Response to Vaccination in Patients Undergoing Maintenance Hemodialysis: A Prospective Cohort Study

Introduction

COVID-19, caused by SARS-CoV-2, has resulted in significant mortality and morbidity worldwide. Patients of chronic kidney disease who are on maintenance hemodialysis represent a vulnerable population cohort that is susceptible to severe disease. Hence, it is of utmost importance to prioritize vaccination in this population and to assess their response to said vaccination.

Methods

This prospective analytical study was conducted at the Institute of Nephrology, Madras Medical College, between August 2021 and February 2022. Patients of chronic kidney disease stage 5 dialysis (CKD5D) who were on maintenance hemodialysis and who consented to receive COVID-19 vaccine were studied. Serum samples were obtained before vaccination, ≥28 days after receiving the first dose of the vaccine, and ≥28 days after receiving the second dose. Antibody titers against the spike protein were estimated using the Roche chemiluminescent immunosorbent assay. Patients were grouped into non-responders/seronegative (<0.8 U/ml) and responders/seropositive (≥0.8 U/ml), with a value ≥250 U/ml considered as robust response.

Results

A total of 96 patients were included. The mean age was 36.70 (±11.53) years and 77.1% of them were male. The median dialysis vintage was 2 (IQR: 0.95-5) years. Twelve patients (9.9%) had a prior COVID-19 infection. Sixty-seven (69.8%) patients had received Covaxin and 29 (30.2%) had received Covishield vaccines. Among the 17 patients who were seronegative at baseline, 4 (23.52%) became seropositive after the first dose of the vaccine, and 11 (64.7%) were seropositive after the second dose, with high titers ("robust response") achieved in two patients (11.76%). No antibody response, despite two doses of the vaccine, was noted in six patients (35.29%).

Conclusion

Our study showed a high baseline seropositivity rate, even prior to vaccination, which indicated a high rate of subclinical COVID infection. Among those who were seronegative at baseline, the seroconversion rate after two doses of Covaxin or Covishield was 64.70%.

A pilot study on Paxlovid therapy for hemodialysis patients with severe acute respiratory syndrome coronavirus 2 infections

We aimed to investigate the safety and efficacy of nirmatrelvir/ritonavir (Paxlovid) therapy for hemodialysis-dependent patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Thirteen hemodialysis patients infected with the Omicron variant of SARS-CoV-2 from April 3 to May 30, 2022, were recruited. Laboratory parameters and chest CT (computed tomography) imaging were analyzed. The treatment group included six patients who received 150 mg/100 mg of Paxlovid orally once daily for 5 days, whereas the control group included seven patients who received basic treatment. No serious adverse reactions or safety events were recorded. Four control patients progressed to moderate disease, and none in the treatment group showed progression of chest CT findings (P < 0.05). Paxlovid therapy tended toward early viral clearance and low viral load on Day 8. Moreover, 83.3% of the patients in the treatment group and 57.1% of the patients in the control group turned negative within 22 days. In the Paxlovid treatment group, we found significantly increased levels of lymphocytes (P=0.03) and eosinophils (P=0.02) and decreased levels of D-dimer on Day 8 compared with those on Day 1. Paxlovid therapy showed a potential therapeutic effect with good tolerance in hemodialysis patients. The optimal dose and effectiveness evaluation must be further investigated in a largeer cohort.

BNT162b2 versus mRNA-1273 Third Dose COVID-19 Vaccine in Patients with CKD and Maintenance Dialysis Patients

BACKGROUND

There is a lack of randomized controlled trial data regarding differences in immunogenicity of varying coronavirus disease 2019 (COVID-19) mRNA vaccine regimens in CKD populations.

METHODS

We conducted a randomized controlled trial at three kidney centers in Toronto, Ontario, Canada, evaluating the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody response after third dose vaccination. Participants ( n =273) with CKD not on dialysis or receiving dialysis were randomized 1:1 to third dose 30- µ g BNT162b2 (Pfizer-BioNTech) or 100- µ g mRNA-1273 (Moderna). The primary outcome of this study was SARS-CoV-2 IgG-binding antibodies to the receptor-binding domain (anti-RBD). Spike protein (antispike), nucleocapsid protein, and vaccine reactogenicity were also evaluated. Serology was measured before third dose and 1, 3, and 6 months after third dose. A subset of participants ( n =100) were randomly selected to assess viral pseudovirus neutralization against wild-type D614G, B.1.617.2 (Delta), and B.1.1.529 (Omicron BA.1).

RESULTS

Among 273 participants randomized, 94% were receiving maintenance dialysis and 59% received BNT162b2 for initial two dose COVID-19 vaccination. Third dose of mRNA-1273 was associated with higher mean anti-RBD levels (1871 binding antibody units [BAU]/ml; 95% confidence interval [CI], 829 to 2988) over a 6-month period in comparison with third dose BNT162b2 (1332 BAU/ml; 95% CI, 367 to 2402) with a difference of 539 BAU/ml (95% CI, 139 to 910; P = 0.009). Neither antispike levels nor neutralizing antibodies to wild-type, Delta, and Omicron BA.1 pseudoviruses were statistically different. COVID-19 infection occurred in 10% of participants: 15 (11%) receiving mRNA-1273 and 11 (8%) receiving BNT162b2. Third dose BNT162b2 was not associated with a significant different risk for COVID-19 in comparison with mRNA-1273 (hazard ratio, 0.78; 95% CI, 0.27 to 2.2; P = 0.63).

CONCLUSIONS

In patients with CKD, third dose COVID-19 mRNA vaccination with mRNA-1273 elicited higher SARS-CoV-2 anti-RBD levels in comparison with BNT162b2 over a 6-month period.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

COVID-19 Vaccine Boosters in Patients With CKD (BOOST KIDNEY), NCT05022329 .

Assessment of humoral immune response to different COVID-19 vaccines in patients undergoing maintenance hemodialysis

INTRODUCTION

The immune response to different Coronavirus Disease 2019 (COVID-19) vaccines is under-investigated in end-stage kidney disease (ESKD) patients, especially in the Middle East and North Africa. We carried out this research to estimate the effectiveness of COVID-19 immunization in ESKD patients on regular hemodialysis (HD).

METHODS

In this prospective observational study, we enrolled 60 ESKD patients on regular HD who had completed COVID-19 vaccination and 30 vaccinated healthy participants. Serum levels of severe acute respiratory syndrome coronavirus 2 immunoglobulin G (SARS-COV2 IgG) were quantified 1 month after completing the vaccination schedule, and all participants were followed up from October 2021 to March 2022. The vaccines used in the study were from Pfizer-BioNTech, AstraZeneca, and Sinopharm.

RESULTS

The median level of SARS-COV2 IgG was lower in HD patients than in healthy participants (p < 0.001). Regarding the type of COVID-19 vaccination, there was no statistical difference in SARS-COV2 IgG levels among HD patients. During the observation period, none of the HD patients had COVID-19.

CONCLUSION

COVID-19 vaccination appeared to be protective in HD patients for 6 months and the side effects of vaccines were tolerable.

Omicron variant neutralizing antibodies following BNT162b2 BA.4/5 versus mRNA-1273 BA.1 bivalent vaccination in patients with end-stage kidney disease

Neutralization of Omicron subvariants by different bivalent vaccines has not been well evaluated. This study characterizes neutralization against Omicron subvariants in 98 individuals on dialysis or with a kidney transplant receiving the BNT162b2 (BA.4/BA.5) or mRNA-1273 (BA.1) bivalent COVID-19 vaccine. Neutralization against Omicron BA.1, BA.5, BQ.1.1, and XBB.1.5 increased by 8-fold one month following bivalent vaccination. In comparison to wild-type (D614G), neutralizing antibodies against Omicron-specific variants were 7.3-fold lower against BA.1, 8.3-fold lower against BA.5, 45.8-fold lower against BQ.1.1, and 48.2-fold lower against XBB.1.5. Viral neutralization was not significantly different by bivalent vaccine type for wild-type (D614G) (P = 0.48), BA.1 (P = 0.21), BA.5 (P = 0.07), BQ.1.1 (P = 0.10), nor XBB.1.5 (P = 0.10). Hybrid immunity conferred higher neutralizing antibodies against all Omicron subvariants. This study provides evidence that BNT162b2 (BA.4/BA.5) and mRNA-1273 (BA.1) induce similar neutralization against Omicron subvariants, even when antigenically divergent from the circulating variant.

COVID-19 vaccine in hemodialysis patients: Time for a boost

OBJECTIVES

To evaluate anti-spike immunoglobulin G (IgG) antibody levels of hemodialysis patients and correlate them with the patients' demographic data and to evaluate these patients' need for a coronavirus disease-19 (COVID-19) vaccine booster.

METHODS

A cross-sectional multi-center study carried out at King Abdulaziz Kidney Center, Hasan Tahir Hemodialysis Center, and Hayat Organization Hemodialysis Center in Al-Madinah Al-Munawarah, Saudi Arabia. Patients (n=167) who received a minimum single dose of COVID-19 vaccine were recruited. The samples were collected between March 2022 and January 2023. Anti-spike IgG antibody levels were measured using enzyme-linked immunosorbent assays.

RESULTS

A significantly higher proportion of patients who received 3 doses of COVID-19 vaccine had positive serostatus compared with patients who received one or 2 doses (3 doses: 87.2%, one dose: 0.0%, 2 doses: 77.3%; p=0.000). Compared with patients who received one dose, significantly higher IgG antibody levels were detected in patients who received 2 (p=0.013) and 3 doses (p=0.025; n=35). In contrast, there was no significant difference in IgG antibody levels between patients who received 2 or 3 doses (p=0.45). Significant IgG antibody levels were detected in patients who received 2 and 3 doses (p=0.0125) compared with those received one vaccine dose (p=0.0004). Furthermore, patients who received 3 doses had significantly higher IgG antibody levels than patients who received 2 doses (p=0.000).

CONCLUSION

The results show a dose-dependent association between IgG antibody levels and the number COVID-19 vaccines received. The study highlights the need for booster COVID-19 vaccination for patients on hemodialysis.

Effects of SARS-CoV-2 vaccination on the severity of COVID-19 infection in patients on chronic dialysis

BACKGROUND

COVID-19 is associated with increased morbidity and mortality in patients with end-stage kidney disease on dialysis. Efficacy of SARS-CoV-2 vaccination to prevent severe COVID-19 disease in end-stage kidney disease patients remains limited. We compared the incidence of COVID-19-related hospitalization and death in dialysis patients based on SARS-CoV-2 vaccine status.

METHODS

Retrospective study of adults on chronic dialysis within Mayo Clinic Dialysis System in the Midwest (USA) between April 1st, 2020 and October 31st, 2022, who had a laboratory test positive for SARS-CoV-2 by PCR. Incidence of both COVID-19-related hospitalization and death were compared between vaccinated and unvaccinated patients.

RESULTS

SARS-CoV-2 infection was identified in 309 patients, including 183 vaccinated and 126 unvaccinated. The incidence of death (11.1% vs 3.8%, p = 0.02) and hospitalization (55.6% vs 23.5%, p < 0.001) was significantly higher in unvaccinated compared to vaccinated patients. Age at infection, sex, Charlson comorbidity index, dialysis modality, and hospital stays did not differ between the two groups. The incidence of hospitalization was significantly higher in partially vaccinated (63.6% vs 20.9%, p = 0.004) and unboosted (32% vs 16.4%, p = 0.04) patients compared to fully vaccinated and boosted, respectively. Among the 21 patients who died in the whole cohort, 47.6% (n = 10) died during the pre-vaccine period. The composite risk of death or hospitalization was lower among vaccinated patients after adjusting for age, sex and Charlson comorbidity index (OR 0.24, 95% CI 0.15-0.40).

CONCLUSIONS

This study supports the use of SARS-CoV-2 vaccination to improve COVID-19 outcomes in patients on chronic dialysis.

Nephrologists' perspectives on the impact of COVID-19 on caring for patients undergoing dialysis in Latin America: a qualitative study

OBJECTIVE

To describe the experiences of nephrologists on caring for patients undergoing in-centre haemodialysis during the COVID-19 pandemic in Latin America.

DESIGN

Twenty-five semistructured interviews were conducted by Zoom videoconference in English and Spanish languages during 2020 until data saturation. Using thematic analysis, we conducted line-by-line coding to inductively identify themes.

SETTING

25 centres across nine countries in Latin America.

PARTICIPANTS

Nephrologists (17 male and 8 female) were purposively sampled to include diverse demographic characteristics and clinical experience.

RESULTS

We identified five themes: shock and immediate mobilisation for preparedness (overwhelmed and distressed, expanding responsibilities to manage COVID-19 infection and united for workforce resilience); personal vulnerability (being infected with COVID-19 and fear of transmitting COVID-19 to family); infrastructural susceptibility of dialysis units (lacking resources and facilities for quarantine, struggling to prevent cross-contamination, and depletion of personal protective equipment and cleaning supplies); helplessness and moral distress (being forced to ration life-sustaining equipment and care, being concerned about delayed and shortened dialysis sessions, patient hesitancy to attend to dialysis sessions, being grieved by socioeconomic disparities, deterioration of patients with COVID-19, harms of isolation and inability to provide kidney replacement therapy); and fostering innovative delivery of care (expanding use of telehealth, increasing uptake of PD and shifting focus on preventing syndemics).

CONCLUSION

Nephrologists felt personally and professionally vulnerable and reported feeling helpless and morally distressed because they doubted their capacity to provide safe care for patients undergoing dialysis. Better availability and mobilisation of resources and capacities to adapt models of care, including telehealth and home-based dialysis, are urgently needed.

Factors Related to Quality of Life of Hemodialysis Patients during the COVID-19 Pandemic

Taiwan had the second highest number globally of end-stage renal disease patients undergoing treatment in 2018. A meta-analysis of Chen et al. (2021) showed the incidence and mortality rates of COVID-19 were 7.7% and 22.4%, respectively. Few studies have explored the effects of patients' self-participation and perceptions of hemodialysis on their quality of life. This study aimed to explore the factors related to hemodialysis patients' quality of life during the COVID-19 pandemic. This study was a descriptive correlational study. Patients were recruited (n = 298) from the hemodialysis unit of a medical center in northern Taiwan. Variables included patients' sociodemographic, psychological, spiritual, and clinical characteristics (i.e., perceived health level, comorbidities, hemodialysis duration, weekly frequency, transportation, and accompaniment during hemodialysis), perceptions of hemodialysis, self-participation in hemodialysis, and health-related quality of life (KDQOL-36 scale). Data were analyzed using descriptive and bivariate and multivariate linear regression. Multivariate linear regression, after adjusting for covariates, showed that anxiety, self-perceived health status, two vs. four comorbidities, and self-participation in hemodialysis were significantly associated with quality of life. The overall model was significant and accounted for 52.2% (R² = 0.522) of the variance in quality of life during hemodialysis (adjusted R² = 0.480). In conclusion, the quality of life of hemodialysis patients with mild, moderate, or severe anxiety was poorer, whereas that of patients with fewer comorbidities, higher self-perceived health status, and higher self-participation in hemodialysis was better.

Clinical Outcomes and Vaccine Effectiveness for SARS-CoV-2 Infection in People Attending Advanced CKD Clinics: A Retrospective Provincial Cohort Study

BACKGROUND

People with advanced CKD are at high risk of mortality and morbidity from coronavirus disease 2019 (COVID-19). We measured rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe outcomes in a large population attending advanced CKD clinics during the first 21 months of the pandemic. We examined risk factors for infection and case fatality, and we assessed vaccine effectiveness in this population.

METHODS

In this retrospective cohort study, we analyzed data on demographics, diagnosed SARS-CoV-2 infection rates, outcomes, and associated risk factors, including vaccine effectiveness, for people attending a province-wide network of advanced CKD clinics during the first four waves of the pandemic in Ontario, Canada.

RESULTS

In a population of 20,235 patients with advanced CKD, 607 were diagnosed with SARS-CoV-2 infection over 21 months. The case fatality rate at 30 days was 19% overall but declined from 29% in the first wave to 14% in the fourth. Hospitalization and intensive care unit (ICU) admission rates were 41% and 12%, respectively, and 4% started long-term dialysis within 90 days. Significant risk factors for diagnosed infection on multivariable analysis included lower eGFR, higher Charlson Comorbidity Index, attending advanced CKD clinics for more than 2 years, non-White ethnicity, lower income, living in the Greater Toronto Area, and long-term care home residency. Being doubly vaccinated was associated with lower 30-day case fatality rate (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.03 to 0.52). Older age (OR, 1.06 per year; 95% CI, 1.04 to 1.08) and higher Charlson Comorbidity Index (OR, 1.11 per unit; 95% CI, 1.01 to 1.23) were associated with higher 30-day case fatality rate.

CONCLUSIONS

People attending advanced CKD clinics and diagnosed with SARS-CoV-2 infection in the first 21 months of the pandemic had high case fatality and hospitalization rates. Fatality rates were significantly lower in those who were doubly vaccinated.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_04_10_CJN10560922.mp3.

Sex differences in COVID-19 symptoms and outcomes in people with kidney failure treated with dialysis: a prospective cohort study

BACKGROUND

People with kidney failure treated with dialysis are at increased risk of SARS-CoV-2 infection, and severe COVID-19 outcomes such as hospitalization and death. Though there are well-defined sex differences in outcomes for the general population with COVID-19, we do not know whether this translates into kidney failure populations. We aimed to estimate the differences in COVID-19 symptoms and clinical outcomes between males and females treated with maintenance dialysis.

METHODS

In this prospective observational cohort study, we included adults treated with maintenance dialysis in Southern Alberta, Canada that tested positive for COVID-19 between March 2020 and February 2022. We examined the association between sex (dichotomized as male and female) with COVID-19 symptoms including fever, cough, malaise, shortness of breath, muscle joints/aches, nausea and/or vomiting, loss of appetite, diarrhea, headache, sore throat, and loss of smell/taste using chi-square or Fisher's exact tests. Secondary outcomes included 30-day hospitalization, ICU admission, and death.

RESULTS

Of 1,329 cohort participants, 246 (18.5%) tested positive for SARS-CoV-2 and were included in our study, including 95 females (39%). Of 207 participants with symptoms assessed, females had less frequent fever (p = 0.003), and more nausea or vomiting (p = 0.003) compared to males, after correction for multiple testing. Males exhibited no symptoms 25% of the time, compared with 10% of females (p = 0.01, not significant when corrected for multiple testing). We did not identify statistically significant differences in clinical outcomes between the sexes, though vaccinated patients had lower odds of hospitalization.

CONCLUSIONS

Sex differences in COVID-19 symptoms were identified in a cohort of patients treated with maintenance dialysis, which may inform sex-specific screening strategies in dialysis units. Further work is necessary to examine mechanisms for identified sex differences.

Effectiveness of Three Doses of mRNA COVID-19 Vaccines in the Hemodialysis Population during the Omicron Period

BACKGROUND

Coronavirus disease 2019 (COVID-19) vaccine effectiveness studies in the hemodialysis population have demonstrated that two doses of mRNA COVID-19 vaccines are effective against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe complications when Alpha and Delta were predominant variants of concern. Vaccine effectiveness after a third dose versus two doses for preventing SARS-CoV-2 infection and severe COVID-19 in the hemodialysis population against Omicron is not known.

METHODS

We conducted a retrospective cohort study in Ontario, Canada, between December 1, 2021, and February 28, 2022, in the maintenance hemodialysis population who had received two versus three doses of mRNA COVID-19 vaccines. COVID-19 vaccination, SARS-CoV-2 infection, and related hospitalization and death were determined from provincial databases. The primary outcome was the first RT-PCR confirmed SARS-CoV-2 infection, and the secondary outcome was a SARS-CoV-2-related severe outcome, defined as either hospitalization or death.

RESULTS

A total of 8457 individuals receiving in-center hemodialysis were included. At study initiation, 2334 (28%) individuals received three doses, which increased to 7468 (88%) individuals by the end of the study period. The adjusted hazard ratios (aHR) for SARS-CoV-2 infection (aHR, 0.58; 95% confidence interval [CI], 0.50 to 0.67) and severe outcomes (hospitalization or death) (aHR, 0.40; 95% CI, 0.28 to 0.56) were lower after three versus two doses of mRNA vaccine. Prior infection, independent of vaccine status, was associated with a lower risk of reinfection, with an aHR of 0.44 (95% CI, 0.27 to 0.73).

CONCLUSIONS

Three-dose mRNA COVID-19 vaccination was associated with lower incidence of SARS-CoV-2 infection and severe SARS-CoV-2-related outcomes during the Omicron period compared with two doses.

Clinical manifestations of COVID-19 infection in dialysis patients and protective effect of COVID-19 vaccine

BACKGROUND AND OBJECTIVE

COVID-19 infection poses a special challenge to patients with dialysis patients. The purpose of this study was to evaluate the clinical manifestations of dialysis patients with COVID-19 and the protective effect of the vaccine.

METHODS

We included 41 studies based on big data, mainly analyzing the clinical symptoms of dialysis patients with COVID-19, the proportion of severe patients before and after vaccination, and the humoral reaction of vaccine in the body.

RESULTS

6.1% to 35.7% of dialysis patients with COVID-19 developed respiratory distress symptoms and needed to be admitted to an intensive care unit for mechanical ventilation. The incidence and mortality of COVID-19 in dialysis patients before vaccination were 5.5% and 1.1%, respectively, and decreased to 4.5% and 0.6% in breakthrough infected patients. There was no statistical difference in serum conversion rates between dialysis patients and healthy controls, but the neutralizing antibody titer in the control group was 1922 (IQR 533 to 3186) AU/mL, and the neutralizing antibody titer in dialysis patients significantly decreased to 367 (IQR 171 to 1650) AU/mL (P=0.046).

CONCLUSIONS

Dialysis is associated with an increased risk of severe COVID-19, and generally has a poor seroconversion response to vaccines. It also confirms the protective effect of vaccines on high-risk populations such as dialysis.

Early Experience with Modified Dose Nirmatrelvir/Ritonavir in Dialysis Patients with Coronavirus Disease 2019

BACKGROUND

Nirmatrelvir/ritonavir was approved for use in high-risk outpatients with coronavirus disease 2019 (COVID-19). However, patients with severe CKD were excluded from the phase 3 trial, and the drug is not recommended for those with GFR <30 ml/min per 1.73 m 2 . On the basis of available pharmacological data, we developed a modified low-dose regimen of nirmatrelvir/ritonavir 300/100 mg on day 1, followed by 150/100 mg daily from day 2 to 5. In this study, we report our experience with this modified dose regimen in dialysis patients in the Canadian province of Ontario.

METHODS

We included dialysis patients who developed COVID-19 and were treated with the modified dose nirmatrelvir/ritonavir regimen during a 60-day period between April 1 and May 31, 2022. Details of nirmatrelvir/ritonavir use and outcomes were captured manually, and demographic data were obtained from a provincial database. Data are presented with descriptive statistics. The principal outcomes we describe are 30-day hospitalization, 30-day mortality, and required medication changes with the modified dose regimen.

RESULTS

A total of 134 dialysis patients with COVID-19 received nirmatrelvir/ritonavir during the period of study. Fifty-six percent were men, and the mean age was 64 years. Most common symptoms were cough and/or sore throat (60%). Medication interactions were common with calcium channel blockers, statins being the most frequent. Most patients (128, 96%) were able to complete the course of nirmatrelvir/ritonavir, and none of the patients who received nirmatrelvir/ritonavir died of COVID-19 in the 30 days of follow-up.

CONCLUSIONS

A modified dose of nirmatrelvir/ritonavir use was found to be safe and well tolerated, with no serious adverse events being observed in a small sample of maintenance dialysis patients.

COVID-19 in Elderly Patients Receiving Haemodialysis: A Current Review

There is an increased incidence of elderly adults diagnosed with kidney failure as our global aging population continues to expand. Hence, the number of elderly adults indicated for kidney replacement therapy is also increasing simultaneously. Haemodialysis initiation is more commonly observed in comparison to kidney transplantation and peritoneal dialysis for the elderly. The onset of the coronavirus 2019 (COVID-19) pandemic brought new paradigms and insights for the care of this patient population. Elderly patients receiving haemodialysis have been identified as high-risk groups for poor COVID-19 outcomes. Age, immunosenescence, impaired response to COVID-19 vaccination, increased exposure to sources of COVID-19 infection and thrombotic risks during dialysis are key factors which demonstrated significant associations with COVID-19 incidence, severity and mortality for this patient group. Recent findings suggest that preventative measures such as regular screening and, if needed, isolation in COVID-19-positive cases, alongside the fulfillment of COVID-19 vaccination programs is an integral strategy to reduce the number of COVID-19 cases and consequential complications from COVID-19, particularly for high-risk groups such as elderly haemodialysis patients. The COVID-19 pandemic brought about the rapid development and repurposing of a number of medications to treat patients in the viral and inflammatory stages of their disease. However, elderly haemodialysis patients were grossly unrepresented in many of these trials. We review the evidence for contemporary treatments for COVID-19 in this population to provide clinicians with an up-to-date guide. We hope our article increases awareness on the associations and impact of COVID-19 for the elderly haemodialysis population, and encourage research efforts to address knowledge gaps in this topical area.

Health System-Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis

BACKGROUND

Living donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure and offers significant medical and economic advantages for both patients and health systems. Despite this, rates of LDKT in Canada have stagnated and vary significantly across Canadian provinces, the reasons for which are not well understood. Our prior work has suggested that system-level factors may be contributing to these differences. Identifying these factors can help inform system-level interventions to increase LDKT.

OBJECTIVE

Our objective is to generate a systemic interpretation of LDKT delivery across provincial health systems with variable performance. We aim to identify the attributes and processes that facilitate the delivery of LDKT to patients, and those that create barriers and compare these across systems with variable performance. These objectives are contextualized within our broader goal of increasing rates of LDKT in Canada, particularly in lower-performing provinces.

METHODS

This research takes the form of a qualitative comparative case study analysis of 3 provincial health systems in Canada that have high, moderate, and low rates of LDKT performance (the percentage of LDKT to all kidney transplantations performed). Our approach is underpinned by an understanding of health systems as complex adaptive systems that are multilevel and interconnected, and involve nonlinear interactions between people and organizations, operating within a loosely bounded network. Data collection will comprise semistructured interviews, document reviews, and focus groups. Individual case studies will be conducted and analyzed using inductive thematic analysis. Following this, our comparative analysis will operationalize resource-based theory to compare case study data and generate explanations for our research question.

RESULTS

This project was funded from 2020 to 2023. Individual case studies were carried out between November 2020 and August 2022. The comparative case analysis will begin in December 2022 and is expected to conclude in April 2023. Submission of the publication is projected for June 2023.

CONCLUSIONS

By investigating health systems as complex adaptive systems and making comparisons across provinces, this study will identify how health systems can improve the delivery of LDKT to patients with kidney failure. Our resource-based theory framework will provide a granular analysis of the attributes and processes that facilitate or create barriers to LDKT delivery across multiple organizations and levels of practice. Our findings will have practice and policy implications and help inform transferrable competencies and system-level interventions conducive to increasing LDKT.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44172.

Infection Control Practices in In-Center Hemodialysis Units During Wave 1 of the COVID-19 Pandemic in Ontario, Canada: Research Letter

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a virus that caused coronavirus disease 2019 (COVID-19), the multisystem disease central to the COVID-19 pandemic. As patients receiving in-center maintenance hemodialysis require treatment 3 times weekly, they were unable to fully isolate. It was important for in-center hemodialysis units to implement robust infection control practices to ensure patient safety and minimize risk of transmitting SARS-CoV-2 among patients and staff. There are 27 renal programs within Ontario, Canada, providing care for about 9000 people across about 100 in-center hemodialysis units. These units are funded by the Ontario Renal Network (ORN), which is part of the provincial agency Ontario Health.

Objective

The objective was to track infection control practices that were implemented by in-center hemodialysis units and be able to provide a descriptive narrative of the COVID-19 pandemic response of Ontario's hemodialysis units between March and September 2020.

Methods

Between May and September 2020, data were collected from Ontario's 27 renal programs on the implementation of key infection control practices, including symptom screening, use of personal protective equipment, testing, practices specifically related to patients from congregate living settings, other prevention practices, and outbreak management. There were 4 data collection cycles, each approximately 1 month apart. The results were compiled and shared across the province, and infection control practices were also discussed at provincial COVID-19 teleconferences hosted by the ORN.

Results

By March 2020, all but one renal program had implemented one or more forms of symptom screening, all renal programs had implemented physical distancing in waiting rooms and restricted visitors, and 74% of renal programs had implemented universal masking for all staff. By April 2020, 89% of renal programs had implemented universal masking for all patients, 52% had implemented enhanced contact and droplet precautions for suspected or positive cases, and 59% of renal programs tested all patients from congregate living settings regularly (with a low symptom threshold for testing). Infection control practices became more homogeneous across renal programs over time, and most practices were in place as of the last data collection.

Conclusions

The renal system in Ontario was able to respond quickly within the first 2 months of the pandemic to minimize the spread of COVID-19 within in-center hemodialysis units. Through provincial teleconferences, infection control practices were shared across the province as the pandemic and hemodialysis unit responses evolved. This supported renal programs to advocate locally if their hospital was lagging in practices felt to be of value in other hemodialysis units. Although no direct correlation can be made regarding the implementation of infection control practices within in-center hemodialysis units and the number of COVID-19 cases in this population, the limited number of outbreaks in hemodialysis units may have been influenced by the proactive response of renal programs. Practices described in this article may support management and response to subsequent waves of COVID-19 or future similar infectious diseases.

SARS-CoV-2 infection in chronic kidney disease patients with pre-existing dialysis: description across different pandemic intervals and effect on disease course (mortality)

PURPOSE

Patients suffering from chronic kidney disease (CKD) are in general at high risk for severe coronavirus disease (COVID-19) but dialysis-dependency (CKD5D) is poorly understood. We aimed to describe CKD5D patients in the different intervals of the pandemic and to evaluate pre-existing dialysis dependency as a potential risk factor for mortality.

METHODS

In this multicentre cohort study, data from German study sites of the Lean European Open Survey on SARS-CoV-2-infected patients (LEOSS) were used. We multiply imputed missing data, performed subsequent analyses in each of the imputed data sets and pooled the results. Cases (CKD5D) and controls (CKD not requiring dialysis) were matched 1:1 by propensity-scoring. Effects on fatal outcome were calculated by multivariable logistic regression.

RESULTS

The cohort consisted of 207 patients suffering from CKD5D and 964 potential controls. Multivariable regression of the whole cohort identified age (> 85 years adjusted odds ratio (aOR) 7.34, 95% CI 2.45-21.99), chronic heart failure (aOR 1.67, 95% CI 1.25-2.23), coronary artery disease (aOR 1.41, 95% CI 1.05-1.89) and active oncological disease (aOR 1.73, 95% CI 1.07-2.80) as risk factors for fatal outcome. Dialysis-dependency was not associated with a fatal outcome-neither in this analysis (aOR 1.08, 95% CI 0.75-1.54) nor in the conditional multivariable regression after matching (aOR 1.34, 95% CI 0.70-2.59).

CONCLUSIONS

In the present multicentre German cohort, dialysis dependency is not linked to fatal outcome in SARS-CoV-2-infected CKD patients. However, the mortality rate of 26% demonstrates that CKD patients are an extreme vulnerable population, irrespective of pre-existing dialysis-dependency.

Impact of COVID-19 infection on the dialysis population prospective, observational, nationwide study

INTRODUCTION

Hemodialysis (HD) patients are at increased risk of severe COVID-19 infection but infection rates vary. Our objectives are to describe COVID-19 positive HD patients' characteristics, infection rates, and factors associated with mortality in HD COVID-19 cases in Kuwait.

METHODS

Data on demographics, comorbidities, and treatments received, as well as mortality for HD patients admitted to hospitals for COVID-19, from 1/March to 31/July 2020, prospectively collected and analyzed.

RESULTS

A total of 141 infected HD patients were admitted (Mean age 58 ± 16.1; Males 56%), representing 7% of the total HD population and 0.2% of all COVID-19 cases during the study period. Of those 141 infected HD patients, 27 (19%) died, and this represents 6% of total COVID-19-related mortality and 27% of the total HD mortality. In contrast, total covid-19-related mortality of all positive cases was only 0.7%, and total HD mortality during the study period was only 5%. COVID-19-positive HD patients who died were older and 59% were males. However, the differences were not statistically significant. Of the 61 infected HD patients who needed to be switched to continuous kidney replacement therapy (CKRT), 34% died, and of the 29 infected HD patients who needed admission to intensive care, 65% died.

CONCLUSION

HD population represents a small fraction of the total population; however, positive HD COVID-19 cases represent a sizable proportion of COVID-19 cases and a significant percentage of total COVID-19-related mortality, and total HD mortality.

Health System–Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis (Preprint).. [DOI: 10.2196/preprints.44172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Living donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure and offers significant medical and economic advantages for both patients and health systems. Despite this, rates of LDKT in Canada have stagnated and vary significantly across Canadian provinces, the reasons for which are not well understood. Our prior work has suggested that system-level factors may be contributing to these differences. Identifying these factors can help inform system-level interventions to increase LDKT.

OBJECTIVE

Our objective is to generate a systemic interpretation of LDKT delivery across provincial health systems with variable performance. We aim to identify the attributes and processes that facilitate the delivery of LDKT to patients, and those that create barriers and compare these across systems with variable performance. These objectives are contextualized within our broader goal of increasing rates of LDKT in Canada, particularly in lower-performing provinces.

METHODS

This research takes the form of a qualitative comparative case study analysis of 3 provincial health systems in Canada that have high, moderate, and low rates of LDKT performance (the percentage of LDKT to all kidney transplantations performed). Our approach is underpinned by an understanding of health systems as complex adaptive systems that are multilevel and interconnected, and involve nonlinear interactions between people and organizations, operating within a loosely bounded network. Data collection will comprise semistructured interviews, document reviews, and focus groups. Individual case studies will be conducted and analyzed using inductive thematic analysis. Following this, our comparative analysis will operationalize resource-based theory to compare case study data and generate explanations for our research question.

RESULTS

This project was funded from 2020 to 2023. Individual case studies were carried out between November 2020 and August 2022. The comparative case analysis will begin in December 2022 and is expected to conclude in April 2023. Submission of the publication is projected for June 2023.

CONCLUSIONS

By investigating health systems as complex adaptive systems and making comparisons across provinces, this study will identify how health systems can improve the delivery of LDKT to patients with kidney failure. Our resource-based theory framework will provide a granular analysis of the attributes and processes that facilitate or create barriers to LDKT delivery across multiple organizations and levels of practice. Our findings will have practice and policy implications and help inform transferrable competencies and system-level interventions conducive to increasing LDKT.

INTERNATIONAL REGISTERED REPORT

DERR1-10.2196/44172

What is the health impact of COVID-19 among Black communities in Canada? A systematic review

OBJECTIVE

The objective of this systematic review was to identify the health impact of COVID-19 on mortality, morbidity, hospital admission, and hospital readmission rates in the Black population across Canada.

METHODS

A comprehensive search strategy consisting of relevant subject headings and keywords was executed in five databases: OVID Medline, OVID Embase, EBSCO CINAHL Plus, Web of Science, and Scopus. Additional searches were conducted for gray literature in ProQuest Dissertations and Theses Global, Google Scholar, and an advanced customized Google search for Canadian government documents. All eligible studies included in this review underwent quality assessment.

RESULTS

Clinical health outcomes identified included mortality, morbidity, and hospital admission rates; none of the studies reported hospital readmission rates. The search identified 616 citations, and following the removal of duplicates and screening according to our inclusion/exclusion criteria, four articles were eligible for inclusion in the review. All of these studies were conducted in Canada. Study dates ranged from 2020 to 2021.

CONCLUSION

A systematic review of studies on the impact of COVID-19 on the Black population in Canada highlights two key points. First, the collection and availability of race-based data are necessary to clarify the impact of COVID-19 and other diseases on Black populations in Canada. Second, with the limited available data, studies suggest that COVID-19 disproportionately impacts Black populations in Canada, making up high shares of cases, deaths, and hospitalizations compared to most of the population.

Predictors of shorter- and longer-term mortality after COVID-19 presentation among dialysis patients: parallel use of machine learning models in Latin and North American countries

Background

We developed machine learning models to understand the predictors of shorter-, intermediate-, and longer-term mortality among hemodialysis (HD) patients affected by COVID-19 in four countries in the Americas.

Methods

We used data from adult HD patients treated at regional institutions of a global provider in Latin America (LatAm) and North America who contracted COVID-19 in 2020 before SARS-CoV-2 vaccines were available. Using 93 commonly captured variables, we developed machine learning models that predicted the likelihood of death overall, as well as during 0–14, 15–30, > 30 days after COVID-19 presentation and identified the importance of predictors. XGBoost models were built in parallel using the same programming with a 60%:20%:20% random split for training, validation, & testing data for the datasets from LatAm (Argentina, Columbia, Ecuador) and North America (United States) countries.

Results

Among HD patients with COVID-19, 28.8% (1,001/3,473) died in LatAm and 20.5% (4,426/21,624) died in North America. Mortality occurred earlier in LatAm versus North America; 15.0% and 7.3% of patients died within 0–14 days, 7.9% and 4.6% of patients died within 15–30 days, and 5.9% and 8.6% of patients died > 30 days after COVID-19 presentation, respectively. Area under curve ranged from 0.73 to 0.83 across prediction models in both regions. Top predictors of death after COVID-19 consistently included older age, longer vintage, markers of poor nutrition and more inflammation in both regions at all timepoints. Unique patient attributes (higher BMI, male sex) were top predictors of mortality during 0–14 and 15–30 days after COVID-19, yet not mortality > 30 days after presentation.

Conclusions

Findings showed distinct profiles of mortality in COVID-19 in LatAm and North America throughout 2020. Mortality rate was higher within 0–14 and 15–30 days after COVID-19 in LatAm, while mortality rate was higher in North America > 30 days after presentation. Nonetheless, a remarkable proportion of HD patients died > 30 days after COVID-19 presentation in both regions. We were able to develop a series of suitable prognostic prediction models and establish the top predictors of death in COVID-19 during shorter-, intermediate-, and longer-term follow up periods.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02961-x.

Associations of COVID-19 Outcomes with Dialysis Modalities and Settings

How maintenance dialysis modality, dialysis setting, and residence in a nursing facility have jointly associated with coronavirus disease 2019 (COVID-19)-related outcomes in the United States is relevant to future viral outbreaks. Using Medicare claims, we determined the incidence of COVID-19-related infection, hospitalization, and death between March 15, 2020 and June 5, 2021. The exposure was one of five combinations of dialysis modality and care setting: in-facility hemodialysis without a recent history of skilled nursing facility care, in-facility hemodialysis with a recent history of skilled nursing facility care, hemodialysis in a skilled nursing facility, home hemodialysis, and (home) peritoneal dialysis. Patient-weeks were pooled to estimate the adjusted associations of event incidence with each dialysis modality/setting during four intervals in 2020-2021. Relative to in-facility hemodialysis without a recent history of skilled nursing facility care, home dialysis was associated with 36%-60% lower odds of all events during weeks 12-23 of 2020; 24%-37% lower odds of all events during weeks 24-37 of 2020; 20%-33% lower odds of infection and hospitalization during the winter of 2020-2021; and similar odds of all events thereafter. In contrast, exposure to skilled nursing facilities was associated with 570%-1140% higher odds of all events during spring of 2020, although excess risk attenuated as the pandemic transpired, especially among patients who received hemodialysis in skilled nursing facilities. In conclusion, home dialysis was associated with lower risks of COVID-19 diagnosis, hospitalization, and death until vaccines were available, whereas care in skilled nursing facilities was associated with higher risks.

SARS-CoV-2 in dialysis patients and the impact of vaccination

Background

In centre haemodialysis (ICHD) patients have been identified as high risk of contracting Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection due to frequent healthcare contact and poor innate and adaptive immunity. Our ICHD patients were offered immunisation from January 2021. We aimed to assess outcomes following SARS-CoV-2 infection and report on the effect of vaccination in our ICHD patients.

Methods

Demographics, SARS-CoV-2 status, hospitalisation, mortality and vaccination status were analysed. From 11^th March 2020 to 31^st March 2021, 662 ICHD patients were included in the study and these patients were then followed up until 31^st August 2021.

Results

SARS-CoV-2 infection occurred in 28.4% with 51.1% of them requiring hospitalisation in contrast to community infection rates of 13.9% and hospitalisation of 9.0%. 28-day mortality was 19.2% in comparison to 1.9% of the community. Mortality increased to 34.0% over the study period. Mortality over the study period was 1.8 times in infected patients (HR 1.81 (1.32–2.49) P < 0.001) despite adjustment for age, gender and ethnicity. 91.3% of ICHD patients have now received both doses of SARS-CoV-2 vaccinations.

Conclusions

ICHD patients are at increased risk of acquiring SARS-CoV-2, with increased rates of hospitalisation and mortality. The increased mortality extends well beyond the 28 days post-infection and persists in those who have recovered. Peaks and troughs in infection rates mirrored community trends. Preliminary data indicates that the SARS-CoV-2 vaccination provides protection to ICHD patients, with ICHD case rates now comparable to that of the local population.

Vaccination and COVID-19 in Polish Dialysis Patients: Results from the European Clinical Dialysis Database

Background: Patients with end-stage kidney disease undergoing hemodialysis are particularly vulnerable to severe COVID-19 as a result of older age and multimorbidities. Objectives: Data are still limited and there are no published data on mortality in hemodialyzed patients in Poland, in particular when vaccines became available. We assessed the epidemiologic and clinical data of patients with laboratory-confirmed COVID-19 and assessed the mortality in 2019, 2020, and 2021, as well as the vaccination rate in 2021. Patients and Methods: Retrospectively collected data from 73 Fresenius Nephrocare Poland hemodialysis centers and one public unit were analyzed. Results: In 2021, the vaccination rate was 96%. The unadjusted mortality (number of deaths divided by number of patients) in 2019 was 18.8%, while the unadjusted (after exclusion of COVID-related deaths) mortality in 2020 was 20.8%, and mortality in 2021 was 16.22%. The prevalence of cardiovascular deaths in 2019 and 2020 was almost identical (41.4% vs. 41.2%, respectively), and in 2021, the figures increased slightly to 44.1%. The prevalence of sudden cardiac deaths in 2019 was higher than in 2020 (19.6% vs. 17.3%, respectively) and consequently decreased in 2021 (10.0%), as well as strokes (6.2% vs. 5.4%, and 3.31% in 2021), whereas deaths due to gastrointestinal tract diseases were lower (2.5% vs. 3.2%, and 2.25% in 2021), diabetes complications (0.5% vs. 1.3%, and 0.5% in 2021), sepsis (5.1% vs. 6.3%, and 8.79% in 2021), respiratory failure (1.2 vs. 1.6%, and 2.83% in 2021), and pneumonia (1.4% vs. 2.0%, and 0.82%). There were 1493 hemodialyzed COVID-19 positive patients, and among them, 191 died in 2020 (12.79%). In 2021, there were 1224 COVID-19 positive patients and 260 died (21.24%). The mortality of COVID-19 positive dialyzed patients contributed 13.39% in 2020 and 16.21% in 2021 of all recorded deaths. Conclusions: The mortality among HD patients was higher in 2021 than in 2020 and 2019, despite the very high vaccination rate of up to 96%. The higher non-COVID-19 mortality may be due to the limited possibility of hospitalization and dedicated care during the pandemic. This information is extremely important in order to develop methods to protect this highly vulnerable patient group. Prevention plays a key role; other measures are essential in the mitigation and spread of COVID-19 in HD centers.

Epidemiology of peritoneal dialysis outcomes

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.

The use of peritoneal dialysis (PD) can be advantageous compared with haemodialysis treatment, although several barriers limit its broad implementation. This review examines the epidemiology of peritoneal dialysis (PD) outcomes, including clinical, patient-reported and surrogate PD outcomes.

Peritoneal dialysis (PD) has distinct advantages compared with haemodialysis, including the convenience of home treatment, improved quality of life, technical simplicity, lesser need for trained staff, greater cost-effectiveness in most countries, improved equity of access to dialysis in resource-limited settings, and improved survival, particularly in the first few years of initiating therapy.

Important barriers can hamper PD utilization in low-income settings, including the high costs of PD fluids (owing to the inability to manufacture them locally and the exorbitant costs of their import), limited workforce availability and a practice culture that limits optimal PD use, often leading to suboptimal outcomes.

PD outcomes are highly variable around the world owing in part to the use of variable outcome definitions, a heterogeneous practice culture, the lack of standardized monitoring and reporting of quality indicators, and kidney failure care gaps (including health care workforce shortages, inadequate health care financing, suboptimal governance and a lack of good health care information systems).

Key outcomes include not only clinical outcomes (typically defined as medical outcomes based on clinician assessment or diagnosis) — for example, PD-related infections, technique survival, mechanical complications, hospitalizations and PD-related mortality — but also patient-reported outcomes. These outcomes are directly reported by patients and focus on how they function or feel, typically in relation to quality of life or symptoms; patient-reported outcomes are used less frequently than clinical outcomes in day-to-day routine care.

Impact of the COVID-19 pandemic on patients with chronic kidney disease: A narrative review

ABSTRACT

Severe acute respiratory disease coronavirus 2 is currently causing the coronavirus disease 2019 (COVID-19) pandemic, placing extreme strain on the global health system. Vaccination is the main measure for preventing the COVID-19 epidemic, especially for high-risk groups including patients with chronic kidney disease (CKD). However, CKD patients receiving dialysis or kidney transplant may be characterized by decreased renal function and immune disorders, which may have uncertainties in their health. This overview aims to introduce the possible impact of the COVID-19 vaccine on kidney disease and its application in patients with CKD to provide evidence for the COVID-19 vaccine in patients with CKD. The data for this study were collected from PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and the China Knowledge Resource Integrated Database (CNKI). The following keywords were used: "COVID-19", "COVID-19 vaccine," and "CKD". The publication time of the papers was set from the establishment of the databases to September 2021. A total of 47 studies were included, and patients with CKD are a high-risk group for COVID-19 infection and severe illness. Vaccination is a powerful tool for preventing CKD patients from COVID-19. Because of possible side effects, the recurrence or deterioration of kidney disease may occur in CKD patients after vaccination. Although vaccination for patients with CKD remains a problem, with the advantages outweighing the disadvantages, stable CKD patients should complete a vaccination plan, and doctors should be aware of the recurrence or deterioration of kidney disease and close monitoring.

DATA ACCESS STATEMENT

Research data supporting this publication are available from the electronic databases of PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and the China Knowledge Resource Integrated Database (CNKI).

BNT162b2 Booster Vaccination Induced Immunity against SARS-CoV-2 Variants among Hemodialysis Patients

Background: The emergence of new SARS-CoV-2 variants, which evade immunity, has raised the urgent need for multiple vaccine booster doses for vulnerable populations. In this study, we aimed to estimate the BNT162b2 booster effectiveness against the spread of coronavirus variants in a hemodialysis population. Methods: We compared humoral and cell-mediated immunity in 100 dialysis patients and 66 age-matched volunteers, before and 2-3 weeks following the first booster vaccine dose. Participants were assessed for anti-spike (RBD) antibody titer, neutralizing antibodies against B.1.617.2 (Delta) and B.1.1.529 (Omicron) variants, spike-specific T-cell responses by FACS and infection outbreak after the first and second booster. Results: Anti-spike antibody titer was significantly increased following the booster, with reduced humoral and cellular response in the dialysis patients. Neutralizing antibody levels increased significantly after the booster dose, with an inferior effect (≤2 fold) against Omicron compared with the Delta variant. Furthermore, CD4+ and CD8+ T-cell activation by Delta spike protein was preserved in 70% of PBMCs from the dialysis patients. A second booster dose tended to reduce breakthrough infections in the dialysis patients. Conclusions: Until the release of an updated vaccine, BNT162b2 booster doses will improve the humoral and cell-mediated immunity against variants. These findings support the importance of repetitive booster doses for hemodialysis patients.

Prevalence and Risk Factors for Anti-SARS-CoV-2 Antibody in Chronic Kidney Disease (Dialysis Independent and Not)

Background: The evidence in the medical literature regarding the prevalence of antibody towards SARS-CoV-2 in patients with chronic kidney disease is limited, particularly among those at the pre-dialysis stage. Aim: We have prospectively performed a cohort study at a third-level university hospital to evaluate frequency and risk factors for anti-SARS-CoV-2-positive serology among chronic kidney disease patients. Methods: We have tested a cohort of consecutive outpatients with chronic kidney disease on regular follow-up at a major metropolitan hospital, during the SARS-CoV-2 outbreak in Italy. We adopted an enzyme immunoassay for the assessment of IgM/IgG antibodies to SARS-CoV-2 in human serum or plasma (DIA.PRO COVID-19 Serological Assay); the assay detects antibodies against Spike (1/2) and Nucleocapsid proteins of the SARS-CoV-2 genome. Results: There were 199 (65.8%) out of 302 patients with dialysis-independent CKD; 2 patients were anti-SARS-CoV-2 IgM antibody positive, 23 were anti-SARS-CoV-2 IgM/IgG positive and 37 had detectable anti-SARS-CoV-2 IgG antibody in serum. The prevalence of anti-SARS-CoV-2 IgG was 20.5% (60/302). All patients positive for anti-SARS-CoV-2 antibody tested negative by nasopharyngeal swab. A significant and independent relationship between anti-SARS-CoV-2-positive serologic status and serum albumin (a marker of nutritional status) was observed (p < 0.046). The prevalence of anti-SARS-CoV-2 antibody was greater in CKD than in control populations (health care workers and blood donors) attending the hospital a few months before the current study (7.6% and 5.2%, respectively). Conclusions: The great prevalence of anti-SARS-CoV-2 antibody in our study group could be, at least partially, explained with the fact that our patients were living in Milan, an area severely hit by SARS-CoV-2 infection. It seems that a poor nutritional status supports the acquisition of SARS-CoV-2 antibody in CKD patients. Clinical studies to understand the mechanisms responsible for the high frequency of SARS-CoV-2 infection are under way.

Peritoneal catheter insertion: combating barriers through policy change

Barriers to accessing home dialysis became a matter of life and death for many patients with kidney failure during the coronavirus disease 2019 (COVID-19) pandemic. Peritoneal dialysis (PD) is the more commonly used home therapy option. This article provides a comprehensive analysis of PD catheter insertion procedures as performed around the world today, barriers impacting timely access to the procedure, the impact of COVID-19 and a roadmap of potential policy solutions. To substantiate the analysis, the article includes a survey of institutions across the world, with questions designed to get a sense of the regulatory frameworks, barriers to conducting the procedure and impacts of the pandemic on capability and outcomes. Based on our research, we found that improving patient selection processes, determining and implementing correct insertion techniques, creating multidisciplinary teams, providing appropriate training and sharing decision making among stakeholders will improve access to PD catheter insertion and facilitate greater uptake of home dialysis. Additionally, on a policy level, we recommend efforts to improve the awareness and feasibility of PD among patients and the healthcare workforce, enhance and promulgate training for clinicians—both surgical and medical—to insert PD catheters and fund personnel, pathways and physical facilities for PD catheter insertion.

Impact of Moderna mRNA-1273 Booster Vaccine on Fully Vaccinated High-Risk Chronic Dialysis Patients after Loss of Humoral Response

The long-term effect of protection by two doses of SARS-CoV-2 vaccination in patients receiving chronic intermittent hemodialysis (CIHD) is an urging question. We investigated the humoral and cellular immune response of 42 CIHD patients who had received two doses of SARS-CoV-2 vaccine, and again after a booster vaccine with mRNA-1273 six months later. We measured antibody levels and SARS-CoV-2-specific surrogate neutralizing antibodies (SNA). Functional T cell immune response to vaccination was assessed by quantifying interferon-γ (IFN-γ) and IL-2 secreting T cells specific for SARS-CoV-2 using an ELISpot assay. Our data reveal a moderate immune response after the second dose of vaccination, with significantly decreasing SARS-CoV-2-specific antibody levels and less than half of the study group showed neutralizing antibodies six months afterwards. Booster vaccines increased the humoral response dramatically and led to a response rate of 89.2% for antibody levels and a response rate of 94.6% for SNA. Measurement in a no response/low response (NR/LR) subgroup of our cohort, which differed from the whole group in age and rate of immunosuppressive drugs, indicated failure of a corresponding T cell response after the booster vaccine. We strongly argue in favor of a regular testing of surrogate neutralizing antibodies and consecutive booster vaccinations for CIHD patients to provide a stronger and persistent immunity.

The Impact of COVID-19 on Patient, Family Member, and Stakeholder Research Engagement: Insights from the PREPARE NOW Study

BACKGROUND

Little is known about the impact of COVID-19 on patient, family member, and stakeholder patient-centered outcomes research engagement.

OBJECTIVE

To answer the research questions: (1) What is the impact of COVID-19 on the lives of patients with kidney disease and their families? (2) What is the impact of COVID-19 on research engagement for patient and family member research team members who are themselves at very high risk for poor COVID-19 outcomes? and (3) How can we help patients, family members, and stakeholder team members engage in research during COVID-19?

DESIGN

We conducted virtual semi-structured interviews with patient and family member co-investigators and kidney disease stakeholders from the PREPARE NOW study during November 2020. The interview guide included questions about participants' experiences with the impact of COVID-19 on research engagement.

PARTICIPANTS

Seven patient and family member co-investigators and eight kidney disease stakeholders involved in a kidney disease patient-centered outcomes research project participated in the interviews, data analysis, and writing this manuscript.

APPROACH

We used a content analysis approach and identified the main themes using an inductive process.

KEY RESULTS

Respondents reported three main ways that COVID-19 has impacted their lives: emotional impact, changing behaviors, and changes in health care delivery. The majority of respondents reported no negative impact of COVID-19 on their ability to engage in this research project. Suggestions for patient-centered outcomes research during COVID-19 and other emergencies include virtual research activities; active engagement; and promoting trust, honesty, transparency, and authenticity.

CONCLUSIONS

COVID-19 has had a significant negative impact on patient, family member, and stakeholder research team members; however, this has not resulted in less research engagement.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02722382.

Vaccine Effectiveness Against SARS-CoV-2 Infection and Severe Outcomes in the Maintenance Dialysis Population in Ontario, Canada

BACKGROUND

Vaccination studies in the hemodialysis population have demonstrated decreased antibody response compared with healthy controls, but vaccine effectiveness for preventing SARS-CoV-2 infection and severe disease is undetermined.

METHODS

We conducted a retrospective cohort study in the province of Ontario, Canada, between December 21, 2020, and June 30, 2021. Receipt of vaccine, SARS-CoV-2 infection, and related severe outcomes (hospitalization or death) were determined from provincial health administrative data. Receipt of one and two doses of vaccine were modeled in a time-varying cause-specific Cox proportional hazards model, adjusting for baseline characteristics, background community infection rates, and censoring for non-COVID death, recovered kidney function, transfer out of province, solid organ transplant, and withdrawal from dialysis.

RESULTS

Among 13,759 individuals receiving maintenance dialysis, 2403 (17%) were unvaccinated and 11,356 (83%) had received at least one dose by June 30, 2021. Vaccine types were BNT162b2 (n=8455, 74%) and mRNA-1273 (n=2901, 26%); median time between the first and second dose was 36 days (IQR 28-51). The adjusted hazard ratio (HR) for SARS-CoV-2 infection and severe outcomes for one dose compared with unvaccinated was 0.59 (95% CI, 0.46 to 0.76) and 0.54 (95% CI, 0.37 to 0.77), respectively, and for two doses compared with unvaccinated was 0.31 (95% CI, 0.22 to 0.42) and 0.17 (95% CI, 0.1 to 0.3), respectively. There were no significant differences in vaccine effectiveness among age groups, dialysis modality, or vaccine type.

CONCLUSIONS

COVID-19 vaccination is effective in the dialysis population to prevent SARS-CoV-2 infection and severe outcomes, despite concerns about suboptimal antibody responses.

Accessing hemodialysis clinics during the COVID-19 pandemic

Transportation is a key element of access to healthcare. The COVID-19 pandemic posed unique and unforeseen challenges to patients receiving hemodialysis who rely on three times weekly transportation to receive their life-saving treatments, but there is little data on the problems they faced. This study explores the attitudes, fears, and concerns of hemodialysis patients during the pandemic with a focus on their travel to/from dialysis treatments. A mixed methods travel survey was distributed to hemodialysis patients from three urban centers in Montréal, Canada, during the pandemic (n = 43). The survey included closed questions that were analysed through descriptive statistics as well as open-ended questions that were assessed through thematic analysis. Descriptive statistics show that hemodialysis patients are more fearful of contracting COVID-19 in transit than they are at the treatment center. Patients taking paratransit, public transportation, and taxis are more fearful of COVID-19 while traveling than those who drive, who are driven, or who walk to the clinic. In the open-ended questions, patients reported struggling with confusing COVID-19 protocols in public transport, including conflicting information on whether paratransit taxis allowed one or multiple passengers. Paratransit was the most used travel mode to access treatment (n = 30), with problems identified in the open-ended questions, such as long and unreliable pickup windows, and extended travel times. To limit COVID-19 exposure and stress for paratransit users, agencies should consider sitting one patient per paratransit taxi, clearly communicating COVID-19 protocols online and in the vehicles, and tracking vehicles for more efficient pickups.

Differences in mRNA-1273 (Moderna) and BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 vaccine immunogenicity among patients undergoing dialysis

BACKGROUND

Differences in immunogenicity between mRNA SARS-CoV-2 vaccines have not been well characterized in patients undergoing dialysis. We compared the serologic response in patients undergoing maintenance hemodialysis after vaccination against SARS-CoV-2 with BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna).

METHODS

We conducted a prospective observational cohort study at 2 academic centres in Toronto, Canada, from Feb. 2, 2021, to July 20, 2021, which included 129 and 95 patients who received the BNT162b2 and mRNA-1273 SARS-CoV-2 vaccines, respectively. We measured SARS-CoV-2 immunoglobulin G antibodies to the spike protein (anti-spike), receptor binding domain (anti-RBD) and nucleocapsid protein (anti-NP) at 6-7 and 12 weeks after the second dose of vaccine and compared those levels with the median convalescent serum antibody levels from 211 controls who were previously infected with SARS-CoV-2.

RESULTS

At 6-7 weeks after 2-dose vaccination, we found that 51 of 70 patients (73%) who received BNT162b2 and 83 of 87 (95%) who received mRNA-1273 attained convalescent levels of anti-spike antibody (p < 0.001). In those who received BNT162b2, 35 of 70 (50%) reached the convalescent level for anti-RBD compared with 69 of 87 (79%) who received mRNA-1273 (p < 0.001). At 12 weeks after the second dose, anti-spike and anti-RBD levels were significantly lower in patients who received BNT162b2 than in those who received mRNA-1273. For anti-spike, 70 of 122 patients (57.4%) who received BNT162b2 maintained the convalescent level versus 68 of 71 (96%) of those who received mRNA-1273 (p < 0.001). For anti-RBD, 47 of 122 patients (38.5%) who received BNT162b2 maintained the anti-RBD convalescent level versus 45 of 71 (63%) of those who received mRNA-1273 (p = 0.002).

INTERPRETATION

In patients undergoing hemodialysis, mRNA-1273 elicited a stronger humoral response than BNT162b2. Given the rapid decline in immunogenicity at 12 weeks in patients who received BNT162b2, a third dose is recommended in patients undergoing dialysis as a primary series, similar to recommendations for other vulnerable populations.

Effectiveness of COVID-19 Vaccines in Patients Under Maintenance Hemodialysis

BACKGROUND

Several published data on the dialysis population showed that antibody levels decreased after COVID-19 vaccinations in comparison to the overall population. We aimed to illustrate the persistence of humoral response after receiving second dose of the Pfizer or AstraZeneca vaccines in patients under maintenance hemodialysis (HD).

METHODS

A total of 119 adult patients on HD who were recruited from a single hemodialysis center in Madinah, Saudi Arabia. An enzyme-linked immunosorbent assay (ELISA) was utilized to measure the specific antibody response to the spike protein in the serum samples.

RESULTS

Mean age of patients was 48.5 ± 13.5 years, while mean time since starting the renal dialysis was 5.09 ± 5.29 years. Blood samples were collected after 89.2 ± 25.7 days of receiving the second dose of the vaccines. A very high positive correlation between anti-S IgG antibodies in pre- and post-dialysis was found (rs= 0.93, p < 0.001). Additionally, there was a high positive correlation between anti-S IgG antibody collected at baseline and follow-up blood samples (30 days apart) (rs= 0.82, p < 0.001). Moreover, patients who received Pfizer had significantly higher mean change in anti-S IgG antibodies compared to patients who received AstraZeneca (0.41 ± 0.94 vs 0.03 ± 0.30, respectively, p = 0.026).

CONCLUSION

The majority of the patients included in this study were able to yield an immune response to the vaccine after receiving the two doses. Persistence of IgG antibodies in the majority of the patients on HD in response to COVID-19 vaccines is encouraging in terms of continuing to vaccinate this category of patients in addition to monitoring them.

COVID-19 en el paciente en diálisis. Una revisión sistemática

Introducción: La pandemia por COVID-19 acaecida en 2019 afectó con mayor gravedad a la población de mayor edad y con enfermedades subyacentes, siendo estos factores de riesgo de mortalidad. Estas características son propias del paciente renal en diálisis, por lo que es importante conocer cuál fue el impacto del COVID-19 en este grupo poblacional.Objetivo: El objetivo principal fue conocer y sintetizar la evidencia científica existente sobre las características clínicas de la enfermedad COVID-19 en el paciente con enfermedad renal crónica en diálisis.Metodología: Se realizó una revisión sistemática basada en la declaración PRISMA, en la que se analizaron 23 artículos procedentes de las bases de datos PubMed y Scopus. Se incluyeron artículos originales en inglés y español que excluyeran la población pediátrica.Resultados: Se incluyeron 23 artículos de diseño observacional. Principalmente los resultados se centraron en incidencia, características clínicas, como sintomatología o evolución, mortalidad y medidas preventivas en las unidades de diálisis.Conclusiones: La incidencia de la COVID-19 fue mayor en unidades de diálisis que en los pacientes que recibían diálisis domiciliaria. La sintomatología más leve fue la común a la población general. En los casos más graves, cerca del 50% de los pacientes necesitaron hospitalización y/o ingreso en una Unidad de Cuidados Intensivos. La mortalidad fue bastante elevada y se relacionó con la edad avanzada, comorbilidad, sexo masculino o fragilidad clínica. Además, en las unidades de diálisis se implementaron medidas de prevención de la enfermedad, al ser espacios físicos cerrados donde se concentra un gran número de pacientes.

SARS-CoV-2 Infection in Patients on Dialysis: Incidence and Outcomes in the Lazio Region, Italy

Patients with end-stage kidney disease represent a frail population and might be at higher risk of SARS-CoV-2 infection. The Lazio Regional Dialysis and Transplant Registry collected information on dialysis patients with a positive swab. The study investigated incidence of SARS-CoV-2 infection, mortality and their potential associated factors in patients undergoing maintenance hemodialysis (MHD) in the Lazio region. Method: The occurrence of infection was assessed among MHD patients included in the RRDTL from 1 March to 30 November 2020. The adjusted cumulative incidence of infection and mortality risk within 30 days of infection onset were estimated. Logistic and Cox regression models were applied to identify factors associated with infection and mortality, respectively. Results: The MHD cohort counted 4942 patients; 256 (5.2%) had COVID-19. The adjusted cumulative incidence was 5.1%. Factors associated with infection included: being born abroad, educational level, cystic renal disease/familial nephropathy, vascular disease and being treated in a dialysis center located in Local Health Authority (LHA) Rome 2. Among infected patients, 59 (23.0%) died within 30 days; the adjusted mortality risk was 21.0%. Factors associated with 30-day mortality included: age, malnutrition and fever at the time of swab. Conclusions: Factors associated with infection seem to reflect socioeconomic conditions. Factors associated with mortality, in addition to age, are related to clinical characteristics and symptoms at the time of swab.

The global impact of the Coronavirus 2019 pandemic on in-centre haemodialysis services: an International Society of Nephrology -Dialysis Outcomes Practice Patterns Study survey

Introduction

To assess the impact of the COVID-19 pandemic impact on hemodialysis (HD) centers, The Dialysis Outcomes and Practice Patterns Study and ISN collaborated on a web-survey of centers.

Methods

A combined approach of random sampling and open invitation was used between March 2020 and March 2021. Responses were obtained from 412 centers in 78 countries and all 10 ISN regions.

Results

In 8 regions, rates of SARS-CoV-2 infection were <20% in most centers, but in North East Asia (NE Asia) and Newly Independent States and Russia (NIS & Russia), rates were ≥20% and ≥30%, respectively. Mortality was ≥10% in most centers in 8 regions, although lower in North America and Caribbean (N America & Caribbean) and NE Asia. Diagnostic testing was not available in 33%, 37%, and 61% of centers in Latin America, Africa, and East and Central Europe, respectively. Surgical masks were widely available, but severe shortages of particulate-air filter masks were reported in Latin America (18%) and Africa (30%). Rates of infection in staff ranged from 0% in 90% of centers in NE Asia to ≥50% in 63% of centers in the Middle East and 68% of centers in NIS & Russia. In most centers, <10% of staff died, but in Africa and South Asia (S Asia), 2% and 6% of centers reported ≥50% mortality, respectively.

Conclusion

There has been wide global variation in SARS-CoV-2 infection rates among HD patients and staff, personal protective equipment (PPE) availability, and testing, and the ways in which services have been redesigned in response to the pandemic.

Acute kidney injury requiring renal replacement therapy in people with COVID-19 disease in Ontario, Canada: a prospective analysis of risk factors and outcomes

Background

Severely ill people with coronavirus disease 2019 (COVID-19) are at risk of acute kidney injury treated with renal replacement therapy (AKI-RRT). The understanding of the risk factors and outcomes for AKI-RRT is incomplete.

Methods

We prospectively collected data on the incidence, demographics, area of residence, time course, outcomes and associated risk factors for all COVID-19 AKI-RRT cases during the first two waves of the pandemic in Ontario, Canada.

Results

There were 271 people with AKI-RRT, representing 0.1% of all diagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases. These included 10% of SARS-CoV-2 admissions to intensive care units (ICU). Median age was 65 years, with 11% &lt;50 years, 76% were male, 47% non-White and 48% had diabetes. Overall, 59% resided in the quintile of Ontario neighborhoods with the greatest ethnocultural composition and 51% in the two lowest income quintile neighborhoods. Mortality was 58% at 30 days after RRT initiation, and 64% at 90 days. By 90 days, 20% of survivors remained RRT-dependent and 31% were still hospitalized. On multivariable analysis, people aged &gt;70 years had higher mortality (odds ratio 2.4, 95% confidence interval 1.3, 4.6). Cases from the second versus the first COVID-19 wave were older, had more baseline comorbidity and were more likely to initiate RRT  &gt;2 weeks after SARS-CoV-2 diagnosis (34% versus 14%; P &lt; 0.001).

Conclusions

AKI-RRT is common in COVID-19 ICU admissions. Residency in areas with high ethnocultural composition and lower socioeconomic status are strong risk factors. Late-onset AKI-RRT was more common in the second wave. Mortality is high and 90-day survivors have persisting high morbidity.

Antibody response to mRNA SARS-CoV-2 vaccines in haemodialysis patients

Background

Some studies have shown an attenuated immune response in haemodialysis patients after vaccination. The present study examines the humoral response after mRNA vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a large population of haemodialysis patients from different outpatient dialysis centres.

Methods

We retrospectively assessed antibodies against SARS-CoV-2 spike protein and nucleocapsid protein (chemiluminescence immunoassays, Roche diagnostics) 3–6 weeks after the second mRNA vaccine dose in 179 maintenance haemodialysis and 70 non-dialysis patients (control cohort). Differences in anti-SARS-CoV-2 spike protein titers were statistically analysed with respect to patient-relevant factors, including age, gender, previous coronavirus disease 2019 (COVID-19) infection, systemic immunosuppressive therapy and time on dialysis.

Results

We found a favourable, but profoundly lower SARS-CoV-2 spike protein antibody response in comparison with a non-dialysis cohort (median 253.5 versus 1756 U/mL, P < 0.001). In multivariate analysis, previous COVID-19 infection (P < 0.001) and female gender were associated with a significantly higher vaccine response (P = 0.006) in haemodialysis patients, while there was a significant inverse correlation with increasing patient age and systemic immunosuppression (P < 0.001). There was no statistically significant correlation between the antibody titer and time on dialysis. Immune response in haemodialysis patients with a previous COVID-19 infection led to substantially higher antibody titers that were equal to those of vaccinated non-dialysis individuals with previous infection.

Conclusion

We strongly argue in favour of regular antibody testing after COVID-19 vaccination in haemodialysis patients. Further studies should elucidate the utility of booster vaccinations to foster a stronger and persistent antibody response.

Infection control measures to prevent outbreaks of COVID-19 in Quebec hemodialysis units: a cross-sectional survey

BACKGROUND

Limited space and resources are potential obstacles to infection prevention and control (IPAC) measures in in-centre hemodialysis units. We aimed to assess IPAC measures implemented in Quebec's hemodialysis units during the spring of 2020, describe the characteristics of these units and document the cumulative infection rates during the first year of the COVID-19 pandemic.

METHODS

For this cross-sectional survey, we invited leaders from 54 hemodialysis units in Quebec to report information on the physical characteristics of the unit and their perceptions of crowdedness, which IPAC measures were implemented from Mar. 1 to June 30, 2020, and adherence to and feasibility of appropriate IPAC measures. Participating units were contacted again in March 2021 to collect information on the number of COVID-19 cases in order to derive the cumulative infection rate of each unit.

RESULTS

Data were obtained from 38 of the 54 units contacted (70% response rate), which provided care to 4485 patients at the time of survey completion. Fourteen units (37%) had implemented appropriate IPAC measures by 3 weeks after Mar. 1, and all 38 units had implemented them by 6 weeks after. One-third of units were perceived as crowded. General measures, masks and screening questionnaires were used in more than 80% of units, and various distancing measures in 55%-71%; reduction in dialysis frequency was rare. Data on cumulative infection rates were obtained from 27 units providing care to 4227 patients. The cumulative infection rate varied from 0% to 50% (median 11.3%, interquartile range 5.2%-20.2%) and was higher than the reported cumulative infection rate in the corresponding region in 23 (85%) of the 27 units.

INTERPRETATION

Rates of COVID-19 infection among hemodialysis recipients in Quebec were elevated compared to the general population during the first year of the pandemic, and although hemodialysis units throughout the province implemented appropriate IPAC measures rapidly in the spring of 2020, many units were crowded and could not maintain physical distancing. Future hemodialysis units should be designed to minimize airborne and droplet transmission of infection.