Management and outcomes of patients on maintenance dialysis during the first and second wave of the COVID-19 pandemic in Geneva, Switzerland

BACKGROUND

Patients on maintenance dialysis are at high risk for serious complications from COVID-19 infection, including death. We present an overview of local experience with dialysis unit management and reorganisation, local epidemiology and outcomes during the COVID-19 outbreak in Geneva, Switzerland, where SARS-CoV-2 incidence was one of the highest in Europe.

METHODS

All SARS-CoV-2-positive outpatients on maintenance dialysis were transferred from their usual dialysis facility to the Geneva University Hospitals dialysis unit to avoid creation of new clusters of transmission. Within this unit, appropriate mitigation measures were enforced, as suggested by the institutional team for prevention and control of infectious diseases.

RESULTS

From 25 February to 31 December 2020, 82 of 279 patients on maintenance dialysis tested positive for SARS-CoV-2 during two distinct waves, with an incidence rate of 73 cases per 100,000 person-days during the first wave and 342 cases per 100,000 during the second wave, approximately four- to six-fold higher than the general population. The majority of infections (55%) during both waves were traced to clusters. Most infections (62%) occurred in men. Sixteen patients (34%) died from COVID-19 related complications. Deceased patients were older and had a lower body mass index as compared with patients who survived the infection.

CONCLUSION

SARS-CoV-2 is associated with high infection and fatality rates in the dialysis population. Strict mitigation measures seemed to be effective in controlling infection spread among patients on maintenance dialysis outside of clusters. Large scale epidemiological studies are needed to assess the efficacy of preventive measures in decreasing infection and mortality rates within the dialysis population.

MO844COVID-19 PANDEMIC IN DIALYSIS PATIENTS IN SWITZERLAND

Background and Aims

COVID-19 is an infectious disease that can result from infection with the novel coronavirus SARS-CoV-2. The disease, was first described in Wuhan at the end of 2019 and the first case in Switzerland was discovered in February 2020. This analysis gives an overview of dialysis patients in Switzerland that were tested COVID-19 positive.

Method

All dialysis centers reported their cases with COVID-19 to the Swiss dialysis registry srrqap. All patients reported to the registry between March 5 (1st dialysis patient with COVID-19) and June 30, 2020 were included in this analysis and comparisons were made with COVID-19-free dialysis patients (from 2019).

Results

On March 5, 2020, the first dialysis patient was infected with COVID-19 in Ticino. The number of infected dialysis patients increased rapidly over the months of March and April, with the majority of patients in the cantons of Vaud (23.5%), Ticino (22.3%) and Geneva (18.8%) and together making up almost 65% of the COVID-19-infected dialysis patients in Switzerland. COVID-19 cases represented 2.4% of all prevalent patients on dialysis (as of 31.12.2019).

Twenty-seven (12 female, 15 male) out of 93 dialysis patients died, which corresponds to a mortality rate of 29%. Mortality was highest in patients from Switzerland (together with the Netherlands), and lowest in Romania with 8.5% (K. Jager and A. Kramer, submitted for publication, 2020).

Mortality was associated with advanced age in dialysis patients. In contrast to the general population, male sex, diabetes and hypertension were no major risk factors for mortality in our cohort.

Conclusion

Although dialysis patients from Switzerland in general have a better survival compared to those from other European countries, infection with COVID-19 in Switzerland results in the highest mortality compared to other European countries in this population. In addition, male sex, diabetes and hypertension seem not to be associated risk factors in our dialysis population.

MO818SURVIVAL ON DIALYSIS: SWITZERLAND IN COMPARISON WITH OTHER COUNTRIES – A FOLLOW UP

Background and Aims

Survival in dialysis patients is substantially reduced compared to the general population. The aim of the present analysis was to compare the survival of dialysis patients in Switzerland with other countries with an additional year of follow up and a higher number of patients.

Method

Incident dialysis patients (hemo- or peritoneal dialysis; N=5'406) from the Swiss dialysis registry were followed up from 2014 to December 31, 2019 (median follow up days=658). Deaths occurring during this time (N=1'353) were recorded and survival was examined using the Kaplan Meier method, censored for transplantation.

Results

Characteristics of the dialysis population stratified according to survival status are provided in Table 1.

Dialysis patients in Switzerland have an approximately 8% higher survival in the first and second year and about 10% higher 5 years after start of dialysis, compared to other European countries (Annual ERA-EDTA Report 2017).

In the first two years, the proportion in survival rates between genders is similar in Switzerland, as well as in Europe. After 5 years, however, a difference in survival rates between genders becomes apparent, with women having a 5-year survival probability of 56.6%, compared to a lower 5-year survival probability of 49.7% in men.

Conclusion

The markedly better survival in dialysis patients in Switzerland compared to other European countries could be confirmed with an additional year of follow up and more patients. Also, causes of death vary widely among European countries. 5-year survival was calculated for the first time, with Switzerland showing almost 10% better survival rates than other European countries.

The ERA-EDTA Registry Annual Report 2018: a summary

Background

The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) Registry collects data on kidney replacement therapy (KRT) via national and regional renal registries in Europe and countries bordering the Mediterranean Sea. This article summarizes the 2018 ERA-EDTA Registry Annual Report, and describes the epidemiology of KRT for kidney failure in 34 countries.

Methods

Individual patient data on patients undergoing KRT in 2018 were provided by 34 national or regional renal registries and aggregated data by 17 registries. The incidence and prevalence of KRT, the kidney transplantation activity and the survival probabilities of these patients were calculated.

Results

In 2018, the ERA-EDTA Registry covered a general population of 636 million people. Overall, the incidence of KRT for kidney failure was 129 per million population (p.m.p.), 62% of patients were men, 51% were ≥65 years of age and 20% had diabetes mellitus as cause of kidney failure. Treatment modality at the onset of KRT was haemodialysis (HD) for 84%, peritoneal dialysis (PD) for 11% and pre-emptive kidney transplantation for 5% of patients. On 31 December 2018, the prevalence of KRT was 897 p.m.p., with 57% of patients on HD, 5% on PD and 38% living with a kidney transplant. The transplant rate in 2018 was 35 p.m.p.: 68% received a kidney from a deceased donor, 30% from a living donor and for 2% the donor source was unknown. For patients commencing dialysis during 2009-13, the unadjusted 5-year survival probability was 42.6%. For patients receiving a kidney transplant within this period, the unadjusted 5-year survival probability was 86.6% for recipients of deceased donor grafts and 93.9% for recipients of living donor grafts.

Results from the ERA-EDTA Registry indicate a high mortality due to COVID-19 in dialysis patients and kidney transplant recipients across Europe

The aim of this study was to investigate 28-day mortality after COVID-19 diagnosis in the European kidney replacement therapy population. In addition, we determined the role of patient characteristics, treatment factors, and country on mortality risk with the use of ERA-EDTA Registry data on patients receiving kidney replacement therapy in Europe from February 1, 2020, to April 30, 2020. Additional data on all patients with a diagnosis of COVID-19 were collected from 7 European countries encompassing 4298 patients. COVID-19-attributable mortality was calculated using propensity score-matched historic control data and after 28 days of follow-up was 20.0% (95% confidence interval 18.7%-21.4%) in 3285 patients receiving dialysis and 19.9% (17.5%-22.5%) in 1013 recipients of a transplant. We identified differences in COVID-19 mortality across countries, and an increased mortality risk in older patients receiving kidney replacement therapy and male patients receiving dialysis. In recipients of kidney transplants ≥75 years of age, 44.3% (35.7%-53.9%) did not survive COVID-19. Mortality risk was 1.28 (1.02-1.60) times higher in transplant recipients compared with matched dialysis patients. Thus, the pandemic has had a substantial effect on mortality in patients receiving kidney replacement therapy, a highly vulnerable population due to underlying chronic kidney disease and a high prevalence of multimorbidity.

COVID-19-related mortality in kidney transplant and dialysis patients: results of the ERACODA collaboration

BACKGROUND

Patients on kidney replacement therapy comprise a vulnerable population and may be at increased risk of death from coronavirus disease 2019 (COVID-19). Currently, only limited data are available on outcomes in this patient population.

METHODS

We set up the ERACODA (European Renal Association COVID-19 Database) database, which is specifically designed to prospectively collect detailed data on kidney transplant and dialysis patients with COVID-19. For this analysis, patients were included who presented between 1 February and 1 May 2020 and had complete information available on the primary outcome parameter, 28-day mortality.

RESULTS

Of the 1073 patients enrolled, 305 (28%) were kidney transplant and 768 (72%) dialysis patients with a mean age of 60 ± 13 and 67 ± 14 years, respectively. The 28-day probability of death was 21.3% [95% confidence interval (95% CI) 14.3-30.2%] in kidney transplant and 25.0% (95% CI 20.2-30.0%) in dialysis patients. Mortality was primarily associated with advanced age in kidney transplant patients, and with age and frailty in dialysis patients. After adjusting for sex, age and frailty, in-hospital mortality did not significantly differ between transplant and dialysis patients [hazard ratio (HR) 0.81, 95% CI 0.59-1.10, P = 0.18]. In the subset of dialysis patients who were a candidate for transplantation (n = 148), 8 patients died within 28 days, as compared with 7 deaths in 23 patients who underwent a kidney transplantation <1 year before presentation (HR adjusted for sex, age and frailty 0.20, 95% CI 0.07-0.56, P < 0.01).

CONCLUSIONS

The 28-day case-fatality rate is high in patients on kidney replacement therapy with COVID-19 and is primarily driven by the risk factors age and frailty. Furthermore, in the first year after kidney transplantation, patients may be at increased risk of COVID-19-related mortality as compared with dialysis patients on the waiting list for transplantation. This information is important in guiding clinical decision-making, and for informing the public and healthcare authorities on the COVID-19-related mortality risk in kidney transplant and dialysis patients.

Incidence of glomerulonephritis in the western part of Switzerland over the last decade

BACKGROUND

Glomerulonephritis is a rare yet serious group of diseases with a high risk of progression to end-stage renal disease. For optimal healthcare planning, detailed epidemiological and demographic data are essential. Despite their clinical relevance, these data are largely lacking in Switzerland.

OBJECTIVE

The objective of this study was to assess the incidence of the different forms of glomerulonephritis in the western part of Switzerland and its changes over the last 10 years, compared with international data.

METHODS

We listed all renal biopsy reports analysed between 2007 and 2016 at the University hospital of Lausanne, the renal pathology reference centre of all hospitals in the cantons of Vaud, Fribourg, Valais and Neuch&acirc;tel. Biopsies with a first diagnosis of primary glomerulonephritis were included in the analysis. The incidence was calculated as the number of patients newly diagnosed with glomerulonephritis divided by the number of inhabitants of all the above-mentioned cantons during the year under review, as retrieved from the federal statistical office of Switzerland.

RESULTS

We collected biopsy reports from 864 patients between 2007 and 2016; 168 biopsies met the inclusion criteria. The most common primary glomerulonephritis was IgA nephropathy at 32.7% of cases, followed by lupus nephritis (29.8%) and pauci-immune glomerulonephritis (11.9%). Overall, the mean incidence of glomerulonephritis was 1.3/100,000/year. Between 2007 and 2016, the incidence of all glomerulonephritis taken together remained stable. The same was true for the incidence of IgA nephropathy, lupus nephritis and pauci-immune glomerulonephritis. In contrast, we observed a trend towards higher creatinine levels, proteinuria and degree of interstitial fibrosis at diagnosis.

CONCLUSION

The incidence of glomerulonephritis in the western part of Switzerland was low and remained stable over time, in line with European data.

The ERA-EDTA Registry Annual Report 2017: a summary

Background

This article presents a summary of the 2017 Annual Report of the European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry and describes the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 37 countries.

Methods

The ERA-EDTA Registry received individual patient data on patients undergoing RRT for ESRD in 2017 from 32 national or regional renal registries and aggregated data from 21 registries. The incidence and prevalence of RRT, kidney transplantation activity and survival probabilities of these patients were calculated.

Results

In 2017, the ERA-EDTA Registry covered a general population of 694 million people. The incidence of RRT for ESRD was 127 per million population (pmp), ranging from 37 pmp in Ukraine to 252 pmp in Greece. A total of 62% of patients were men, 52% were ≥65 years of age and 23% had diabetes mellitus as the primary renal disease. The treatment modality at the onset of RRT was haemodialysis for 85% of patients. On 31 December 2017, the prevalence of RRT was 854 pmp, ranging from 210 pmp in Ukraine to 1965 pmp in Portugal. The transplant rate in 2017 was 33 pmp, ranging from 3 pmp in Ukraine to 103 pmp in the Spanish region of Catalonia. For patients commencing RRT during 2008–12, the unadjusted 5-year patient survival probability for all RRT modalities combined was 50.8%.

P1377ANEMIA MANAGEMENT IN DIALYSIS PATIENTS IN SWITZERLAND

Background and Aims

Anemia is highly prevalent in dialysis patients and is associated with increased morbidity and mortality. The purpose of the present analysis is to evaluate current anemia management in dialysis patients in Switzerland collected from the Swiss Dialysis Registry (srrqap), which covers all dialysis patients in Switzerland.

Method

All medical establishments in Switzerland (both public and private; N=92) providing chronic treatment by either hemo- and/or peritoneal dialysis, had to provide relevant data for the year 2018. All individuals being on chronic dialytic therapy in the year 2018 were enrolled (N=4646). To calculate survival probabilities, all deaths from incident dialysis patients between 2014 and 2018 were analyzed.

Results: 65 percent of all dialysis patients receive iron and EPO. Regardless of anemia management, 82% of patients reach target hemoglobin levels 10 g/dL. In 18% of patients inadequate management to reach Hb targets may be suspected.

The distribution of iron and EPO substitution is similar in all age groups. However, 26% of the age group 20-44 years receive EPO, but no iron, compared to only 15% in the other age groups.

Survival analysis by Cox regression adjusted for age, Charlson score and treatment modality revealed that patients with Hb levels equal or greater than 11 g/dl have the best survival (reference group). In comparison, patients in the Hb categories below 9, 9-9.9 and 10-10.9 g/dl have an odds ratio of 3.9, 2.0 and 1.3, respectively, to die.

Conclusion

Anemia management to reach Hb target levels following KDIGO guidelines seems to be adequately implemented among dialysis patients in Switzerland. In 18% of patients treatment might be optimized to achieve Hb targets. As expected, patients with Hb levels equal or greater than 11 g/dl have better survival rates compared to patients with lower Hb values.

P1517SURVIVAL ON DIALYSIS: SWITZERLAND IN COMPARISON WITH OTHER COUNTRIES - A FOLLOW UP

Background and Aims

Survival in dialysis patients is substantially reduced compared to the general population. The aim of the present analysis was to compare the survival of Swiss dialysis patients with other countries with an additional year of follow up and a higher number of patients.

Method

Incident dialysis patients (hemo- or peritoneal dialysis; N=4525) from the Swiss dialysis registry were followed up from 2014 on until December 31, 2018 (mean follow up days=684). Deaths occurring during this time (N=976) were recorded and survival was examined using the Kaplan Meier method, censored for transplantation.

Results

Characteristics of the dialysis population stratified according to survival status are provided in Table 1.

Dialysis patients in Switzerland have an approximately 8% higher survival in the first and second year after start of dialysis compared to other European countries (Annual ERA-EDTA Report 2016). In the oldest age group, it amounts to up to 13 and 14%, in the first and in the second year, respectively. The proportion in survival rates between genders is similar in Switzerland, as well as in Europe. Dialysis patients aged younger than 45 years have a worse survival in Switzerland compared to other European countries.

Conclusion

The markedly better survival in dialysis patients in Switzerland compared to other European countries could be confirmed with an additional year of follow up and more patients. Also, causes of death vary widely among European countries. With an additional year of follow up, data to analyze 5-year survival probability will be available for comparison with the ERA-EDTA report. In addition, we will be able to verify whether dialysis patients under 45 years in Switzerland have an increased mortality or whether this is due to the small number of patients in these two age groups.

P1467DEMOGRAPHY OF THE DIALYSIS POPULATION IN SWITZERLAND IN 2018

Background and Aims

The national Swiss Dialysis Registry (srrqap) has been established originally in the year 2006. However, participation is substantial only since 2013, when data collection became mandatory by law. The primary aim of the srrqap is to provide quality control and quality improvement for dialysis therapy in Switzerland. In the present analysis, select demographic characteristics of the Swiss dialysis population are given.

Method

All medical establishments in Switzerland (both public and private; N=92) providing chronic treatment by either hemo- and/or peritoneal dialysis, had to provide relevant data for the year 2018. All individuals being on chronic dialytic therapy in the year 2018 were enrolled (N=4646). For patients alive on December 31 2018, data were gathered from this date or closest to this date. For patients who died during 2018 or were being transplanted, data refer to time of event, or to a date closest to the event.

Results

The median age of dialysis patients in 2018 increased almost by one year compared to 2016. More than fifty percent of the patients were older than 71 years, and nearly ¼ were beyond 80 years. No relevant differences were found between female and male patients regarding mean age (68.6 vs. 68.3 years, respectively). However, women‘s dialysis vintage is significantly higher than men’s (54.4 vs. 45.7 months, respectively) and they are significantly less comorbid than men (4.2 vs. 4.7).

Conclusion

With a coverage of 100% for both centers and patients, the data gathered can be considered highly representative. The incidence of dialysis therapy in Switzerland with 95.9 pmp is clearly lower than in most other countries. In 2018, 3789 prevalent patients (443.7 pmp) were dialyzed in Switzerland. The number of dialysis patients with diabetes increased by almost 1% from 2017, reaching 37.4%.

The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report 2016: a summary

Background

This article summarizes the ERA-EDTA Registry’s 2016 Annual Report, by describing the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 2016 within 36 countries.

Methods

In 2017 and 2018, the ERA-EDTA Registry received data on patients undergoing RRT for ESRD in 2016 from 52 national or regional renal registries. In all, 32 registries provided individual patient data and 20 provided aggregated data. The incidence and prevalence of RRT and the survival probabilities of these patients were determined.

Results

In 2016, the incidence of RRT for ESRD was 121 per million population (pmp), ranging from 29 pmp in Ukraine to 251 pmp in Greece. Almost two-thirds of patients were men, over half were aged ≥65 years and almost a quarter had diabetes mellitus as their primary renal diagnosis. Treatment modality at the start of RRT was haemodialysis for 84% of patients. On 31 December 2016, the prevalence of RRT was 823 pmp, ranging from 188 pmp in Ukraine to 1906 pmp in Portugal. In 2016, the transplant rate was 32 pmp, varying from 3 pmp in Ukraine to 94 pmp in the Spanish region of Catalonia. For patients commencing RRT during 2007–11, the 5-year unadjusted patient survival probability on all RRT modalities combined was 50.5%. For 2016, the incidence and prevalence of RRT were higher among men (187  and 1381 pmp) than women (101 and 827 pmp), and men had a higher rate of kidney transplantation (59 pmp) compared with women (33 pmp). For patients starting dialysis and for patients receiving a kidney transplant during 2007–11, the adjusted patient survival probabilities appeared to be higher for women than for men.