COVID-19 mortality among kidney transplant candidates is strongly associated with social determinants of health

Abstract

The COVID-19 pandemic has affected all portions of the global population. However, many factors have been shown to be particularly associated with COVID-19 mortality including demographic characteristics, behavior, comorbidities, and social conditions. Kidney transplant candidates may be particularly vulnerable to COVID-19 as many are dialysis-dependent and have comorbid conditions. We examined factors associated with COVID-19 mortality among kidney transplant candidates from the National Scientific Registry of Transplant Recipients from March 1 to December 1, 2020. We evaluated crude rates and multivariable incident rate ratios (IRR) of COVID-19 mortality. There were 131 659 candidates during the study period with 3534 all-cause deaths and 384 denoted a COVID-19 cause (5.00/1000 person years). Factors associated with increased COVID-19 mortality included increased age, males, higher body mass index, and diabetes. In addition, Blacks (IRR = 1.96, 95% C.I.: 1.43-2.69) and Hispanics (IRR = 3.38, 95% C.I.: 2.46-4.66) had higher COVID-19 mortality relative to Whites. Patients with lower educational attainment, high school or less (IRR = 1.93, 95% C.I.: 1.19-3.12, relative to post-graduate), Medicaid insurance (IRR = 1.73, 95% C.I.: 1.26-2.39, relative to private), residence in most distressed neighborhoods (fifth quintile IRR = 1.93, 95% C.I.: 1.28-2.90, relative to first quintile), and most urban and most rural had higher adjusted rates of COVID-19 mortality. Among kidney transplant candidates in the United States, social determinants of health in addition to demographic and clinical factors are significantly associated with COVID-19 mortality.

Keywords: clinical research/practice; ethnicity/race; health services and outcomes research; infection and infectious agents; kidney disease; kidney transplantation/nephrology; organ transplantation in general; risk assessment/risk stratification; waitlist management.

FIGURE 1

Rate of COVID-19 mortality by race/ethnicity and age. *Candidate age on March 1, 2020 or the date of listing if after March 1, 2020. “Other” race/ethnic group not displayed [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Rate of COVID-19 mortality by gender and primary diagnosis. * “Other” primary diagnosis not displayed [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 3

Rate of COVID-19 mortality by race/ethnicity, primary insurance, and educational attainment. * “Other” race/ethnicity, “other” insurance, and missing distress index not displayed [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 4

Rate of COVID-19 mortality by race/ethnicity and residential distress index. *Other race and missing residential distress index not shown [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 5

Rate of COVID-19 mortality by race/ethnicity and urban–rural residential continuum. *Other race not shown; original urban–rural continuum categories collapsed to maintain sufficient sample sizes; categories displayed are metropolitan area (population >1 million), metropolitan (population 250 000 ≤ 1 million), urban counties with >20 000 population, and metropolitan areas with <250 000 population and non-metropolitan counties to rural communities. [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 6

Rate of COVID-19 mortality by UNOS region and race/ethnic groups. Race/ethnic groups consolidated to White and non-White (which include Hispanic ethnicity) [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 7

Distribution of COVID-19 mortality in the general population and kidney transplant candidate population by demographic characteristics. Deaths in the general population derived from CDC data through (February 27, 2021) and population demographic characteristics from the US Census (2019). Mortality in the general population by race/ethnicity and gender reflects all available death data; mortality by age only displayed between ages 18–74 for comparison to the transplant candidate population [Color figure can be viewed at wileyonlinelibrary.com]