Excess Death Estimates in Patients with End-Stage Renal Disease - United States, February-August 2020

Abstract

End-stage renal disease (ESRD) is a condition in which kidney function has permanently declined such that renal replacement therapy* is required to sustain life (1). The mortality rate for patients with ESRD in the United States has been declining since 2001 (2). However, during the COVID-19 pandemic, ESRD patients are at high risk for COVID-19-associated morbidity and mortality, which is due, in part, to weakened immune systems and presence of multiple comorbidities (3-5). The ESRD National Coordinating Center (ESRD NCC) supports the Centers for Medicare & Medicaid Services (CMS) and the ESRD Networks^†,§ through analysis of data, dissemination of best practices, and creation of educational materials. ESRD NCC analyzed deaths reported to the Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb), a system that facilitates the collection of data and maintenance of information about ESRD patients on chronic dialysis or receiving a kidney transplant who are treated in Medicare-certified dialysis facilities and kidney transplant centers in the United States. Excess death estimates were obtained by comparing observed and predicted monthly numbers of deaths during February 1-August 31, 2020; predicted deaths were modeled based on data from January 1, 2016, through December 31, 2019. The analysis estimated 8.7-12.9 excess deaths per 1,000 ESRD patients, or a total of 6,953-10,316 excess deaths in a population of 798,611 ESRD patients during February 1-August 31, 2020. These findings suggest that deaths among ESRD patients during the early phase of the pandemic exceeded those that would have been expected based on previous years' data. Geographic and temporal patterns of excess mortality, including those among persons with ESRD, should be considered during planning and implementation of interventions, such as COVID-19 vaccination, infection control guidance, and patient education. These findings underscore the importance of data-driven technical assistance and further analyses of the causes and patterns of excess deaths in ESRD patients.

FIGURE 1

Observed and predicted monthly deaths among patients with end-stage renal disease — United States, January 1, 2016–August 31, 2020 Abbreviation: CROWNWeb = Consolidated Renal Operations in a Web-Enabled Network. * Based on CROWNWeb data from January 1, 2016 through August 31, 2020. ^† Based on a model fit with monthly data from January 1, 2016 through December 31, 2019.

FIGURE 2

Range of high and low estimates of excess deaths per 1,000 ESRD patients, by ESRD Network service area — United States, February 1–August 31, 2020 Abbreviation: ESRD = end-stage renal disease. * High estimates were calculated as the difference between the observed number of deaths and the predicted number of deaths from the model, divided by the number of prevalent ESRD patients as of February 1, 2020. ^† Low estimates were calculated in a similar manner but used the upper end of the one-sided 95% prediction interval from the model in place of the mean model prediction. ^§ Networks 2, 3, and 14 had the highest estimated number of excess deaths per 1,000 patients. Network 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont; Network 2: New York; Network 3: New Jersey, Puerto Rico, and U.S. Virgin Islands; Network 4: Delaware and Pennsylvania; Network 5: District of Columbia, Maryland, Virginia, and West Virginia; Network 6: Georgia, North Carolina, and South Carolina; Network 7: Florida; Network 8: Alabama, Mississippi, and Tennessee; Network 9: Indiana, Kentucky, and Ohio; Network 10: Illinois; Network 11: Michigan, Minnesota, North Dakota, South Dakota, and Wisconsin; Network 12: Iowa, Kansas, Missouri, and Nebraska; Network 13: Arkansas, Louisiana, and Oklahoma; Network 14: Texas; Network 15: Arizona, Colorado, Nevada, New Mexico, Utah, and Wyoming; Network 16: Alaska, Idaho, Montana, Oregon, and Washington; Network 17: American Samoa, Guam, Hawaii, Northern Mariana Islands, and Northern California; Network 18: Southern California.

FIGURE 3

Patterns in observed and predicted monthly deaths in the ESRD population from selected ESRD Network service areas — United States, February 1, 2020–August 31, 2020 Abbreviations: CROWNWeb = Consolidated Renal Operations in a Web-Enabled Network; ESRD = end-stage renal disease. * Observed number of monthly deaths was based on CROWNWeb discharge records. ^† Predicted number of monthly deaths was based on a model fit with data from 2016–2019. One-sided 95% prediction intervals for the model were also calculated.