Reduced COVID-19 morbidity and mortality in hemodialysis patients across the various Omicron sublineages-A retrospective analysis

Abstract

Introduction: Hemodialysis (HD) patients are a COVID-19 high risk population due to comorbidities and impaired immune response. Vaccines, advent of effective treatment and the emergence of novel variants have fundamentally changed the pandemic. We aimed to assess temporal changes of COVID-19 in HD patients of our catchment area, and risk factors for severe and fatal course.

Methods and materials: We retrospectively collected data from 274 patients admitted to the Medical University Graz, Austria for HD between 1st of May 2020 and 31st of August 2022. We analyzed clinical and demographic data between different COVID-19 waves and assessed factors associated with hospitalization, ICU admission and mortality by logistic regression. To further evaluate the dialysis at-risk population, we collected demographic and vaccination data between August 2021 and August 2022.

Results: Time of infection and SARS-CoV-2 sequencing data allowed for distinction of five separate waves of infection with different impact on the dialysis population: While in the initial four waves frequencies of hospitalization, necessity of critical care and mortality were around 60%, 10% and 20%, respectively. These events became rare during the large fifth wave, when Omicron had become the dominant variant. Although only 16.9% had to be hospitalized, this resulted in 29 hospital admissions, due to the high prevalence of COVID-19 during the Omicron era. Furthermore, we observed similar clinical outcomes with BA.4/5 as with BA.1/BA.2 Omicron sublineages. The proportion of previously infected increased simultaneously with the number of vaccination doses in our dialysis population. Vaccination at time of positivity and infection with an Omicron variant conferred protection against hospitalization and mortality in univariate analysis, but only infection with an Omicron variant remained a robust predictor for these outcomes in multivariable analysis.

Discussion: While a fourth of our at-risk population became infected during the Omicron wave, mortality was almost non-existent. Several concomitant factors have contributed to the decrease of COVID-19 severity in HD patients. This trend appears to be continued with BA.4/5, which was equally mild as BA.1 and BA.2 in our well vaccinated dialysis population.

Keywords: BA.4/5; COVID-19; Omicron; hemodialysis; vaccination.

Figure 1

Participating dialysis centers are depicted on a geographical map of Austria with an auxiliary map of Graz (right side). Remote dialysis facilities are shown as blue dots and hospital-based dialysis units are represented as red dots.

Figure 2

(A) PCR confirmed SARS-CoV-2 positive hemodialysis patients in our catchment area are displayed over time and for the duration of PCR positivity. (B) Weekly new PCR confirmed SARS-CoV-2 cases are depicted. Vertical dotted lines indicate different waves.

Figure 3

Dynamics of the at-risk hemodialysis population between 31st of August 2021 (Left) and 31st of August 2022 (Right) are shown.

Figure 4

(A) Vaccination coverage and (B) proportion of recovered HD patients (defined as 28 days after the first PCR positivity) of the at-risk hemodialysis population between 31st of August 2021 and 31st of August 2022 are shown. Gray lines indicate the total number of dialysis patients. The dotted vertical lines indicate the switch from Delta to Omicron wave.

Figure 5

(A) Prevalence and (B) incidence of SARS-CoV-2 positive cases on hemodialysis between 31st of August 2021 and 31st of August 2022. The dotted lines mark the switch from Delta to BA.1/BA.2 and from BA.1/BA.2 to BA.4/5 infections, respectively.