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

Abstract

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.

Keywords: COVID-19; dialysis; kidney; mortality; transplantation.

FIGURE 1

Vital status at Day 28 after presentation with COVID-19 of (A) kidney transplant (n = 305) and (B) haemodialysis patients (n = 768).

FIGURE 2

Relationship between age, clinical frailty score and 28-day case-fatality rate in (A) kidney transplant and (B) dialysis patients with COVID-19. Age and clinical frailty scores are subdivided into three clinical classes.

FIGURE 3

Association of demographic factors, major cardiovascular disease risk factors and chronic lung disease with 28-day mortality in dialysis and kidney transplant patients with COVID-19. Results are shown for a full adjusted multivariate model that includes the covariates shown in the graphs to allow comparison with data from the literature. Panel (A) shows results for patients on dialysis. Panel (B) shows results for patients living with a kidney transplant.