Understanding dialysis patient COVID-19-related mortality

Background: Reported COVID mortality in dialysis patients is high and ranges from 15-25%. We reviewed data from a prospective 14-month study of seriously ill (SI) dialysis patients pre-COVID (May 2019-January 2020) and during COVID (February 2020-June 2020) to better understand COVID-related mortality in SI and not SI patients. Methods: We recruited 10 dialysis centers (6 in NYC, 3 in Denver, CO, and 1 in Dallas, TX) with 1,507 patients. Dialysis staff screened patients monthly with the surprise question (SQ)-Would I be surprised if this patient died in the next 6 months-and recorded outcomes. Those with a No response were identified as SI. A SQ No response is known to identify older patients with multiple comorbidities and an increased risk of early mortality. In this rolling population, we calculated the monthly mortality risk prior to and during COVID and determined the relative risk of death (RR) for SI compared to not SI during both periods. We also compared the increased mortality risk during COVID between patients dialyzed in NYC vs. Denver and Dallas and used logistic regression to determine whether COVID-19-related mortality differed by geographic region. Results: Over 14 months, dialysis centers screened a monthly average of 1,342/1,507 (89.1%) patients and identified 274 (18.2%) as SI, with more consistent screening pre-COVID than during COVID (98.6% vs. 71.2%). Pre-COVID, the monthly mortality rate for SI patients was 2.8% and for not SI patients 0.4%, (RR 7.02, 95% CI, 4.76-10.44). During COVID, the monthly mortality rate for SI patients increased to 4.8% and for not SI to 1.5% (RR 3.19, 95% CI, 2.28-4.44). The absolute increase in monthly mortality risk from pre-COVID to COVID was greater for SI than for not SI patients, 2.0% vs 1.1%. The excess monthly mortality was higher in NYC (2.3% for SI and 1.2% for not SI) than in Denver and Dallas (1.3% for SI and 0.7% for not SI), but the difference was not significant (p = .12). Conclusions: A No response to the SQ identified SI dialysis patients whose 5-month mortality during COVID increased to 23.9% (annualized rate 57.4%). For not SI, the 5-month mortality rate during COVID increased to 7.5% (annualized rate 18%). These findings underscore the importance of advance care planning not only for SI patients but also for all dialysis patients, who are particularly vulnerable to concurrent infections such as COVID-19.