Incidence and Clinical Impacts of COVID-19 Infection in Patients with Hemodialysis: Systematic Review and Meta-Analysis of 396,062 Hemodialysis Patients

Abstract Background: Better understanding of incidence and clinical outcomes of COVID-19 infection in hemodialysis (HD) patients could assist healthcare providers to develop proper preventive strategies and optimal management. However, no published systematic review summarizes current epidemiological evidence regarding COVID-19 infection in HD patients.Methods: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched PUBMED and EMBASE for articles published on incidence or mortality of COVID-19 infection in maintenance HD patients until September 2020, and conducted meta-analysis of proportions for incidence and mortality rate. Heterogeneity was measured by Cochran’s Q and I2 statistic. Publication bias was evaluated by Egger’s test. The study protocol was registered in the PROSPERO database (CRD42020209134).Results: In total, 29 articles with 3,261 confirmed COVID-19 cases from pooled 396,062 HD patients were identified. Overall COVID-19 incidence in these HD patients was 7.7% (95% CI: 5.0-10.9%), with significant heterogeneity among the studies (I2 = 99.7%, p<0.001) and risk of publication bias (Egger’s test, p<0.001). Overall mortality rate was 22.4% (95% CI: 17.9-27.1%) in HD patients with COVID-19, with significant heterogeneity among the studies (I2 = 87.1%, p<0.001). Reported incidence and mortality varied by geographic area, being higher in non-Asian- than Asian countries.Conclusions: Both incidence and mortality of COVID-19 infection were higher in HD patients. Available data may underestimate the real incidence of infection because screening and diagnosis differ between countries. International collaboration and standardized reporting of future epidemiologic studies is encouraged to improve clinical outcomes of COVID-19 infection in HD patients.