COVID-19 Hospitalization and Mortality Trends Among US Dialysis Patients by Race/Ethnicity and Vaccination Status

Rationale & Objective

The coronavirus disease 2019 (COVID-19) pandemic disproportionately affected vulnerable individuals, including people with kidney disease. We elucidated longitudinal trends in hospitalization and mortality among individuals receiving maintenance dialysis before and during the pandemic and explored how universal vaccine availability affected COVID-19 outcomes by race/ethnicity.

Study Design

A retrospective cohort study.

Settings & Participants

Adult maintenance dialysis patients between 2018-2023 at a national not-for-profit US provider.

Predictors

COVID-19 era (2020-2023), race/ethnicity.

Outcomes

COVID-19 vaccination status; hospitalization and death (COVID-related, all-cause).

Analytical Approach

Zero-inflated Poisson models and logistic regression models were used to calculate hospitalization and mortality rates, respectively, adjusted for age, sex, race/ethnicity, dialysis vintage, and number of comorbid conditions.

Results

Among 41,257 patients receiving maintenance dialysis, all-cause hospitalization dropped abruptly in March/April 2020 and increased thereafter, albeit remaining below prepandemic rates. All-cause mortality exhibited typical seasonal variability during 2018-2019, subsequently increasing with onset of the COVID-19 pandemic in March 2020. Mortality peaked in January 2021 at 228 deaths per 1,000 person-years before declining to 151 deaths per 1,000 person-years in March 2021. Subsequently, mortality transiently increased during the Delta and Omicron variant periods, peaking at 188 and 189 deaths per 1,000 person-years, respectively. Thereafter, all-cause mortality remained below prepandemic levels. After widespread SARS-CoV-2 vaccine availability in 2021 with vaccine provision in dialysis facilities, the COVID-19 mortality rate among all race/ethnicity groups declined significantly (b = −5.3; P < 0.001). There were no statistically significant differences by race/ethnicity in the vaccination status at each year’s end.

Limitations

Potential residual confounders and underreporting of COVID-19–related outcomes.

Conclusions

All-cause mortality increased sharply in 2020 and early 2021, reflecting COVID-19-related deaths, whereas non–COVID-19 mortality declined during the early phase of the pandemic and subsequently remained below prepandemic levels. After introduction of SARS-CoV-2 vaccines, all-cause mortality declined to below prepandemic levels, likely reflecting the impact of widespread vaccination in the dialysis population.

Plain-Language Summary

This study evaluated trends for mortality, hospitalization, and vaccination status, before and during the coronavirus disease 2019 (COVID-19) pandemic in a national US dialysis cohort. Among 41,257 patients, all-cause hospitalization rates abruptly dropped in March 2020 despite an increase in all-cause mortality, coinciding with the national lockdown when the pandemic began. COVID-19–related mortality dropped significantly among all races/ethnicities after the availability of COVID-19 vaccines in 2021, with similar vaccination rates for dialysis patients attained across racial/ethnic groups. The continued vulnerability of patients on maintenance dialysis to severe COVID-19 outcomes highlights the need to maintain universal access to vaccines at their most convenient venue while promoting continuous updated vaccine status to limit COVID-19–related hospitalization and death in this high-risk population.