Bourne Auguste, MD, MSc, FRCPC
University of Toronto
The COVID-19 pandemic has and continues to have a profound impact on society and our everyday lives. As of March 2021, more than 2.5 million people around the world have died as result of the pandemic. Patients with kidney failure, particularly those receiving chronic dialysis treatment are at an increased risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulting in higher morbidity and mortality within this vulnerable population. Similarly, a recently published study highlighting the impact of COVID-19 on the dialysis population from Canada’s most populous province, Ontario, showed that patients with kidney failure receiving hemodialysis were five times more likely to be infected compared to the general population.
This pandemic has also highlighted the significant health disparities that exist within various healthcare systems across North America. For instance, a study out of New York City demonstrated that immigrant patients with undocumented status were twice as likely to die from SARS-CoV-2 infection compared to other patients receiving dialysis (Figure 1).
Figure 1: Visual abstract highlighting that patients on dialysis in New York City and Long Island are increased risk of COVID-19 infection compared to general population and risk factors
In recognizing the challenges created by COVID-19 in the early stages of the pandemic, some experts in the United States suggested adjustments in dialysis prescriptions from 4 hours to 3 hours per session to reduce risk of spreading infection between patients and healthcare providers.
Home dialysis adoption in the COVID-19 era
Home dialysis treatments (peritoneal dialysis and home hemodialysis) have been associated with lower risk of SARS-CoV-2 infection compared to in-centre hemodialysis. Emerging data from North America and the United Kingdom indicate patients receiving in-centre hemodialysis are nearly 3 times more likely to contract SARS-CoV-2 infection compared to patients receiving dialysis at home. These differences in infection rates may be attributable to the fact those receiving in-centre dialysis are at increased risk given the need for recurrent visits to the dialysis unit. Additionally, many patients are heavily reliant on public transportation to and from dialysis units which poses inherent risks for infection. Finally, the layout of many dialysis units may be suboptimal in maintaining social distancing measures to reduce infection risk.
As a result, many centres have adopted strategies to mitigate risk and also increase the uptake of home-based dialysis therapies. Patients receiving home dialysis during the COVID-19 pandemic benefited from the fact that they require less visits to healthcare facilities, can maintain their dialysis prescription and adhere to social distancing practices at home (Figure 2). Additionally, the early adoption of telehealth has highlighted the benefits of home dialysis in providing safe and supportive care to patients in the home through virtual care.
Figure 2: Major advantages of home dialysis in the COVID-19 era
Future challenges & opportunities for home dialysis
Although the recently established Advancing American Kidney Health (AAKH) initiative has provided an immense opportunity for home dialysis growth in the United States, there remains significant disparities in home dialysis adoption across different segments of the population. Kidney failure disproportionately affects racial and ethnic minorities and this is further amplified with the disparity that individuals from marginalized populations are less likely to be treated with home dialysis (Figure 3). These differences are primarily driven by a variety of social determinants of health, many of which have been brought to the forefront once again during this pandemic. Health determinants such as a lack of income, food, job and housing may severely impact the quality of care that a patient receives. At the height of the pandemic in April 2020, more than 22 million people filed for unemployment in the United States. As a result, many of the aforementioned health determinants had been further strained within a large segment of the population.
Beyond these health determinants, the adoption of virtual care in home dialysis also poses a set of unique challenges. As mentioned earlier, the virtualization of care has revolutionized medical practice and it will likely remain a significant component in models of care in the post-COVID-19 era. Despite its early success, there are many inequities that still need to be addressed in creating more inclusive models of care for patients on dialysis. There are many language and cultural barriers that have not been explored extensively in the virtualization of care. Additionally, patients may not have access to high-speed internet connections that allow for video-conferencing capabilities, further exacerbating disparities in care by offering patients audio-only options via telephone.
Figure 3: The odds of receiving peritoneal dialysis (A) or home hemodialysis (B) treatment in various races compared to white population. Source: Mehrotra, R et al. JASN vol. 27,7 (2016): 2123-34.
In order to promote more widespread and sustained adoption of home dialysis, we must address inequities in the health care system by providing high-quality care that does not negatively impact these social determinants. We should also explore factors that may widen equity gaps in virtual care as it is likely to remain a prevalent form of care delivery for home dialysis patients in the future. Therefore, beyond funding models and policies that solely incentivize home dialysis adoption, future research should also focus on collecting demographic data. This data will be essential in understanding barriers that various segments of the population face and potential areas for improvement both during austere and normal circumstances. It will also bring to the forefront discussions around health equity, which often remains a forgotten domain in quality improvement practice. The intersection between the COVID-19 pandemic and home dialysis have served as powerful reminders of the current inequities remaining in our healthcare systems. Given the recent push for greater home dialysis adoption with incentivized funding models such as the AAKH initiative, there is a unique opportunity to address these inequities. Monetary incentivization alone will not grow home dialysis but rather a careful analysis of factors that affect its adoption and maintenance across all segments of the population is desperately needed.
Reviewed by Matthew A. Sparks, MD; Amy Yau, MD; Anju Yadav, MD; Nayan Arora, MD