key: cord-0858861-15z7dzvx
authors: Weinhandl, Eric D.; Gilbertson, David T.; Wetmore, James B.; Johansen, Kirsten L.
title: COVID-19-Associated Decline in the Size of the End Stage Kidney Disease Population in the United States
date: 2021-07-24
journal: Kidney Int Rep
DOI: 10.1016/j.ekir.2021.07.019
sha: 487372d7dfd000ce7475cbb9793dcb6ad32b2003
doc_id: 858861
cord_uid: 15z7dzvx

nan

According to the United States Renal Data System (USRDS), the number of people with end stage kidney disease (ESKD) in the United States has increased every year between 1980 and 2018. 1, 2 Between 1980 and 2000, increasing prevalence mostly reflected rapidly increasing incidence of ESKD. Since 2000, increasing prevalence has shifted toward improved survival among patients on maintenance dialysis, as well as those with a functioning kidney transplant.

Recent forecasting of the size of the ESKD population had suggested continued growth during the 2020's. 3 However, no forecast could have anticipated the novel coronavirus disease 2019 (COVID-19) pandemic. During the early part of the pandemic, all-cause mortality was 17% and 30% higher than expected among dialysis and transplant patients, respectively, while the number of patients who initiated kidney replacement therapy (KRT) declined sharply. 2, 4 Considering that the rate of COVID-19 hospitalization was approximately 40 times higher among dialysis patients than in the general population, 4 it is likely that substantial mortality also occurred during the past winter. In this report, we quantified the impact of COVID-19 on the size of the ESKD population at one year after the declaration of a national emergency.

We analyzed data extracted from the End Stage Renal Disease Quality Reporting System (EQRS) in May 2021. For each epidemiologic week (Sunday to Saturday) from week 1 of 2015 to week 13 of 2021, we identified all patients with ESKD at the beginning of the week. We patients, representing a year-over-year decline of 0.6% and a "deficit" of 3.5%, relative to the forecast of 833,236 ESKD patients. Among patients undergoing dialysis, the year-over-year decline in census was 1.6%, representing a deficit of 3.8%, relative to forecast. In all dialysis patient subgroups except Asian patients, the census declined ( Table 1 ). The largest deficits, relative to forecast, were observed among patients aged ≥75 years and non-Hispanic White patients. Among patients with a transplant, the census increased 1.8% between week 13 of 2020 and week 13 of 2021, but the census in week 13 of 2021 was nevertheless 2.9% lower than was forecasted. All transplant patient subgroups experienced year-over-year growth, with relatively larger growth in elderly (age ≥65 years), non-Hispanic Black, and Asian patients (Table 1) . Still, all subgroups experienced lower growth than was forecasted.

The President of the United States declared a national emergency on March 13, 2020.

During the ensuing year, three large waves of COVID-19 swept the United States, resulting in nearly 600,000 deaths due to COVID-19. 5 Remarkably, for the first time in history (dating to 1980), the size of the ESKD population in the United States declined, led by a 1.6% decrease in the number of patients on dialysis. Relative to what was forecasted as a function of long-run trends, the numbers of dialysis and transplant patients in week 13 of 2021 were roughly 4% and 3% lower, respectively. These deficits can be attributed to a combination of changes in ESKD J o u r n a l P r e -p r o o f incidence, kidney transplant incidence, and mortality risk. ESKD incidence was likely lower, kidney transplant incidence was somewhat higher (despite a decrease in living donor kidney transplantation), 6 and mortality risk was almost certainly higher, regardless of the type of KRT.

Variability in year-over-year changes in patient counts among strata defined by age and race/ethnicity offer a mixed picture. Relative to forecasted counts, larger deficits among elderly patients probably reflect that age is a risk factor for COVID-19 hospitalization and death. A contributing factor may be lower incidence, due to COVID-19 mortality in people with advanced chronic kidney disease (CKD) and decisions to defer dialysis initiation in those who remained alive. With respect to race/ethnicity, the story may be more nuanced. Both Black and Hispanic people have suffered greatly during the pandemic. Acute kidney injury associated with COVID-19 may have accelerated loss of kidney function in patients with CKD, 7 thereby placing upward pressure on ESKD incidence and partly countering the downward pressure of COVID-19 mortality on the number of dialysis patients. The precise calculus of how incidence and mortality influenced the size of ESKD population within subgroups remains to be elucidated. Our report is preliminary, with counts subject to minor revisions as late submissions of the End Stage Renal Disease Medical Evidence Report and Death Notification are collected.

We suggest that there are three implications of these data. First, recent forecasts of the number of ESKD patients during the 2020's are now invalid. This has direct consequences for outpatient dialysis capacity and corresponding labor needs in the next several years, especially considering the drive toward greater adoption of home dialysis modalities. Second, due to the year-over-year decrease in the number of dialysis patients and an apparent surge in Medicare Advantage enrollment during the past open enrollment period, 8 original Medicare (i.e., Parts A and B) is suddenly much less exposed to the total cost of care for dialysis patients. This shift has J o u r n a l P r e -p r o o f profound consequences not only for federal entitlement expenditures on ESKD, but also for quality measurement systems that have been built on Parts A and B claims. Third, as the base payment for an outpatient hemodialysis session covered by Part B has increased from $229.63 in 2011 to $239.33 in 2020, 9 dialysis providers have relied on steadily increasing treatment volume to address treatment cost inflation. For small and rural dialysis providers, which are more likely to operate with negative margins, 10 any decrease in the number of dialysis patients is a potential existential threat to operations, possibly forcing further consolidation among providers.

As the pandemic abates, it is plausible that the ESKD population in the United States will grow again. After all, the US population is aging, thereby placing upward pressure on ESKD incidence. Nevertheless, with essentially static adjusted incidence of ESKD and likely expansion of sodium-glucose cotransporter-2 inhibitor utilization, it is also possible that the number of dialysis patients in the country is nearing an apex, thus providing an opportunity for the ESKD population to shift away from its long-standing mixture of 70% of patients undergoing dialysis and 30% of patients with a functioning transplant. 2 However, the future is admittedly uncertain.

Whether the number of people with advanced CKD and high risk of progression to ESKD has declined during the past year is unknown. Even the impact of COVID-19 on outcomes during the upcoming winter is unknown. Continued surveillance will be necessary to guide the nephrology community and policymakers alike. 

Annual Data Report: Epidemiology of Kidney Disease in the United States

BM: Projecting ESRD Incidence and Prevalence in the United States through 2030

Initial Effects of COVID-19 on Patients with ESKD

Organ Procurement and Transplantation Network: National Data

FP: Assessment of Acute Kidney Injury and J o u r n a l P r e -p r o o f Longitudinal Kidney Function After Hospital Discharge Among Patients With and Without COVID-19

Q1 2021 DaVita Inc. Earnings Conference Call

Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, and End-Stage Renal Disease Quality Incentive Program

Medicare Payment Advisory Commission

Patients (N 1000s) undergoing maintenance dialysis Patients (N 1000s) with a functioning transplant Dialysis: forecasted census Dialysis: observed census Transplant: forecasted census Transplant: observed census