Vaccination, Treatment Decisions Studied in Adults with Kidney Diseases during COVID-19

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Two recent studies published in CJASN address different aspects of the COVID-19 pandemic in adults with advanced kidney diseases: one examines whether prior COVID-19 vaccination affected the outcomes of individuals on dialysis who became infected with SARS-CoV-2 (1), and the other assesses the pandemic's impact on treatment decision-making for older patients with chronic kidney disease (CKD) (2).

People with CKD or other severe chronic medical conditions are at higher risk for more serious COVID-19 illness, and patients with kidney failure who rely on in-center hemodialysis face an elevated risk of becoming exposed to the SARS-CoV-2 virus. Research has shown that individuals undergoing hemodialysis have impaired immune responses to COVID-19 vaccines, but few studies have described the efficacy of COVID-19 vaccination in such patients.

To investigate, scientists conducted a multi-center observational study of patients who were receiving hemodialysis in London and who were regularly tested for COVID-19 during the period of vaccine rollout with Pfizer-BioNTech's mRNA-based BNT162b2 and AstraZeneca's adenovirus-based AZD1222. SARS-CoV-2 infection was identified in 1323 patients of different ethnicities (Asian/other, 30%; Black, 38%; and White, 32%), including 1047 (79%) unvaccinated, 86 (7%) after first-dose vaccination, and 190 (14%) after second-dose vaccination. Most patients who tested positive had a mild course of COVID-19, but 515 (39%) were hospitalized, and 172 (13%) died.

Results indicated that older age, diabetes, and immune suppression were associated with greater illness severity. After adjustments, prior two-dose vaccination was associated with a 75% lower risk of hospital admission and an 88% lower risk of death compared with no vaccination. The researchers found it notable that no loss of protection against COVID-19 was seen in patients older than 65 years or with increasing time since vaccination, and no difference was seen between vaccine types.

“COVID-19 continues to be common in patients on dialysis, causing hospital admissions and death, but fortunately it is milder with two doses of the vaccine,” said senior author Debasish Banerjee, MD, FRCP, of St George's University Hospitals, National Health Service (NHS) Foundation Trust, London.

An accompanying editorial (3) noted that the study's encouraging results may prove the effectiveness of COVID-19 vaccines for patients on dialysis, but there is still much work to be done. The authors—Matthew J. Oliver, MD, MHS, FRCPC, and Peter G. Blake, MB, MSc, FRCPC, of Ontario Health—emphasized the importance of looking back and carefully evaluating the clinical effect of decisions made during the pandemic, including the early decision to offer vaccination to patients without high-level evidence of benefit. “While the COVID-19 pandemic is ever changing, making vaccine studies challenging, it also provides new opportunities to examine vaccine effectiveness from many different angles,” they wrote.

In an accompanying Patient Voice article (4), Uwe K. H. Korst, a patient consultant and a co-chair of ERKNet, The European Rare Kidney Disease Reference Network, advocates for additional education for patients, nurses, doctors, and the public to increase vaccine acceptance. He also stressed the need to ensure that patients' voices are heard.

Another concern during the COVID-19 pandemic relates to how uncertainty surrounding the evolving pandemic influences shared decision-making among clinicians, patients with advanced CKD, and their care partners. To investigate this issue, researchers of this second recent study (2) interviewed 76 adults (39 older patients with advanced CKD, 17 care partners, and 20 nephrology clinicians) from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020. The interviews revealed that clinicians perceived greater vulnerability among older patients with CKD and more readily encouraged home-based modalities for these patients during the COVID-19 pandemic, but their discussions of vulnerability, advanced care planning, and conservative management remained limited.

Lack of discussions of COVID-19-related risks, fewer education options, and inconsistent discussions of advanced care planning and conservative management left patients with unaddressed concerns and the need to navigate the emerging COVID-19 guidance on their own. Despite heightened uncertainty, patient preferences for treatment modality (such as dialysis) remained stable, and most perceived their chosen modality to be the safest, the researchers found. Importantly, clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations.

“To improve shared decision-making during the pandemic and its aftermath, clinicians should promote and encourage conversations with patients who want to talk about COVID-19, with an emphasis on safety and quality of life, including the risks posed to them by COVID-19 and the impact of COVID-19 on treatment options. These discussions should present all options, including conservative management, and incorporate advanced care planning,” said senior author Keren Ladin, PhD, MSc, of Tufts University. “Also, clinician burnout must be addressed with adequate resources and appropriate training.”