IMPact of the COVID-19 epidemic on the moRTAlity of kidney transplant recipients and candidates in a French Nationwide registry sTudy (IMPORTANT)

Abstract

End stage kidney disease increases the risk of COVID-19 related death but how the kidney replacement strategy should be adapted during the pandemic is unknown. Chronic hemodialysis makes social distancing difficult to achieve. Alternatively, kidney transplantation could increase the severity of COVID-19 due to therapeutic immunosuppression and contribute to saturation of intensive care units. For these reasons, kidney transplantation was suspended in France during the first epidemic wave. Here, we retrospectively evaluated this strategy by comparing the overall and COVID-19 related mortality in kidney transplant recipients and candidates over the last three years. Cross-interrogation of two national registries for the period 1 March and 1 June 2020, identified 275 deaths among the 42812 kidney transplant recipients and 144 deaths among the 16210 candidates. This represents an excess of deaths for both populations, as compared with the same period the two previous years. This difference was integrally explained by COVID-19, which caused the death of 44% of recipients and 42% of candidates. Taking into account the size of the two populations and the geographical heterogeneity of virus circulation, we found that the excess of risk of death due to COVID-19 was similar for recipients and candidates in high viral risk area but four-fold higher for candidates in the low viral risk area. Thus, in case of a second epidemic wave, kidney transplantation should be suspended in high viral risk areas but maintained outside those areas, both to reduce the excess of deaths of candidates and avoid wasting precious resources.

At least 156 reasons to prioritize COVID-19 vaccination in patients receiving in-centre haemodialysis

“…Vulnerability in uraemic patients is a combination of intrinsic frailty, increased risk of infection (vascular access, exposure to infected individuals) and a high burden of comorbidities [ 1 ]. Although patients on dialysis have a similar overall high risk of death from COVID-19 to patients with kidney transplants [ 4 ], patients on HD and on the waiting list have a 2-fold higher risk of infection because of risk inherent to the HD process [ 5 ]. Age per se is a less significant risk factor among those on dialysis compared with the general population [ 1 ].…”

On the need to better protect hemodialysis patients: a comment on “IMPact of the COVID-19 epidemic on the moRTAlity of kidney transplant recipients and candidates in a French Nationwide registry sTudy (IMPORTANT)”

“…We read with interest the IMPORTANT study, focused on the impact that COVID-19 has had on dialysis and transplant patients. 1 The authors report that 44% and 42% of the deaths recently recorded in kidney transplant recipients and dialysis patients candidates for transplantation, respectively, are attributable to COVID-19 and clearly show that these deaths are in excess over the mortality observed in the previous year. Interpreting these results, the authors are in favor of maintaining kidney transplant activity, at least in areas of low viral circulation, to remove patients from the dialysis pool and thereby protect them from the excess mortality related to dialysis.…”

The authors reply

“…Based on the data of the 1 st epidemic wave, the IMPORTANT study concluded that renal transplantation should be maintained in the areas where the virus circulation is low [ 4 ]. What strategy shall be adopted in areas with intense virus circulation was less clear.…”

“…A comment on the IMPORTANT study": one more IMPORTANT thing! Olivier Thaunat 1,2,3 , Camille Legeai 4 , Olivier Bastien 4 [2]), and that to develop a severe form of COVID-19 (higher in recipients [3,2]). Understanding how these distinct risks compare in each population is critical to establish appropriate guidelines.…”