Abstract
Rationale & Objective
The direct and indirect effects of the coronavirus disease 2019 (COVID-19) pandemic on kidney function in the chronic kidney disease (CKD) population are not well understood.
Study Design
Cohort study.
Setting & Participants
Retrospective study of kidney function trajectories using deidentified administrative claims and laboratory data for Medicare Advantage and commercially insured enrollees with CKD stages G3-4 between 2018 and 2021.
Predictors
COVID-19 infection.
Outcome
Rapid kidney function decline defined as annual estimated glomerular filtration rate (eGFR) decline of ≥40%.
Analytical Approach
Propensity score matching was used to identify individuals without COVID-19 infection matched 1:1 to a COVID-19 infected cohort and indexed on the date of diagnosing COVID-19 infection, age, sex, race or ethnicity, and Charlson comorbidity index score. Outpatient kidney function was compared during the prepandemic period (January 1, 2018, to February 29, 2020) with the pandemic period (March 1, 2020, to August 31, 2021). Two creatinine measurements, after the infection date and ≥60 days apart, were required to reduce correlation with acute infection.
Results
Of 97,203 enrollees with CKD G3-4, 9% experienced a COVID-19 infection. Characteristics of 8,901 propensity matched enrollees include mean age 74 years, 58% women, 67% White, and 63% CKD G3a, 28% CKD G3b, and 9% CKD G4. Median overall annual eGFR change was –2.65 ml/min/1.73m2, with 76% of the cohort experiencing worsened eGFR in the pandemic period. Rapid kidney function decline was observed in 1.9% and 2.0% of enrollees in the prepandemic and pandemic periods, respectively. Rapid kidney function decline was observed in 2.5% of those with COVID-19 infection and 1.5% of those without COVID-19 infection (P < 0.05). Factors associated with increased odds of rapid kidney function decline during pandemic included Asian race, higher Charlson comorbidity index, advancing CKD stage, prepandemic rapid kidney function decline, and COVID-19 infection.
Limitations
Retrospective study design with potential bias.
Conclusions
COVID-19 infection increased odds of rapid kidney function decline during the pandemic. The downstream impact of pandemic-related eGFR decline on health outcomes, such as kidney failure or mortality, requires further study.
Plain-Language Summary
We used a cohort of insured individuals with moderate-to-severe chronic kidney disease (CKD) to compare the rates of rapid kidney function decline in prepandemic and pandemic periods and to evaluate the impact of the coronavirus disease 19 (COVID-19) on kidney function decline. We found that overall rates of rapid kidney function decline did not change during the prepandemic and pandemic periods but were significantly higher in both periods among individuals with a COVID-19 infection. As CKD severity increased, rates of both rapid kidney function decline and COVID-19 increased. Advancing CKD, higher comorbid condition, Asian race, prepandemic rapid kidney function decline, and COVID-19 were all associated with higher odds of rapid kidney function decline in the pandemic. These findings suggest close monitoring is warranted for individuals with CKD and COVID-19.
Index Words: Chronic kidney disease, CKD, COVID-19, outcomes, pandemic, rapid kidney function decline
Graphical abstract
The coronavirus disease 2019 (COVID-19) pandemic has dramatically influenced the delivery of care globally. Infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted in extensive morbidity and mortality, overburdening health systems coping with unrelenting care demands, exhausted health care workers, and supply chain shortages. The pandemic also served as a spotlight on longstanding inequities in care for individuals from the marginalized communities and transformed how we define effective health care delivery. For individuals with chronic kidney disease (CKD), a condition affecting approximately 15% of the US adult population with high risk of adverse health outcomes,1,2 the impact of the COVID-19 pandemic is pronounced.
Although definitions have been heterogenous across investigations, rapid kidney function decline has been associated with cardiovascular events, hospitalization, onset of end stage kidney failure, and mortality.3, 4, 5, 6 Studies before the COVID-19 pandemic have demonstrated associations with psychosocial health and risk of rapid kidney function decline. For example, the China Health and Retirement Longitudinal Study7 of individuals with normal kidney function demonstrated an association between both depression and social isolation with rapid kidney function decline.7,8 Another study in the US preceding the pandemic showed an association between depression and rapid kidney function decline in a population with CKD.9 An analysis of US veterans with CKD confirmed the association between depression and rapid kidney function decline, demonstrating additional longitudinal associations with onset of dialysis, hospitalization, and mortality.10 Moreover, among African Americans participating in the Jackson Heart Study11,12 prepandemic, stress was associated with rapid kidney function decline, whereas optimism was associated with protection from rapid kidney function decline.11,12 However, the overall impact of the extended COVID-19 pandemic on rapid kidney function decline in the CKD population has not been assessed.
In this national study of Medicare Advantage and commercially insured patients, we sought to characterize changes in kidney function trajectories in the pandemic era compared with the prepandemic trends in individuals with CKD G3-G4, and to identify factors associated with rapid kidney function decline during the COVID-19 pandemic.
Methods
Our cohort was defined using deidentified administrative claims data from the OptumLabs Data Warehouse, which includes medical and pharmacy claims, laboratory results, and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information for >200 million patients, representing a mixture of ages and geographical regions across the United States. Demographic information as well as inpatient and outpatient medical encounters are coded using the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9-CM and ICD-10-CM).
Because African American and Hispanic Americans are disproportionately affected by CKD, we anticipated that the COVID-19 pandemic might have a differential impact on these populations and, therefore, acquiring race and ethnicity data were critical to our analysis. Data on race and ethnicity were derived from 2 sources. For the period before June 2019, race and ethnicity data for Medicare members were derived from the membership data. After June 2019, ethnicity for Medicare, and for the duration of the study for commercial members, race and ethnicity were first assigned by an external vendor who employs a rule-based system that uses names, geography, and other data to determine ethnicity. OptumLabs then assigned each ethnicity value to 1 of the 5 race and ethnicity categories: non-Hispanic White, non-Hispanic Black, Hispanic, Asian, and unknown. Because data were deidentified in compliance with the Health Insurance Portability and Accountability Act and customer requirements, institutional review board approval or informed consent was not required.
Study Population
We performed a retrospective study of 4,364,299 deidentified patients continuously enrolled in certain commercial and Medicare Advantage health plans from January 2018 through August 2021. Diagnosis of CKD G3-G4 (estimated glomerular filtration rate [eGFR] 30-59 ml/min/1.73m2) was determined using deidentified claims and/or laboratory data and was defined by a member having either ≥2 CKD claims (based on ICD-10 N18 codes) at least 90 days apart or aligned with Kidney Disease: Improving Global Outcomes (KDIGO) guidelines,13 2 eGFR results <60 ml/min/1.73m2 at least 90 days apart, before the beginning of the COVID-19 pandemic (March 1, 2020). The eGFR was calculated from serum creatinine values using the 2021 CKD-Epidemiology Collaboration creatinine equation refit without a race coefficient.14 For individuals identified through laboratories, CKD stage was defined using the second eGFR result; for those diagnosed through claims, CKD was defined using the first eGFR value. To evaluate for kidney function decline from baseline trajectory, individuals were required to have at least 3 eGFR measurements before the COVID-19 pandemic and at least 2 results during the pandemic period. The total observation period of each set of measurements was required to be ≥90 days. Individuals with CKD stage G5 or eGFR <15 ml/min/1.73m2 were excluded, leaving 97,203 individuals with CKD G3-G4 for propensity score matching.
COVID-19 Cohorts
Individuals were evaluated for evidence of a SARS-CoV-2 infection during the pandemic period from March 1, 2020, through August 31, 2021, and were categorized into a “COVID-19” cohort or “uninfected” cohort. COVID-19 cases were defined by the evidence of a positive laboratory test for SARS-CoV-2 or a claim for COVID-19. Members who did not meet the definition for COVID-19 cases were categorized as uninfected and became eligible for propensity score matching with the COVID-19 cohort. The COVID-19 members and uninfected members were first matched on infection date. Because the latter group did not have an infection date, we randomly assigned an infection date using the pool of COVID-19 infection dates and then greedy matched the 2 groups on those dates. Propensity score matching was then conducted to minimize differences in baseline characteristics between the 2 groups, leaving a final analytic sample of 8,901 individuals (Fig S1).
Kidney Function Decline
To assess changes in kidney function, we calculated the annual eGFR slope for each member before and during the COVID-19 pandemic. We required that at least 2 measurements occur after the infection index date (or matched index date in the uninfected cohort) and the measurements be at least 60 days apart to reduce correlation of eGFR measurements with the acuity of a SARS-CoV-2 infection. Furthermore, to minimize acute changes in eGFR because of an acute hospitalization, inpatient measurements were excluded. For each member, ≥3 serum creatinine measurements were used to determine the eGFR slope in the prepandemic period, and ≥2 measurements were used in the pandemic period. The corresponding daily slopes obtained from the regression models were multiplied by 365 days to estimate the annual eGFR slope. We then quantified an eGFR slope difference by subtracting the prepandemic eGFR slope from the pandemic eGFR slope. A positive eGFR slope difference indicated kidney function improvement while a negative difference indicated worsening of kidney function.
Rapid kidney function decline was defined as a sustained decline in eGFR of ≥40% per year.15 the prevalence of rapid kidney function decline during the prepandemic period from January 1, 2018, through February 29, 2020, was compared with the prevalence of rapid kidney function decline during the pandemic period, and stratified by CKD stages (G3a, G3b, and G4) and COVID-19 cohort.
Statistical Analysis
Study cohort characteristics were summarized using mean and standard deviation for continuous variables as well as frequency and percentage for categorical variables. Propensity score matching was used to develop the final analytic cohort. The propensity scores were calculated using logistic regression model with COVID-19 infection as the dependent variable and patient characteristics as independent variables. The independent variables included age, sex, race/ethnicity, and Charlson comorbidity index (CCI) score. Patients were matched using the nearest neighbor method with no replacement, a 0.2 caliper width, and 1:1 matching.
To estimate eGFR slope, we used a linear mixed model with random intercept and random slope to reduce the variance derived from unreliable estimates of each member during the prepandemic and pandemic periods. We used restricted maximum likelihood estimation to estimate the model parameters. The corresponding slopes obtained from the regression models represented the daily eGFR change and, therefore, were multiplied by 365 days to signify an annual eGFR change. The Mann-Whitney U test was used to assess slope difference distributions between the COVID-19 and uninfected cohorts. To compare proportions of members with worsened eGFR slopes, a 2-proportion z-test was used. To examine factors independently associated with rapid kidney function decline, we performed a multivariate logistic regression adjusted for age group, sex, race/ethnicity, CCI, CKD stage, and evidence of rapid kidney function decline in the prepandemic period or evidence of COVID-19 during the pandemic period (COVID-19 cohort). Due to small numbers, Native American (n=4) race/ethnicity category was combined with the “Other” category for use in the multivariable regression. Calculations were performed using Python version 3.3.
Results
Of the 4,364,299 individuals with continuous enrollment from January 2018, to August 2021, 97,203 individuals with CKD stage G3-4 were identified. Of these, 8,695 (8.9% of the full cohort) individuals had a documented COVID-19 infection in the pandemic period. After applying exclusion criteria based on the available eGFR measurements, the final analytic matched cohort included 8,901 members: 4,475 in the COVID-19 cohort and 4,426 in the uninfected cohort. Mean age of the cohort was 74.3 years with female predominance (58.2%). A total of 962 (21.5%) of the cohort was categorized as Black and 204 (4.6%) as Hispanic (Table 1). The majority (95.6%) had a Medicare Advantage insurance plan. Only 9.3% of the cohort were in stage G4 CKD, with the majority were in stage G3a (63.1%). During the pandemic period, 9% of members were found to have a COVID-19 diagnosis.
Table 1.
Baseline Characteristics of CKD Cohort
| Characteristic | Full cohort |
PS-matched cohorta |
||
|---|---|---|---|---|
| COVID-19 n=8,695 | Uninfected n=88,508 | COVID-19 n=4,475 | Uninfected n=4,426 | |
| Age, y | ||||
| Mean (SD) | 74.28 (9.29) | 75.41 (8.49) | 74.18 (9.16) | 74.34 (8.71) |
| Sex, n (%) | ||||
| Male | 3,680 (42.3) | 37,218 (42.1) | 1,885 (42.1) | 1,837 (41.5) |
| Female | 5,015 (57.7) | 51,288 (58.0) | 2,590 (57.9) | 2,589 (58.5) |
| Race/ethnicity, n (%) | ||||
| Asian | 95 (1.1) | 1,413 (1.6) | 56 (1.3) | 52 (1.2) |
| Black | 1,799 (20.7) | 16,812 (19.0) | 962 (21.5) | 949 (21.4) |
| Hispanic | 379 (4.4) | 2,321 (2.6) | 204 (4.6) | 160 (3.6) |
| Others/Unknown | 503 (5.8) | 5,716 (6.5) | 269 (6.0) | 249 (5.6) |
| White | 5,919 (68.1) | 62,246 (70.3) | 2,984 (66.7) | 3,016 (68.1) |
| Charlson comorbidity index score | ||||
| Mean (SD) | 4.68 (2.76) | 4.25 (2.68) | 4.75 (2.79) | 4.75 (2.83) |
| Insurance plan, n (%) | ||||
| Medicare Advantage | 8,272 (95.1) | 85,081 (96.1) | 4,254 (95.1) | 4,253 (96.1) |
| Private commercial plan | 423 (4.9) | 3,427 (3.9) | 221 (4.9) | 173 (3.9) |
| CKD stage, n (%) | ||||
| Stage 3a | 5,527 (63.6) | 56,281 (63.6) | 2,848 (63.6) | 2,769 (62.6) |
| Stage 3b | 2,405 (27.7) | 25,408 (28.7) | 1,216 (27.2) | 1,244 (28.1) |
| Stage 4 | 763 (8.8) | 6,819 (7.7) | 411 (9.2) | 413 (9.3) |
Abbreviations: COVID-19, coronavirus disease 2019; CKD, chronic kidney disease; PS, propensity score.
Matched on infection date, age, sex, race/ethnicity, and Charlson comorbidity index score.
Differences in eGFR from the prepandemic to pandemic periods are shown in Table 2 and Tables S1-S3. Overall, median eGFR decline was 2.65 ml/in/1.73m2 with 75.9% of the cohort experiencing worsened eGFR during the pandemic period. There was an inverse association between advancing CKD G stage and eGFR slope difference, because members with CKD stage G3a experienced a median eGFR slope decline of 3.4 ml/min/1.73m2 compared with a decline of 0.28 ml/min/1.73m2 among members with CKD stage G4. A similar pattern was observed with respect to proportion of members with worsened eGFR slope, noted in 81.7%, 70%, and 53.2% of members with CKD G3a, 3b, and G4, respectively. The loss of eGFR findings were significantly (P < 0.001) more pronounced in the overall COVID-19 cohort compared with the uninfected cohort.
Table 2.
Estimated Glomerular Filtration Rate Annual Slope Differences for CKD Cohort by COVID-19 Status During the COVID-19 Pandemic.
| Cohort | Overall | COVID-19 | Uninfected | P value |
|---|---|---|---|---|
| Overall cohort | ||||
| Slope differencea (ml/min/1.73m2), median (IQR) | –2.65 (5.26) | –2.94 (5.51) | –2.36 (4.98) | <0.001 |
| Worsenedb, n (%) | 6,751 (75.85) | 3,456 (77.23) | 3,295 (74.44) | 0.002 |
| CKD stage G3a | ||||
| Slope difference (ml/min/1.73m2), median (IQR) | –3.37 (5.10) | –3.65 (5.32) | –3.12 (4.89) | <0.001 |
| Worsened, n (%) | 4,590 (81.72) | 2,354 (82.65) | 2,236 (80.75) | 0.07 |
| CKD stage G3b | ||||
| Slope difference (ml/min/1.73m2), median (IQR) | –1.76 (4.50) | –2.09 (4.82) | –1.36 (4.23) | <0.001 |
| Worsened, n (%) | 1,723 (70.04) | 874 (71.88) | 849 (68.25) | 0.05 |
| CKD stage G4 | ||||
| Slope difference (ml/min/1.73m2), median (IQR) | –0.28 (4.14) | –0.53 (4.44) | –0.08 (3.96) | 0.27 |
| Worsened, n (%) | 438 (53.16) | 228 (55.47) | 210 (50.85) | 0.21 |
Abbreviations: COVID-19, coronavirus disease 2019; CKD, chronic kidney disease; IQR, interquartile range.
Mann-Whitney U test.
Two-proportions Z-test.
Overall, the estimated proportion of members with rapid kidney function decline was similar in the prepandemic and pandemic periods (1.9% and 2.0%, respectively). There was a graded association of advancing CKD stage G and proportion of individuals experiencing rapid kidney function decline which was similar in the prepandemic and pandemic periods: CKD stage G3a was 1.5% in the prepandemic period versus 1.3% in the pandemic period, G3b was 2.3% versus 2.8%, and G4 was 3.9% versus 4.6%. Figure 1 illustrates the proportion of CKD members with rapid kidney function decline in the prepandemic and pandemic periods by COVID-19 infection status in the pandemic period. In general, individuals in the COVID-19 cohort had higher rates of rapid kidney function decline in both prepandemic and pandemic periods than those in the uninfected cohort, irrespective of the CKD stage.
Figure 1.
Percentage of CKD population with rapid kidney function decline in the prepandemic and pandemic periods by COVID-19 status in the pandemic period. Comparison of rapid kidney function decline in the study periods is illustrated above. Overall, the rates of rapid kidney function decline were similar in the pandemic period than in the prepandemic period for all CKD stages; the proportion of rapid kidney function decline increased with advancing CKD stage. Individuals with COVID-19 (orange bars) had higher proportion of rapid kidney function decline in all study periods than those without COVID-19 (teal bars), the proportion of which similarly increased with advancing CKD stage.
Factors associated with rapid kidney function decline during the pandemic are illustrated in Figure 2 and Table S4. After multivariable adjustment, Asian members had higher odds of rapid kidney function decline during the pandemic than White members (odds ratio [OR], 4.21; 95% confidence interval [CI], 1.73-8.77), as did members with higher (vs lower) CCI score (OR, 1.09; 95% CI, 1.03-1.14). Compared with members with CKD stage G3a, those with CKD stages G3b and G4 were more likely to experience rapid kidney function decline during the pandemic (G3b: OR, 2.09; 95% CI, 1.49-2.93 and G4: OR, 3.09; 95% CI, 2.02-4.66). Similarly, members who experienced rapid kidney function decline in the prepandemic period had higher odds of rapid kidney function decline during the pandemic than those without prepandemic rapid kidney function decline (OR, 3.11; 95% CI, 1.66-5.41). Members with COVID-19 infection also had greater odds of rapid kidney function decline (OR, 1.64; 95% CI, 1.21-2.24).
Figure 2.
Factors associated with rapid kidney function decline in the COVID-19 pandemic. Factors associated with odds of rapid kidney function decline in the propensity score–matched cohort are illustrated above. Individuals identified as Asian had higher odds of rapid kidney function decline than individuals identified as White. (because of small numbers, the ‘Other’ category includes individuals identified as Native American [n=4]). Increasing Charlson comorbidity index score and CKD stage were directly associated with rapid kidney function decline risk. Rapid kidney function decline in the prepandemic period (vs not) and COVID-19 (vs no COVID-19) was also directly associated with rapid kidney function decline in the pandemic period.
Discussion
In approximately 9,000 individuals with CKD stages G3-4, we found an overall annual deterioration in eGFR slope of 2.65 ml/min/1.73m2 from the prepandemic to pandemic periods, with almost 3-quarters of the cohort experiencing a worsened eGFR slope during the COVID-19 pandemic. This pattern was higher among those with a documented COVID-19 infection. We observed comparable rates of rapid kidney function decline between the pandemic period and prepandemic period but higher rates with advanced CKD G stage. Similarly, this pattern was observed in both COVID-19 and uninfected subgroups but was more pronounced in the COVID-19 subgroup. The association of COVID-19 history with rapid kidney function decline persisted after adjustment. We also found Asian race to be associated with rapid kidney function decline in the pandemic period, even after adjustment for prepandemic rapid kidney function decline and CKD G stage. These findings suggest the COVID-19 pandemic affected the CKD population in 2 ways: directly through COVID-19 disease and indirectly through pandemic-related experiences.
Mounting evidence supports our findings of the direct effect of COVID-19 on kidney outcomes. One recent study by Bowe et al16 in the Veterans Health Administration compared rates of acute kidney injury (AKI), eGFR decline, and major adverse kidney events (a composite of eGFR decline ≥50%, kidney failure, and all-cause mortality) in a general population of Veteran survivors of COVID-19 and matched controls. The investigators found an excess burden of all kidney outcomes across care settings (outpatient, hospitalized in the intensive care unit, and hospitalized in the intensive care unit) following acute infection, supporting the longer-term consequences of an acute COVID-19 infection. One mechanistic link between COVID-19 disease and adverse kidney outcomes is through the development of AKI. AKI is a common consequence of COVID-19, affecting approximately 40% of the hospitalized patients and having a strong association with poor clinical outcomes, such as need for kidney replacement therapy and mortality.17, 18, 19, 20 In the nondialysis CKD population with COVID-19, individuals who develop AKI have a significantly amplified risk of adverse outcomes.21 Further, CKD itself is an independent risk factor for severe illness and mortality in those with COVID-19.21, 22, 23 Taken together, these findings support CKD as both a risk factor for severe COVID-19 and a consequence of COVID-19. Therefore, close monitoring of the CKD population for long-term consequences of COVID-19 is warranted.
Care disruptions during the COVID-19 pandemic shown in a study of the >248,000 US patients with the same CKD stages as in this study included reduced access to routine outpatient encounters and fewer medications refills that may have contributed to kidney function decline in the CKD population.24 Specifically, the proportion of days covered for medication fills was reduced by 9%-20% during the pandemic period, and with diabetes and hypertension drugs most commonly involved, that could have contributed to uncontrolled CKD risk factors. Our study found an increase in the proportion of individuals with advancing CKD experiencing rapid kidney function decline in the pandemic period, which is of significance given rapid kidney function decline is established as a predictor of increased cardiovascular disease and all-cause mortality independent of baseline eGFR.3, 4, 5, 6
Although rapid kidney function decline estimates were higher in the COVID-19 cohort compared with the CKD population without COVID-19, notably this proportion increased in the uninfected cohort with CKD stages G3b and G4 as well. We hypothesize that noninfection-related experiences of the pandemic, likely, indirectly contributed to this increased incidence of rapid kidney function decline. Further, several studies have demonstrated a relation between psychosocial factors, such as low optimism, elevated stress, and social isolation, with the risk of rapid kidney function decline.7,8,11,12 The effects of stressful experiences may contribute to worsened kidney function biologically, via elevations in allostatic load,25 or behaviorally, via reduced engagement with the health care system and healthy behaviors.26 Therefore, the COVID-19 pandemic, resulting in widespread negative mental health effects and dramatic disruptions in social interactions, is a potential illustration of the indirect impact that environmental stressors may have on the kidney function. This may help explain findings of elevated risk of rapid kidney function decline independent of COVID-19 or prior rapid kidney function decline. It also speaks for the longstanding care inequities that have been even more clearly demonstrated during the pandemic but which were not examined in this study.27
Our study had limitations. Our data did not represent all payers, limiting the generalizability of the findings. However, a notable strength is the availability of national data from both Medicare Advantage and commercial populations. Further, requirements for the availability of serial laboratory measurements for eGFR slope determination and continuous enrollment limited our analysis to a selective population with multiple available laboratories before and during the COVID-19 pandemic and functionally excluded individuals who died during this period. Our use of propensity matching based on infection date and demographic characteristics mitigated but did not eliminate inherent bias in retrospective data analysis. Therefore, this is likely a unique study population with residual confounding and bias. In addition, our detection of CKD was based on either laboratory data or billing codes, the latter of which has limited sensitivity for CKD detection,28 and therefore may underestimate the true population with CKD. In a similar way, the uninfected group could have included members who had COVID-19 but were not diagnosed. We were also unable to comprehensively characterize COVID-19 course and examine mechanisms through which an infection may have accelerated CKD progression (ie, via AKI, hospitalizations, and exposure to nephrotoxins). Finally, our data from March 2020 through August 2021 did not capture kidney function trends in the latter months of the pandemic. It is also important to note that for data during the pandemic period, race, and ethnicity were imputed using a proprietary algorithm. Prior validations of this imputation method have been previously published, which found African American race to be underestimated, misclassifying 52% of all African American participants as White.29
The COVID-19 pandemic resulted in rates of rapid kidney function decline comparable with prepandemic values, which was exacerbated by COVID-19, suggesting that reduced kidney function may be both a risk factor for and a consequence of COVID-19. Similarly, over 3-quarters of the population experienced worsened kidney function irrespective of COVID-19, suggesting that the effects of the pandemic on kidney function extend beyond the illness alone, which should be a continued consideration in care management strategies for prolonged consequences of the pandemic. The downstream impact of pandemic-related eGFR decline on health outcomes, such as cardiovascular disease, kidney failure, or mortality, particularly in ethnic and racial minorities who were found to experience a disproportionate burden of kidney-related outcomes, requires targeted attention and resource allocation.
Article Information
Authors’ Full Names and Academic Degrees
Clarissa J. Diamantidis, MD, MHS, David J. Cook, MD, Cyd Kristoff Redelosa, BS, Rachell B. Vinculado, BS, Alden A. Cabajar, BS, and Joseph A. Vassalotti, MD.
Authors’ Contributions
Study conception and design: CD, DC, JV; data acquisition, analysis and/or interpretation: all authors. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.
Support
This study was supported by OptumLabs, the research and development arm of the UnitedHealth Group, and the authors Dr Cook, Ms Vinculado, Mr Cabajar, and Mr Redelosa are full-time or former employees of the UnitedHealth Group. These authors played an active role in all aspects of study development, including the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The funder of the study, the organizational entity OptumLabs, did not have any role in study design, data collection, analysis, interpretation or the drafting of the manuscript. OptumLabs provided the staffing, expertise, and the data required to conduct the investigation.
Financial Disclosure
Dr Diamantidis reports consultancy for OptumLabs. Dr Vassalotti reports consultancy for AstraZenica, inc and Renalytix, plc. The remaining authors declare that they have no relevant financial interests.
Acknowledgments
The authors acknowledge Ms K. Hiegel and A. Okaya, full-time employees of OptumLabs, for providing editorial support for the manuscript.
Peer Review
Received November 16, 2022. Evaluated by 2 external peer reviewers, with direct editorial input from the Statistical Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form May 19, 2023.
Footnotes
Complete author and article information provided before references.
Figure S1: Study CONSORT diagram
Table S1: Rapid kidney function decline for the CKD cohort, overall and by CKD Stage
Table S2: Rapid kidney function decline for the COVID-19 cohort
Table S3: Rapid kidney function decline for the uninfected cohort
Table S4: Factors associated with rapid kidney function decline
Supplementary Material
Figure S1. Supplementary Files 2-5 (xlsx). Tables S1-S4.
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Supplementary Materials
Figure S1. Supplementary Files 2-5 (xlsx). Tables S1-S4.