Authors’ Reply

We thank Jacobs et al. for their interest in our recent report,¹ which concerned treatment changes in patients with incident ESKD during the first wave of the coronavirus disease 2019 (COVID-19) pandemic in the United States. In their letter, Jacobs et al. report an 8% decrease in the number of patients initiating treatment for ESKD in French-speaking areas of Belgium in 2020 (relative to 2019). Their finding of a substantial drop in patients with newly diagnosed ESKD is generally concordant with our own, although we found an even greater decline of approximately 25% during the height of the first wave of the pandemic in the United States (April 2020). In contrast to our findings, however, they report relatively steeper declines in rates of preemptive kidney transplant or initiation of dialysis on a home-based dialysis modality relative to dialysis initiation with in-center hemodialysis (HD).

It is not unexpected that clinical practices regarding treatment of patients with late-stage CKD approaching ESKD during a global pandemic would vary by country or region. A host of factors likely influence clinical decision-making, particularly in situations for which there is no precedent. Rates of infection in the general population, government policies regarding “lockdowns” and physical distancing, hospital-based resource constraints such as the availability of operating rooms (to perform kidney transplants, place dialysis catheters, or create permanent HD accesses), practices regarding transportation of patients to dialysis centers, and availability of outpatient dialysis facility treatment—heavily influenced by the need to cohort infected patients and to consider the health of dialysis facility staff members themselves²—all likely affect decisions to initiate a patient on dialysis or to move forward with preemptive transplantation.

The letter by Jacobs et al., along with many other important studies, reminds us all that the changes in practice during the COVID-19 pandemic raise critically important questions for the nephrology community. Did the pandemic and its widespread effects on healthcare systems worldwide cause patients who were approaching ESKD to die prior to the dialysis initiation, or was dialysis initiation merely delayed? If dialysis was delayed, were such delays actually harmful, given that clinical trial evidence³ suggests that initiation of ESKD treatment at lower levels of kidney function may be a superior treatment approach? Which, if any, of the changes in use of various ESKD treatment modalities in incident dialysis patients, which varied by country even before the pandemic began,⁴ will be permanent or merely transitory?

In our report, we speculated that efforts at physical distancing may have cast home-based dialysis modalities, such as peritoneal dialysis, in a relatively favorable light among nephrologists and patients alike. Whether this is the case is uncertain, but an important research question is whether COVID-19, or indeed other respiratory illnesses, are less likely to occur in patients utilizing peritoneal dialysis or home HD (relative to in-center HD). Although it is highly plausible that home-based dialysis modalities may be superior in this regard, empirical evidence on this matter would be important to acquire as developed countries attempt to increase the use of home-based modalities⁵ and developing countries confront the need to provide care for millions of people with ESKD who cannot, at present, access maintenance dialysis.^6,7

The letter by Jacobs et al. adds to the nephrology community’s understanding of the effect of the COVID-19 pandemic on treatment modalities in patients with incident ESKD. Owing to the factors outlined above and, surely, many others, there is likely substantial variation in how the pandemic affected nephrology treatment practices the world over. The nephrology community should use the tragedy of the pandemic to continue to learn how to best treat patients with kidney disease, not only during times of pandemics, but during pandemic-free times as well.

Disclosures

K.L. Johansen serves as a member of the Akebia Advisory Board, participates in the steering committee of Anemia Studies in Chronic Kidney Disease (ASCEND), a clinical trial program evaluating the efficacy and safety of the prolyl hydroxylase inhibitor daprodustat supported by GlaxoSmithKline,and receives research funding from NIH (NIDDK).She is an Associate Editor for the Journal of the American Society of Nephrology. E.D. Weinhandl reports consultancy agreements with Fresenius Medical Care North America, Outset Medical, and Quanta Dialysis Technologies; scientific advisor or membership with Advisory Board, Home Dialyzors United and Board of Directors, Medical Education Institute; and other interests/relationships with University of Minnesota. J.B. Wetmore reports receiving research funding via the Hennepin Healthcare Research Institute from Amgen, AstraZeneca, the Bristol Myers Squibb-Pfizer Alliance, Genentech, Merck, NIH (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK]), and OPKO Health; receiving honoraria from Aurinia, the BMS–Pfizer Alliance, OPKO Health, and Reata for participating in advisory boards; and receiving honoraria for academic continuing medical education from Healio and the Nephrology Self-Assessment Program.

Funding

The data reported here have been supplied by the USRDS, which is funded by National Institute of Diabetes and Digestive and Kidney Diseases contract N01 75N94019C00006.