Will COVID-19 Finally Force the U.S. to Address Causes and Treatments for Kidney Failure?

COVID-19 is having a huge, negative, long-term effect on those who are hospitalized with it and survive. Greatly reduced kidney function from long-COVID is now a major concern of healthcare professionals dealing with COVID. Approximately 28% of those hospitalized with COVID-19 were diagnosed with acute kidney injury (AKI) and 9% required kidney replacement therapy.¹

A large study by the U.S. Veterans Affairs healthcare system analyzed data from 89,216 COVID patients over the period March 1, 2020 to March 15, 2021. The results revealed that between 1 and 6 months after being infected, COVID survivors were 35% more likely to to have substantial declines in kidney function than non-COVID patients.²

Even more worrisome, the pandemic is likely to have an adverse, long-term impact on the health of patients who did not contract COVID, but had long delays in seeing healthcare professionals who manage their chronic illnesses, like diabetes and hypertension.

And international data from 22 countries over the period January 1 to Dec 30, 2020, showed a 40% drop in living kidney donor transplants. The pandemic effectively tied up medical personnel and resources—to the detriment of thousands of ESRD patients awaiting transplant.³

Doctors aren’t sure why COVID causes kidney damage. Kidneys seem to be especially sensitive to surges of inflammation or immune system activation. Also, blood-clotting problems often seen in COVID patients may disturb kidney function.²

The Need for More Basic Research into the Causes of Kidney Failure

Kidney disease has become its own pandemic. It’s America’s 8^th largest killer, causing more deaths than breast cancer or prostate cancer.⁴ It is an under-recognized public health crisis affecting an estimated 37 million people in the U.S.: 15% of the adult population; more than 1 in 7 adults. Approximately 90% of those with kidney disease don’t know they have it.⁵ Because of long COVID-19, these numbers will only get worse. And when they do, will we have enough capacity in our current dialysis centers to provide adequate replacement therapy? Will Congress have the backbone to increase Medicare payments to meet the increased demand?

So why don’t we do something about it?

Why don’t we do the basic research like we do for various cancers, heart disease, and Alzheimers? And why don’t we mount national awareness campaigns, like knowing the signs of cancer or smoking cessation, so more people become aware of kidney disease and advocate for a cure and increased research funding?

For example, since 2008, annual funding for Alzheimers disease has gone from $412 million to over $3 billion, a 630% increase as of 2021. Compare that to funding for research in kidney disease. $523 million to $660 million annually over the same time frame. That’s a paltry 26% increase over the same 13 years, or just 2% a year. It sounds like a lot of money, but it isn’t, not when spread over almost 800,000 U.S. dialysis patients, many of whom will not survive 5 years after starting treatment—not to mention the millions who have CKD and don’t yet know it.⁶

Innovation is required to solve this CKD pandemic.

Yes, there are a few incentive programs like Kidney-X which is a collaborative effort among a few research universities to invent and perfect an implantable, artificial kidney, but it is woefully underfunded and progress is agonizingly slow. More innovation is needed to meet current and future demand.

Research into alternative kidney replacement therapies besides transplantation and dialysis ground to a halt in the late 1960s and has been greatly underfunded since. If the innovation in consumer electronics had followed that of dialysis machines, an average smartphone would be the size of 10 New York city blocks.

Look at ventilators. People who are unable to breathe were confined to an iron lung since WWII, but, in the 1960s, smaller and better ventilators were invented and people were able to live a much freer life. Nowadays, ventilators are small enough to pack in a small bag and people who travel with them are urged to bring an extra in case the one they use breaks down. In contrast a traditional dialysis machine is no smaller than it was in the mid-1960s when we took people out of iron lungs; NxStage is an exception. Not only that, but the basic technology behind them hasn’t changed much either. We are still using physical filters to filtrate solids out of the blood.

The Failure to Encourage Home Dialysis

Home dialysis could also be a major improvement in effective kidney replacement therapy, but there are few monetary incentives to get the big, for-profit dialysis providers to move their in-center patients toward home dialysis, which we know greatly improves quality of life and longevity.

At the end of 2018, fewer than 69,000 patients (8.7%) were performing home dialysis out of a U.S. population of 786,000 dialysis patients. Of those, only 10,350 (1.3%) were doing home hemodialysis.⁷

Compare this to 1973 when almost 40% were on home hemodialysis. As dialysis pioneer Christopher R. Blagg, MD, of the University of Washington and Northwest Kidney Centers, Seattle, Washington, has succinctly stated:

A number of factors have contributed to this change. First, with almost universal entitlement for treatment under…Medicare, there was rapid growth in the number of new dialysis units…This proliferation occurred at a time when clinical nephrology,...was not emphasized and was poorly taught in most U.S. nephrology training programs. Thus, many of the individuals who became the nephrologists and administrators developing the new units had little or no practical experience with dialysis for chronic renal failure. Outpatient hemodialysis units were relatively simple to develop and in-center dialysis simple to provide compared with providing a more complex home hemodialysis training program and its associated support services.⁸

At the same time, patients seemingly became more passive and began to develop a lack of acceptance of responsibility for their own health. In many cases, some refused to take any active part in their treatments. Or, did the in-center experience take away their agency?

It won’t be long before we begin to see real evidence of long-COVID’s impact on national kidney health. And we won’t be prepared, because we are too vested in the status quo. And that’s a big mistake among policy makers in D.C. and university think tanks. Even the Trump administration—not known for effective follow-through—was concerned enough to get the public’s attention about moving toward home dialysis replacement therapies. They didn’t provide any more funding or much else, but if they know it’s a huge problem, everyone else in a position to make things happen is painfully aware that this is a time bomb waiting to explode.

So, now is the time to begin advocating for major healthcare system reform. COVID-19 has taxed our hospitals and healthcare professionals to the breaking point. Long-COVID-induced kidney disease may just break it.

References:

1 Yende S, Parikh CR. Long COVID and kidney disease. Nature Rev Nephrol. 2021 Sep 9;1-2

2 Belluck, P. https://www.nytimes.com/2021/09/01/health/COVID-kidney-damage.html

3 Aubert O, Yoo D, Zielinski D, Cozzi E, Cardillo M, Durr M, Dominguez-Gil B, Coll E, Da Silva MI, Sallinen V, Lemstrom K, Midtvedt K, Ulloa C, Immer F, Weissenbacher A, Vallant N, Basic-Jukic N, Tanabe K, Papatheodoridis G, Menoudakou G, Torres M, Soratti C, Krogh DH, Lefaucheur C, Ferreira G, Silva Jr HT, Hartell D, Forsythe J, Mumford L, Reese PP, Kerbaul F, Jacquelinet C, Vogelaar S, Papalois V, Loupy A. COVID-19 pandemic and worldwide organ transplantation: a population-based study. Lancet Public Health. 2021 Oct;6(10):e709-e719

4 National Vital Statistic System; CDC 2021 report of 2018 data.

5 National Kidney Foundation, https://www.kidney.org/news/newsroom/fsindex.

6 National Institutes of Health, RCDC Funding Summary_09092021. https://report.nih.gov/funding/categorical-spending#/

7 USRDS 2020 Annual Report. adr.usrds.org/2020 

8 Blagg, C. What went wrong with home hemodialysis in the United States and what can e done now? Hemodial Int. 2000 Jan;4(1):55-58