Treatment impact on COVID-19 evolution in hemodialysis patients.

To the editor:

We retrospectively studied 248 patients on maintenance hemodialysis affected by coronavirus disease 2019 (COVID-19) in 19 private and academic maintenance hemodialysis centers in the Paris, France, area.

The mean follow-up period was 40 ± 19 days. The hospitalization rate was 58%. The overall mortality was 18.1% (30% in hospitalized patients) (Supplementary Tables S1 and S2). Ninety-six patients (39%) were previously treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. By multivariate analysis (Table 1 ), the main risk factors associated with mortality were age, facility living, dyspnea, and previous immunosuppressive treatment. Average treatment effects were further analyzed by propensity score analysis (Supplementary Methods and Supplementary Table S3). Hydroxychloroquine (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.6–1.71; P = 0.95), macrolides (OR, 1.64; 95% CI, 0.94–2.84; P = 0.079), and third-generation cephalosporins (OR, 1.35; 95% CI, 0.8–2.29; P = 0.265) had no significant effect on mortality. Conversely, previous immunosuppressive treatment was associated with increased mortality (OR, 2.67; 95% CI, 1.43–5.01; P = 0.002), and previous treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with reduced mortality (OR, 0.51; 95% CI, 0.31–0.85; P = 0.01).

Table 1

Multivariate analysis of the risk of death (outcome)

Variable	OR (95% CI)	P
Characteristics
Age	1.04 (1.01–1.09)	0.029
Facility living	17.29 (3.95–75.6)	<0.001
Comorbidities
Chronic respiratory failure	7.47 (1.18–47.39)	0.03
Immunosuppressive therapy	8.32 (2.19–31.55)	0.002
Symptoms at diagnosis
Dyspnea	3.14 (1.24–7.96)	0.015
Blood tests
Procalcitonin	1.005 (0.99–1.0107)	0.065

CI, confidence interval; OR, odds ratio.

P values in bold are considered as statistically significant.

In this large cohort of patients on maintenance hemodialysis, we highlight the deleterious role of previous immunosuppressive therapy in coronavirus disease 2019 outcome. These data are in line with those observed in patients who had undergone kidney transplantation, who demonstrate a high mortality rate (∼20%–30%).

Moreover, since angiotensin-converting enzyme 2 is the receptor for viral cellular entry, a role for angiotensin-converting enzyme inhibitors and angiotensin receptor blockers has been suggested in coronavirus disease 2019 pathophysiology. In our cohort, these treatments were associated with a significant reduction in mortality risk after propensity score weighting. However, large retrospective studies have not confirmed the impact of these treatments on severity of coronavirus disease 2019 , in the general population. Further studies of cellular angiotensin-converting enzyme 2 expression in patients on maintenance hemodialysis could explain this effect since decreased angiotensin-converting enzyme 2 activity has been reported in this population.5, 6, 7