It follows: the effects of covid on the incidence of optimal renal replacement therapy years after its onset

Background and Aims Patients with advanced chronic kidney disease and those on dialysis have had increased morbidity and mortality in relation to COVID infection. However, patients who did not contract the infection also suffered its effects; since the lack of face-to-face consultations and the impossibility of going to the Emergency Department during the pandemic had negative results on the care of these patients’ kidney condition. Method We present a single-center retrospective observational study of a cohort of 423 patients that were discharged from the ACKD clinic from the start of 2018 to the end of 2022 to initiate renal replacement therapy. We recorded whether the initiation had been optimal or not, defining non-optimal renal replacement therapy as patients who had: • Initiated RRT due to an acute decompensation of their underlying disease that required hospitalization. • Initiated hemodialysis through a central venous catheter instead of an arteriovenous fistula, because the access was not mature yet or otherwise unavailable. • Had to change their preferred form of renal replacement therapy because of rapid decompensation. • Chose conservative management, but died without benefiting from home medical and nursing care. We also collected their age, cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidemia, obesity and smoking), initial preferred therapy, actual RRT, reason of non-optimal therapy and whether there had been an intercurrent COVID infection at the time of initiation. Results We analyzed 423 patients that had chosen a preferred RRT (16,8% chose conservative therapy and were treated by home care services, 34% initiated hemodialysis through an AVF, 27,4% initiated dialysis through a permanent central venous catheter, 5,2% through a temporal CVC, 13,5% initiated peritoneal dialysis, 1,7% died before initiating their preferred technique and 1,4% underwent a preemptive kidney transplant). The patients that initiated hemodialysis before the pandemic started had a significantly lower risk (p 0,001) of starting RRT in a non-optimal manner (HR 0,514 [95% CI] 0,341-0,775) compared to those after the pandemic. Of the cardiovascular risk factors, only diabetes mellitus was significantly associated with non-optimal RRT (p 0,005). Patients without diabetes had significantly less risk of substandard RRT initiation (HR 0,561 [95% CI] 0,373-0,845). Patients with COVID at the time of starting renal replacement therapy had a significantly higher risk of beginning it in a non-optimal way (p 0,013). Age had no statistically significant relation to optimal RRT. The most frequent reason for non-optimal RRT was an acute decompensation that required hospitalization, which accounted for 62% of the patients. 9,6% had a catheter inserted even though they were arteriovenous fistula carriers, and 9% had to change techniques. As for the rest, they chose conservative management but died without home care or two or more reasons were named. Conclusion The incidence of COVID has decreased since the early years of the pandemic, and the effects of the virus are less lethal thanks to vaccines. However, the harmful effects of the pandemic on the care of renal patients and the evolution of their disease are still present, as it is shown by the result of our study. We should be especially mindful of patients with diabetic disease and undergoing a covid infection, because these factors may precipitate non-optimal renal replacement therapy initiation.