Patients with end-stage kidney disease and COVID-19 are commonly hospitalized early during COVID-19 illness: an opportunity for early intervention

Antiviral medications such as remdesivir, molnupiravir, and nirmatrelvir/ritonavir are most effective when used early in the course of coronavirus disease 2019 (COVID-19). These medications are mainly authorized for outpatient use in high risk populations. End-stage kidney disease (ESKD) is among the strongest risk factors for mortality from COVID-19, however, therapeutic options have been lacking in this patient population given exclusion of ESKD in the registrational trials of antiviral therapy leading to limited FDA approval. In our retrospective study of patients with ESKD on dialysis admitted for symptomatic COVID-19 from March 2020 to January 2020, we found that majority of patients (>80%) were admitted to the hospital early during their disease course (within 5 days of symptom onset). Despite this pattern of early admission, there was a high risk of respiratory failure within 90 days since admission (30%) among this population. We argue that this unique pattern of early presentation and high risk of progression to respiratory failure of the ESKD patients suggests an opportunity for further research to determine if outpatient antiviral therapies should be expanded to patients with ESKD to address the huge unmet need of therapeutic intervention in this vulnerable population. ### Competing Interest Statement Financial Disclosures: Dr. Sise: Research funding: Angion, Otsuka, Gilead, Abbvie, Cabaletta, Novartis, EMD-Serono Scientific advisory boards: Vera, Travere, Calliditas, Mallinckrodt, Novartis DSMB member: Alpine Immunosciences Consulting: Resonance All remaining authors have nothing to disclose. ### Funding Statement This work was funded by Gilead through an investigator-initiated grant to Massachusetts General Hospital (MGH) awarded to Dr. Sise. All aspects of the study (protocol design, data capture, analysis, and manuscript preparation) were performed by Dr. Sise and her co-authors. RS, NK, DM, DH performed chart review and data collection. QW, MS designed study, performed data analysis and manuscript drafting. IS captured and organized clinical data. RB critically revised the manuscript. All authors participated in manuscript revision and are in agreement with the content of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Massachusetts General Hospital Institutional Review Board I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes De-identified data is available upon reasonable request to Dr. Meghan Sise via email and after execution of a data use agreement with Mass General Brigham.