Estimated impact of novel coronavirus‐19 and transplant center inactivity on end‐stage renal disease‐related patient mortality in the United States

Abstract To predict whether the COVID‐19 pandemic and transplant center responses could have resulted in preventable deaths, we analyzed registry information of the US end‐stage renal disease (ESRD) patient population awaiting kidney transplantation. Data were from the Organ Procurement and Transplantation Network (OPTN), the US Centers for Disease Control and Prevention, and the United States Renal Data System. Based on 2019 OPTN reports, annualized reduction in kidney transplantation of 25%–100% could result in excess deaths of wait‐listed (deceased donor) transplant candidates from 84 to 337 and living donor candidate excess deaths from 35 to 141 (total 119–478 potentially preventable deaths of transplant candidates). Changes in transplant activity due to COVID‐19 varied with some centers shutting down while others simply heeded known or suspected pandemic risks. Understanding potential excess mortality for ESRD transplant candidates when circumstances compel curtailment of transplant activity may inform policy and procedural aspects of organ transplant systems allowing ways to best inform patients and families as to potential risks in shuttering organ transplant activity. Considering that more than 700 000 Americans have ESRD with 100 000 awaiting a kidney transplant, our highest annual estimate of 478 excess total deaths from postponing kidney transplantation seems modest.


Funding information
There was no extramural support for this research. Each author contributed time and effort voluntarily. Except for the authors, no person or institution had a role in defining the content of the manuscript.

Abstract
To predict whether the COVID-19 pandemic and transplant center responses could have resulted in preventable deaths, we analyzed registry information of the US end-stage renal disease (ESRD) patient population awaiting kidney transplantation.
Data were from the Organ Procurement and Transplantation Network (OPTN), the

US Centers for Disease Control and Prevention, and the United States Renal Data
System. Based on 2019 OPTN reports, annualized reduction in kidney transplantation of 25%-100% could result in excess deaths of wait-listed (deceased donor) transplant candidates from 84 to 337 and living donor candidate excess deaths from 35 to 141 (total 119-478 potentially preventable deaths of transplant candidates). Changes in transplant activity due to COVID-19 varied with some centers shutting down while others simply heeded known or suspected pandemic risks. Understanding potential excess mortality for ESRD transplant candidates when circumstances compel curtailment of transplant activity may inform policy and procedural aspects of organ transplant systems allowing ways to best inform patients and families as to potential risks in shuttering organ transplant activity. Considering that more than 700 000 Americans have ESRD with 100 000 awaiting a kidney transplant, our highest annual estimate of 478 excess total deaths from postponing kidney transplantation seems modest.

K E Y W O R D S
COVID-19, excess mortality, kidney transplant candidates, transplant program activity who might be expected to die due to delay in receipt of a living or deceased donor kidney. 8 Estimates of US deaths due to delays and cancelations of kidney transplantation may not only shed light on lost opportunities to save lives, but also point to revisions of policies and planning which could address future interruptions in the practice of organ transplantation.
Especially with ESRD transplant candidates, the ubiquitous asset of US dialysis may compel an unsubstantiated assessment that kidney transplantation can wait because no patient will suffer or die while waiting longer for a kidney. Other factors such as reduced social interactions, organ donation, and recovery imperatives, as well as the already-stated program cancelations may support such a temporizing approach. While ESRD professionals understand the mortality risks associated with ongoing dialysis, there is little to enlighten patients, caregivers, or families about additive risks if kidney transplantation were partially or completely curtailed for some period of time.
This study seeks to predict the possible loss of US lives due to the delay and cancelation of kidney transplantation. The analyses are based on past measures of known mortality risks among different categories of patients receiving maintenance dialysis, those who are wait-listed for a deceased donor kidney, those scheduling a living donor transplant, and kidney recipients already transplanted. We sought to estimate the number of excess deaths related to various levels of interruptions to kidney transplant care in circumstances such as the COVID-19 pandemic. Calculations considered that a patient who is on the deceased donor waitlist and is subsequently transplanted exchanges one risk (dialysis mortality) for another typically lower risk (transplant mortality). The higher mortality estimates are based on the delta (Δ) loss rate where the former is the mortality for wait-listed dialysis patients and the latter is the loss rate experienced if patients had been transplanted.

| Outcomes
The Δ mortality rate is based on the reported values of mortality risk for wait-listed patients in 2016 (5.3%/year), compared with the lower transplant mortality risk for a patient with a successfully functioning transplant (3.26%/year). 12 Therefore, the difference (5.30% − 3.26% = 2.04%) in mortality was rounded to 2 percentage points. Stated otherwise, the lower risk of dying with a kidney transplant was subtracted from the higher risk of dying while on dialysis but wait-listed for a kidney, the difference being excess mortality.
For completeness and comparison, mortality rates for the general population and Medicare beneficiaries over age 65 years were noted. Counts of excess mortality were estimated for a range of possible reductions in transplant services (25%-100%).

CO N FLI C T S O F I NTE R E S T
The authors of this manuscript have no conflicts of interest to disclose. Research idea and study design: TGP, JLB-G

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available at: