COVID-19 Vaccine Distribution Makes Another Case for Digital CKD Registries in Africa
Triage. It’s been one year since the COVID-19 pandemic began to rampage and change our lives forever, while adding a plethora of new terms into our collective lexicon. One such term we can expect to hear more frequently, as the COVID-19 vaccine distribution picks up pace globally, is “triage”.
Triage, in pre-pandemic terms, was most often used in the context of an emergency room, whereby patients are ranked and given care according to the severity and life-threatening nature of their presenting complaints; rather than on a strictly “first-come-first-serve” basis. Triage is the reason a person with a minor sprain may wait for three hours in some emergency rooms to receive care, while a patient suffering a heart attack is attended to immediately. In the context of the COVID-19 vaccine, triage refers to the process whereby public health officials determine the order in which the vaccine is distributed to various groups of the population, based on each group’s risk of severe illness and virus exposure. For example, elderly people (higher risk of severe illness due to age and co-morbidities) will be offered the vaccine earlier than young healthy people — especially those who do not work in “essential” jobs with frequent contact with the public. So, what does this have to do with chronic kidney disease?
COVID-19 & Chronic Kidney Disease
As the scientific community strived to learn about this novel coronavirus at breakneck speed, one of the earliest clinical patterns to emerge was the impact of the virus on the kidneys. First, it was observed that severe cases tended to lead to Acute Kidney Injury and eventual kidney failure in a significant proportion of patients. More pertinently, it was also observed that people with Chronic Kidney Disease (CKD) tend to suffer more severe forms of infection, leading to higher risk of hospitalization and death than patients with other co-morbidities. Since then, a number of studies have analyzed this relationship to delineate the risk of severe COVID-19 illness and mortality, for people with Chronic Kidney Disease.
Researchers in the United Kingdom, Gansevoort & Hilbrands (2020), used the OpenSAFELY health analytics platform which contains data for more than 17 million people to demonstrate that patients with CKD are at a higher risk for death from COVID-19 than those with other known risk factors, including chronic heart and lung disease. The study concluded that people with CKD deserve special attention with regard to COVID-19, and patients with CKD “including those on dialysis or living with a kidney transplant should be included in vaccination trials, because uraemia and the use of immunosuppressive agents could potentially hamper vaccination responses.”
In another European study, Hilbrands et al. (2020), researchers designed a COVID-19 specific database (European Renal Association COVID-19 Database) to prospectively collect detailed data on kidney transplant and dialysis patients with COVID-19. The study reported the 28-day probability of death was 21.3% in kidney transplant and 25% in dialysis patients.
Finally, Williamson et. al (2020), analyzed EHR data from the NHS and confirmed reports of the increased risk of COVID-19 related hospital admission due to co-morbidities such as diabetes, heart failure hypertension and chronic kidney disease. Remarkably, their study “further highlighted the magnitude of the kidney disease related risk, whereby patients with end stage renal disease, were found to be at 11 fold increase the odds of hospitalization.”
The Case for Digital CKD Registries
The case for Electronic Health Record (EHR) CKD registries has been well documented in recent times, as they are thought to be central to population health strategies to improve CKD care. In a 2015 study, performed by Mendu et al, an EHR-based CKD registry was created within the Harvard-affiliated Partners Healthcare System to identify opportunities for quality improvement activities associated with clinical care. The registry, containing 60,503 patients, categorized patients by CKD stage and included rates of annual testing for EGFR and proteinuria, blood pressure control, use of CKD-appropriate blood pressure lowering medications, nephrotoxic medication use, Hepatitis B virus immunization, vascular access placement, transplant status, CKD progression risk, number of outpatient nephrology visits and hospitalizations. The researchers concluded that, “a CKD registry of this type, can identify modifiable care gaps across the spectrum of CKD care and enable population health strategy implementation.”
As the COVID-19 and CKD risk studies have clearly indicated, special protections are required for people with Chronic Kidney Disease. Thus, they should be in the front of the line for safely receiving COVID-19 vaccines. When African countries succeed in receiving early batches of the scarce COVID-19 vaccine en masse, debates around triage for distribution will arise. However, many African governments do not have the required data to make decisions about how many, who, and where the chronic kidney disease patients in their countries are. Hence, the case for building digital CKD registries.
Given the fact that the African continent suffers disproportionately from the effects of Chronic Kidney Disease, building out a database of CKD patients through public-private partnerships, taking advantage of the ongoing mobile data revolution on the Continent, would be a good first step. While it may take some time for many countries on our continent to receive doses of the vaccine, we can start to collect and analyze the data needed for effective triage and distribution immediately, especially for CKD patients who we know require special attention and protection from COVID-19.