COVID-19 in Elderly Patients Receiving Haemodialysis: A Current Review

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TL;DR

This review examines the heightened risk and poor outcomes of COVID-19 in elderly haemodialysis patients, driven by factors like immunosenescence, comorbidities, frailty, and reduced vaccine response. It highlights that these patients have mortality rates over 20 times higher than matched controls and often experience prolonged viral shedding. The paper provides evidence-based prevention and treatment strategies, including vaccination with mRNA vaccines and cautious use of antivirals like nirmatrelvir/ritonavir and remdesivir.

Full summary

4,010 CHARS

**Background:** The COVID-19 pandemic has disproportionately affected vulnerable populations, particularly elderly individuals with chronic kidney disease (CKD) receiving haemodialysis. These patients face unique challenges due to frequent hospital visits, increased exposure risk, and a high burden of comorbidities and frailty. This narrative review synthesizes current evidence on risk factors, pathophysiology, prevention, and treatment of COVID-19 in elderly haemodialysis patients (age >65 years).

**Methods:** The authors conducted a narrative review of the literature, summarizing findings from observational studies, clinical trials, and guidelines. Key data sources include large cohort studies (e.g., NHS England, US dialysis registry), randomized controlled trials (e.g., EPIC-HR, PINETREE, RECOVERY), and emerging studies on vaccination and therapeutics in dialysis populations.

**Key Results:** - **Risk Factors:** Age is the greatest predictor of mortality, with hazard ratio increasing linearly. CKD with eGFR <30 mL/min/1.73 m² is one of the strongest predictors of poor outcomes. Mortality rates in dialysis patients are over 20 times higher than propensity-matched historic controls. Nursing home stay, number of comorbidities, and frailty severity are significant risk factors. Immunosenescence is accelerated in dialysis patients, with T-cell status comparable to individuals 20 years older. Dialysis patients have a 7-day longer time to negative PCR test compared to non-CKD populations. Over 65% of dialysis patients remain PCR positive at 20 days. Serological response to vaccination is reduced: after first dose, 45% of dialysis patients mount a threshold response vs. 95% in controls; after second dose, 89% vs. 100%. Antibody titers are lower, and protection against reinfection is only 45% in dialysis patients vs. 90% in the general population. - **Prevention:** Symptom-based screening may miss 10–50% of asymptomatic cases. Universal PCR screening identified 19% positive in one study, with 10% asymptomatic. Rapid antigen tests (RAT) picked up 27.7–54% of cases. Cohorting and isolation are recommended, with longer isolation periods for dialysis patients due to prolonged viral shedding. mRNA vaccines (especially mRNA-1273) show superior immunogenicity compared to adenovirus vector vaccines in dialysis patients. A third dose elicits adequate antibody levels. - **Treatment:** Nirmatrelvir/ritonavir (Paxlovid) reduced hospitalization risk in EPIC-HR (median age 45, subgroup >65 showed increased effect). A proposed dose for dialysis: 300 mg nirmatrelvir/100 mg ritonavir day 1, then 150 mg/100 mg after each dialysis. Remdesivir in a retrospective study of 118 haemodialysis patients (mean age 68.5) showed lower composite mortality and disease aggravation, with no significant adverse events. Molnupiravir in 20 dialysis patients led to symptom improvement within 24–48 hours. Dexamethasone (6 mg for 10 days) reduced all-cause mortality in hospitalized patients requiring oxygen (RECOVERY trial, mean age 66.9). IL-6 inhibitors (tocilizumab/sarilumab) reduced mortality in hospitalized patients with CRP >75 or rapidly increasing oxygen needs. Baricitinib showed benefit in RECOVERY but is not recommended for dialysis patients.

**Clinical Implications:** Elderly haemodialysis patients require tailored prevention strategies including universal PCR screening during high prevalence, mRNA vaccination with booster doses, and extended isolation periods. Treatment should follow guidelines with dose adjustments for renal clearance. Nirmatrelvir/ritonavir and remdesivir appear safe and effective, while molnupiravir shows promise. Dexamethasone and IL-6 inhibitors are recommended for hospitalized patients with oxygen requirements. Ongoing trials (PANORAMIC, PROTECT-V) are actively recruiting dialysis patients to address evidence gaps. Clinicians must consider the unique pathophysiology of immunosenescence, inflammaging, and hypercoagulability in this population.