What to Know About Chronic Kidney Disease and COVID-19

If you’re living with chronic kidney disease (CKD) during the current COVID-19 pandemic, you may have concerns about your risk of becoming seriously ill should you contract the infection, or if any changes should be made to your medications or dialysis schedule.

While early reports didn’t list chronic kidney disease as a risk factor for severe COVID-19, more recent studies have found there is significant reason for concern. Out of risk factors for serious COVID-19 infections, it’s now thought that CKD is the most common risk factor for severe COVID-19 worldwide. And of all medical conditions that increase risk, CKD appears to confer the highest risk for severe COVID-19.

While these findings may be frightening, we are learning more about how the virus is transmitted and how people can reduce their risk of contracting the infection.

Chronic Kidney Disease and COVID-19 Risk

Having chronic kidney disease may affect both your risk of acquiring a COVID-19 infection and the severity of the infection if you become ill.

Chronic Kidney Disease and Risk of Infection

Chronic kidney disease may affect the risk of acquiring COVID-19 both directly (susceptibility) and indirectly (due to exposures related to receiving medical care outside the home such as dialysis).

For those receiving dialysis in a hemodialysis unit (and thus having greater exposure to other people), there does appear to be an increased incidence of infection.

In one study looking specifically at efforts to control a COVID-19 outbreak in a hemodialysis unit, it was noted that certain exposures raised the risk of contracting the infection. These include:

• Frequently visiting the hospital (such as for dialysis)
• Sharing healthcare transportation to the dialysis unit with other patients
• Living in a nursing home
• Having been admitted to the hospital within the previous two weeks

Since dialysis is primarily used with end-stage kidney disease, it’s not known how early stages of chronic kidney disease would affect risk.

Chronic Kidney Disease and Severity of Infection

Having chronic kidney disease does increase the risk of a severe COVID-19 infection, including:

• Hospitalization
• ICU admission
• Mechanical ventilation
• Death

Early on in the pandemic, the role of chronic kidney disease in COVID-19 was less clear. A lack of awareness of CKD and the fact that the diagnosis may not be recorded in a person’s medical chart led to the condition being underestimated as a risk factor.

Some factors that make people with chronic kidney disease particularly susceptible to severe infection include:

• Altered immune cell function
• The loss of antibodies (and complement) through the urine
• Bodyside inflammation
• Immunosuppressive medications (in some cases)

Since then, studies have shown that a history of chronic kidney disease both increases the risk of severe infection and increases mortality in those who are hospitalized.

An analysis of electronic health records has now identified chronic kidney disease as the leading risk factor for hospitalization in people who contract COVID-19. In this analysis, people with severe (end-stage) kidney disease on dialysis (or post transplant) were 11 times more likely to be hospitalized than those who do not have kidney disease.

Looking at the overall risk for a specific individual, a review and analysis of studies found that roughly 20% of people with chronic kidney disease who contracted COVID-19 had severe disease. When controlled for other risk factors—such as age—this risk was three times higher than that of people who did not have chronic kidney disease.

COVID-19 and Risk of Long-Term Kidney Problems

Another risk to consider is the worsening of kidney function in people with CKD who contract COVID-19. It’s clear that COVID-19 can affect the kidneys, but it’s still unknown at this time what the long-term effects may be or whether people with CKD are more likely to develop long-COVID symptoms.

Complications of Chronic Kidney Disease and COVID-19

People with chronic kidney disease can develop the same complications of COVID-19 as those without CKD, such as:

• COVID pneumonia
• Acute respiratory distress
• Abnormalities in blood clotting

How COVID-19 Affects the Kidneys

There are a number of ways (both direct and indirect) that COVID-19 affects the kidneys. A few of these include via:

• Direct damage to cells (cytotoxic damage) and inflammation when the virus enters kidney cells (this can occur even in people who are not critically ill)
• Tiny blood clots. Unlike the flu, COVID-19 commonly affects blood vessels. This has been seen in large blood vessels and has resulted in heart attacks, strokes, and clots in the lungs, but clots in the tiny blood vessels in the kidneys can reduce kidney function.
• Sepsis (an overwhelming secondary infection that can develop due to the virus)
• Changes in blood pressure that fail to adequately perfuse the kidneys
• The effect of immune chemicals (cytokines) that are released due to the infection
• Breakdown of muscle (rhabdomyolysis) that in turn results in products that damage the kidneys

Chronic Kidney Disease Treatments and COVID-19

When looking at CKD and treatment, it’s important to look at both how the pandemic may affect your CKD treatment and how your treatment may differ if you contract COVID-19.

Treatments for Chronic Kidney Disease During the Pandemic

The treatment for chronic kidney disease can vary with the stage of the disease as well as by the presence of coexisting conditions. For stage 4 and stage 5 disease, dialysis or a kidney transplant may be needed.

Medications

At the current time, the Centers for Disease Control and Prevention (CDC) recommends that you continue to use your regular medications as prescribed by your healthcare provider. These might include drugs such as:

• Angiotensin-converting enzyme inhibitors (ACE inhibitors)
• Angiotensin II receptor blockers (ARBs)
• Diuretics
• Red blood cell stimulating agents
• Phosphorus-reducing medications
• Supplements such as vitamin D and iron
• Immunosuppressive therapy (for transplant recipients)
• Treatments for coexisting conditions such as diabetes

You may also require a special diet (such as one low in protein or potassium), and this should be continued.

Dialysis

If you are on dialysis, the CDC recommends that you continue your treatments, being careful not to miss any appointments. If you should feel ill, it’s important to contact your dialysis center to ask how you should proceed.

As noted, receiving dialysis can increase your risk of exposure to COVID-19, and many dialysis units have a comprehensive plan of preventive measures in place. This is especially true in the case of people who test positive for COVID-19 and may include, for example, separate rooms for those who are infected vs. uninfected.

Home dialysis is an alternative for some people, but has its own challenges.

For outpatient dialysis treatments, most people visit the center three times per week for three to four hours. Some researchers have postulated that reducing the frequency to two times weekly may be an option, and a very small study (of carefully selected people) found it to be possible and safe.

That said, decreasing the frequency of dialysis or missing appointments can be problematic. A review of studies found that a delay in hemodialysis due to COVID-19 infections can worsen sequelae of either new kidney disease or end-stage kidney disease such as:

• High potassium levels (hyperkalemia)
• Swelling in the arms and legs (fluid overload)
• Symptoms of confusion, lethargy, or delirium due to a build-up of toxins in the blood

Treatment If You Should Contract COVID-19 With CKD

If you suspect you may be infected with COVID-19, you should have testing done as soon as possible and, if positive, contact your kidney healthcare provider.

Chronic Kidney Disease Treatments During COVID-19 Infections

If you test positive for COVID-19 with CKD, it’s important to contact your healthcare provider right away to discuss management.

Those who are on immunosuppressive medications for a kidney transplant may shed the virus longer than someone who is not on these medications, even if you do not have symptoms. Your healthcare provider may recommend that you quarantine longer than ordinarily recommended.

Regular medications for kidney failure can usually be continued.

For those who are on immunosuppressive medications for a kidney transplant, however, your healthcare provider may recommend changes (such as reducing steroid dose, withdrawing anti-rejection drugs, using IgG in people who have hypogammaglobulinemia to reduce the risk of secondary infections, etc.).

COVID-19 Treatments in People With Kidney Disease

Most medications and therapies used to treat COVID-19 in people without kidney disease can be used for those with chronic kidney disease. In general, dexamethasone is considered safe.

Antibody treatments such as Remdesivir may or may not be recommended, as they are often not considered for adults who have an eGFR less than 30 mL/min/m2 (stage 4 and 5 CKD).

For those at risk of becoming seriously ill, transfer to a medical center that offers a higher level of care should be considered.

Frequently Asked Questions

Should people with chronic kidney disease get the vaccine?

Everyone 6 months and older is eligible for the COVID-19 vaccine. Due to the risk of severe illness with COVID-19, people with CKD should get the vaccine. Full vaccination, plus the booster is the most effective way to protect yourself from COVID-19.

While the available COVID-19 vaccines have been shown to be safe for people with CKD, some studies have found that some people with CKD have a reduced immune response to vaccination. The CDC recommends a third primary dose and an updated bivalent booster for immunocompromised people.

The updated bivalent boosters from Pfizer-BioNTech and Moderna target both the original virus and the Omicron variant.

Is one vaccine better than another for people with CKD?

In the United States, the four vaccines that are currently available are:

• Pfizer-BioNTech, available to people 6 months and older
• Moderna, available to people 6 months and older
• Janssen/Johnson & Johnson (J&J), available to people 18 years and older
• Novavax, available to people 12 years and older

Due to possible side effects from the J&J COVID-19 vaccine, should only be considered in certain limited situations. The CDC recommends that people, with or without CKD, receive one of the mRNA vaccines (Moderna or Pfizer) or the Novavax vaccine over the J&J vaccine.

How has the COVID-19 pandemic affected the mental health of people with chronic kidney disease?

According to a recent study, compared with people without chronic kidney disease, people on dialysis were relatively unaffected. The researchers thought that perhaps these individuals were less affected by social distancing, but also postulated that they may be better able to cope with the pandemic since they have high resilience.

Perhaps this is a silver lining to having coped with a chronic disease before the pandemic.

How to Stay Safe

Taking simple measures to protect yourself from infection can be very helpful until you are fully vaccinated (and even if vaccinated, as it’s still unknown how effective immunization will be with chronic kidney disease). The CDC recommends:

• Wear a mask when in public.
• COVID-19 primary series vaccines for everyone ages 6 months and older, and COVID-19 boosters for everyone eligible ages 5 years and older.
• If you were exposed to COVID-19, wear a high-quality mask for 10 days and get tested after day 5 (on day 6 or later).
• If you test positive for COVID-19, stay home for at least 5 days and isolate yourself from others in your home. You are likely most infectious during these first 5 days. Wear a high-quality mask when you must be around others at home and in public.
• Wash your hands frequently and use hand sanitizer in public to sanitize things that you will touch (such as doorknobs and your phone case).
• Avoid crowds.
• Stay away from anyone who is ill.

If your kidney disease is stable, telehealth is often a good option. In some cases, you may have an outpatient lab appointment and then follow up with a telemedicine appointment.

If you are on dialysis, ask about home dialysis. Since most people, however, receive hemodialysis in a dialysis clinic, ask about their infection prevention policies to make sure you are comfortable. Many dialysis units have prepared thorough precautions to minimize risk.

Be your own advocate. Ask any questions you may have. If you should become infected, ask whether a higher-level hospital might be a good idea.

A Word From Verywell

It’s important to keep in mind that any statistics you might see represent the past. Researchers are learning more every day, and death rates are decreasing, even for people who have risk factors for severe disease.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.