It is clear that patients on MHD are vulnerable to SARS-CoV-2 infection and are at higher risk of developing severe complications due to their relative immunocompromised state. Many patients also have comorbidities such as diabetes mellitus, hypertension, and/or cardiovascular disease, which further increase their risk of poor outcomes. Of the 290 MHD patients, 107 patients (37%) acquired SARS-CoV-2 infection from the community, and the overall mortality rate was 33%, mainly due to SARS-CoV-2 infection. Most of the deceased patients had preexisting comorbidities; more than 20% had chronic kidney disease (CKD), according to Ida Gagliard et al. [9]. At a single HD center in Renmin Hospital, Wuhan University, 37 out of 230 patients on HD developed SARS-CoV-2 infection between 14 January and 17 February 2020. A total of seven patients on HD died, six of whom had SARS-CoV-2 infection [8]. As in non-dialysis patients [10,11,12], age seemed to be the most important risk factor for SARS-CoV-2 infection in MHD patients, which was most common in the age group 50–65 years (44%), and the mortality rate of older MHD patients infected with SARS-CoV-2, especially those > 65 years, was also higher than that of younger patients (55% in > 65 years versus 29% in 50–65 years and 14% in < 50 years, p = 0.000007). Our study also showed that vaccination played a crucial role in reducing the risk of infection and mortality in MHD patients infected with SARS-CoV-2; in addition to the number of vaccinations, the willingness of people and patients to be vaccinated also played a role.
Since the start of vaccination (in late March 2021), the mortality rate of MHD patients infected with SARS-CoV-2 has dramatically decreased from 42% in unvaccinated patients to 24% in patients vaccinated with one dose and 21% in patients vaccinated with two doses (p = 0.01). The vaccination program in our city started at the end of March 2021, when the pandemic incidence was at its peak. The vaccine used was from Astra-Zeneca, Pfizer, and Moderna, which were first donated to Vietnam directly or through the World Health Organization (WHO)’s Covax program by countries such as the USA, Japan, and Australia, as well as the European Union (EU), and then purchased by the government. MHD patients were given priority for vaccination. Surprisingly, the mortality in MHD patients younger than 50 years was 17%, regardless of their vaccination status (with or without vaccination and number of doses). However, in MHD patients > 50 years of age, the mortality rate was much lower in individuals with only one dose compared with those without vaccination (33% versus 67%, p = 0.0007), highlighting the essential role of vaccination in the outcome of individuals aged ≥ 50 years. In addition to the virulence and spread characteristics of COVID-19, the pandemic management policy contributed significantly to the outcomes of individuals infected with SARS-Cov-2, especially MHD patients infected with SARS-Cov-2.
In the initial phase of the pandemic (no vaccination yet), with the imposition of the zero-COVID policy, all patients infected with SARS-Cov-2, including MHD patients and their first, secondary, tertiary contacts, had to be concentrated in the newly established COVID-19 specialized centers, which had a lack of staff experience and equipment, poor infrastructure, and shortage of professional staff, resulting in very high transmission and mortality rates. The SARS-CoV-2 infected MHD patients were very much associated with the fact that they were not properly cared for and treated as they were previously in the dialysis centers, resulting in high mortality of these subjects. After learning many painful and heartbreaking lessons from the zero-COVID policy, the city government implemented what we call a “modified zero-COVID policy” in conjunction with the vaccination program (right after the vaccine became available). All hospitals were transformed into “divided hospitals,” which was introduced in some countries such as Korea [13]. All hospitals were divided into two separate and isolated sectors: one for non-SARS-Cov-2 patients and one for patients infected with SARS-Cov-2. In the COVID-19 quarantine sector, in addition to units for the care of patients infected with SARS-Cov-2 with or without comorbidities, there was a dialysis unit reserved for patients with SARS-Cov-2-induced acute kidney injury or MHD patients infected with SARS-Cov-2. All staff were required to work 24 h a day, 7 days a week, with a shift change every 2 weeks (each assigned staff team was required to work continuously 24 h a day, 7 days a week in the hospital or on the epidemic front for 2 weeks without a day off).
Although exhausted by the working hours, the overwhelming workload, and being away from their families, the staff always worked with dedication to ensure the survival of the patients. Unfortunately, the mortality rate was still high at 57% when the policy was first implemented. The causes were multifactorial, including the severity of the disease and comorbidities, the lack of adequate equipment and experience in caring for MHD patients infected with SARS-Cov-2, the shortage of staff, and the overwhelming number of patients compared with the number of dialysis machines [only one dialysis unit with a mini-reverse osmosis (RO) system used for ten patients/day], forcing shorter or delayed dialysis; in addition, the vaccination had not yet taken effect. Faced with this tragedy, the hospital’s board of directors launched a humanitarian campaign, appealing to benefactors, patrons, and humanitarian organizations to donate the necessary equipment, including dialysis machines and mini-RO systems. This event, coupled with the dedication and enthusiasm of the staff, the reallocation of dialysis machines from non-COVID-19 to COVID-19 zones, and the staff’s experience in caring for patients infected with SARS-Cov-2, contributed greatly to the remarkable decrease in mortality from 57% to 42% and then to 14% (p = 0.00025) when the “co-living with COVID-19” policy was implemented due to the large-scale vaccination program conducted throughout the country, with more than 80% of the population vaccinated in a short period of time. At that time, the majority of MHD patients infected with SARS-Cov-2 were quarantined at home, and the small remaining number had to be hospitalized due to the severity of their infection and/or comorbidities, and thus the mortality rate of these patients was still high compared with those quarantined at home (31% versus 14%).
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