In This Article
- It appears that COVID-19 can trigger APOL1-related kidney failure in African Americans
- Even among African Americans who have only mild COVID-19, there may be a large spike in chronic kidney disease in the coming years
- When rationing of access to dialysis and other life-saving interventions is necessary during the COVID-19 pandemic, it is typically done according to the principle of utilitarianism, which considers short-term prognosis and life-limiting comorbidities
- Utilitarianism has the potential to perpetuate health inequity by disadvantaging African Americans and other groups that have high rates of other, so-called "comorbidities," e.g., heart disease, diabetes, hypertension and chronic kidney disease. These medical conditions often occur as a result of lack of access to preventative health screening, poor health literacy and socioeconomic status and limited access to high quality health care
Both biologic and socioeconomic factors contribute to the disparities in outcomes among African Americans, according to a virtual Grand Rounds presentation by the Department of Medicine at Massachusetts General Hospital on May 21, 2020.
The excessively high burden of COVID-19 on African Americans may be partly attributable to a genetic profile that puts some African Americans at high risk of severe kidney injury, according to research presented by David J. Friedman, MD, of the Department of Medicine at Beth Israel Deaconess Medical Center.
Winfred W. Williams, MD, associate chief of the Division of Nephrology at Mass General, discussed how decisions about the allocation of scarce life-saving interventions, including dialysis, have the potential to exacerbate health disparities in populations with chronic kidney disease (CKD).
APOL1 Kidney Disease
Populations in sub-Saharan Africa have genetic variants in a gene called APOL1 that protect them from African sleeping sickness. In the United States, individuals who have recent African ancestry may also have these variants—about 13% of all African Americans—markedly increasing their risk of a wide range of nondiabetic kidney diseases.
Two of the most aggressive of these diseases are HIV-related kidney disease and the focal segmental glomerulosclerosis (FSGS) that can occur with interferon therapy. Both lead to a pattern of kidney injury called collapsing glomerulopathy. These diseases have something important to teach about COVID-19 and kidney disease:
- HIV-related kidney disease seems to be triggered by a direct viral infection of the kidney
- In patients with FSGS, APOL1 expression is dramatically upregulated by interferon
There is accumulating evidence that SARS-CoV-2 directly affects kidney tissue, most prominently in the glomeruli. Putting all this together, it appears that COVID-19 can trigger APOL1 kidney disease, either via the cytokine storm (which includes a cascade of interferons) or viral infection of glomeruli.
Dr. Friedman and colleagues have seen or heard of dozens of reports of African Americans with COVID-19 who developed high-grade proteinuria and acute kidney injury. In two of the first reported cases, kidney biopsies showed collapsing glomerulopathy, and both patients had the high-risk APOL1 variants. Both patients are now dependent on dialysis.
An equally grave concern is that among African Americans who have had mild COVID-19, there may be a large spike in cases of CKD in the coming years.
Equitable Rationing of Dialysis
At the height of the COVID-19 epidemic in New York, hospitals had to ration life-saving interventions. In settings such as disaster and military triage, rationing is typically done according to the principle of utilitarianism, which aims to maximize the number of lives and life-years saved. Thus, the typical considerations are:
- Short-term prognosis
- Underlying medical conditions expected to be significantly life-limiting
This approach is efficient and avoids the need for comparative judgments. However, it has the potential to exacerbate underlying health disparities.
The COVID-19 pandemic has presented clear examples. At Mass General, African American and Latino patients admitted for COVID-19 are outnumbering white patients in every adult age group, sometimes by 2:1 or more. Nationally, the latest overall COVID-19 mortality rate for Black Americans is 2.4 times as high as the rate for white Americans. Due to a variety of social factors, including the paucity of available high-quality health care services and preventative health screening, these communities tend to have high rates of life-limiting chronic diseases, including CKD.
Basing access to dialysis on estimates of short-term survival or life-limiting comorbidities has the potential to perpetuate health inequity—many African Americans and Latinos would not be eligible because they already had poor access to care and multiple comorbidities. Some commentators propose that allocators of scarce resources should give priority or special consideration to low-paid essential workers and members of historically disadvantaged groups.
Dr. Williams posed ethics questions related to scarcity:
- How do we ensure that underserved communities who are at the highest risk of contracting COVID-19 are prioritized for testing?
- How can we ensure adequate post-acute care to individuals at high risk of poor outcomes, including those with CKD and those who will be newly dependent on dialysis following critical illness with COVID-19?
- How might patients with CKD be disproportionately affected by allocation frameworks for scarce critical care resources?
- How should we allocate dialysis if we are unable to provide it to all patients who need it and wish to receive it?
He urged clinicians to do all they can to mitigate the glaring health disparities that have emerged during the pandemic.
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