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Estimated SARS-CoV-2 Seroprevalence in US Patients Receiving Dialysis 1 Year After the Beginning of the COVID-19 Pandemic

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To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What is the SARS-CoV-2 seroprevalence among patients receiving dialysis and the adult population in the US as of January 2021?

Findings  In this cross-sectional study of 21 464 patients receiving dialysis in the US, who broadly represent persons most at risk of to SARS-CoV-2 infection (eg, older people, members of racial/ethnic minority groups), the SARS-CoV-2 seroprevalence was 18.9%. Seroprevalence varied little by US region. Younger persons, those living in communities with a majority Hispanic population, and those living in lower-income neighborhoods were the groups with the highest seroprevalence rates.

Meaning  After standardizing seroprevalence rates for patients receiving dialysis to the US adult population, results of this study suggest that most adults did not have evidence of natural SARS-CoV-2 infection by January 2021.


Importance  Seroprevalence studies complement data on detected cases and attributed deaths in assessing the cumulative spread of the SARS-CoV-2 virus.

Objective  To estimate seroprevalence of SARS-CoV-2 antibodies in patients receiving dialysis and adults in the US in January 2021 before the widespread introduction of COVID-19 vaccines.

Design, Setting, and Participants  This cross-sectional study used data from the third largest US dialysis organization (US Renal Care), which has facilities located nationwide, to estimate SARS-CoV-2 seroprevalence among US patients receiving dialysis. Remainder plasma (ie, plasma that would have otherwise been discarded) of all patients receiving dialysis at US Renal Care facilities from January 1 to 31, 2021, was tested for SARS-CoV-2 antibodies. Patients were excluded if they had a documented dose of SARS-CoV-2 vaccination or if a residence zip code was missing from electronic medical records. Crude seroprevalence estimates from this sample (January 2021) were standardized to the US adult population using the 2018 American Community Survey 1-year estimates and stratified by age group, sex, self-reported race/ethnicity, neighborhood race/ethnicity composition, neighborhood income level, and urban or rural status. These data and case detection rates were then compared with data from a July 2020 subsample of patients who received dialysis at the same facilities.

Exposures  Age, sex, race/ethnicity, and region of residence as well as neighborhood race/ethnicity composition, poverty, population density, and urban or rural status.

Main Outcomes and Measures  The spike protein receptor-binding domain total antibody assay (Siemens Healthineers; manufacturer-reported sensitivity of 100% and specificity of 99.8%) was used to estimate crude SARS-CoV-2 seroprevalence in the unweighted sample, and then the estimated seroprevalence rates for the US dialysis and adult populations were calculated, adjusting for age, sex, and region.

Results  A total of 21 464 patients (mean [SD] age, 63.1 [14.2] years; 12 265 men [57%]) were included in the unweighted sample from January 2021. The patients were disproportionately older (aged 65-79 years, 7847 [37%]; aged ≥80 years, 2668 [12%]) and members of racial/ethnic minority groups (Hispanic patients, 2945 [18%]; non-Hispanic Black patients, 4875 [29%]). Seroprevalence of SARS-CoV-2 antibodies was 18.9% (95% CI, 18.3%-19.5%) in the sample, with a seroprevalence of 18.7% (95% CI, 18.1%-19.2%) standardized to the US dialysis population, and 21.3% (95% CI, 20.3%-22.3%) standardized to the US adult population. In the unweighted sample, younger persons (aged 18-44 years, 25.9%; 95% CI, 24.1%-27.8%), those who self-identified as Hispanic or living in Hispanic neighborhoods (25.1%; 95% CI, 23.6%-26.4%), and those living in the lowest-income neighborhoods (24.8%; 95% CI, 23.2%-26.5%) were among the subgroups with the highest seroprevalence. Little variability was observed in seroprevalence by geographic region, population density, and urban or rural status in the January 2021 sample (largest regional difference, 1.2 [95% CI, 1.1-1.3] higher odds of seroprevalence in residents of the Northeast vs West).

Conclusions and Relevance  In this cross-sectional study of patients receiving dialysis in the US, fewer than 1 in 4 patients had evidence of SARS-CoV-2 antibodies 1 year after the first case of SARS-CoV-2 infection was detected in the US. Results standardized to the US population indicate similar prevalence of antibodies among US adults. Vaccine introduction to younger individuals, those living in neighborhoods with a large population of racial/ethnic minority residents, and those living in low-income neighborhoods may be critical to disrupting the spread of infection.

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Article Information

Accepted for Publication: April 28, 2021.

Published: July 12, 2021. doi:10.1001/jamanetworkopen.2021.16572

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2021 Anand S et al. JAMA Network Open.

Corresponding Author: Shuchi Anand, MD, Divison of Nephrology, Department of Medicine, Stanford University, 777 Welch Rd, Ste DE, Palo Alto, CA 94304 (sanand2@stanford.edu).

Author Contributions: Drs Anand and Montez-Rath had full access to anonymized data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Anand, Montez-Rath, Hunsader, Beyer, Dittrich, Parsonnet, Chertow.

Acquisition, analysis, or interpretation of data: Anand, Montez-Rath, Han, Cadden, Hunsader, Kerschmann, Boyd, Garcia, Block, Parsonnet, Chertow.

Drafting of the manuscript: Anand, Montez-Rath, Han, Cadden, Hunsader.

Critical revision of the manuscript for important intellectual content: Anand, Montez-Rath, Han, Kerschmann, Beyer, Boyd, Garcia, Dittrich, Block, Parsonnet, Chertow.

Statistical analysis: Montez-Rath, Han.

Obtained funding: Chertow.

Administrative, technical, or material support: Han, Cadden, Kerschmann, Boyd, Garcia, Dittrich, Block, Chertow.

Supervision: Anand, Montez-Rath, Hunsader, Beyer, Chertow.

Conflict of Interest Disclosures: Dr Anand reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases during the conduct of the study. Dr Montez-Rath reported that the funding for sample analysis was provided by Ascend Clinical Laboratory. Ms Cadden, Ms Hunsader, Dr Kerschmann, and Mr Beyer reported being employed by Ascend Clinical Laboratory; Drs Dittrich and Block reported being employed by US Renal Care. Dr Boyd reported receiving personal fees from Regeneron Sanofi for consulting regarding antibody therapeutics unrelated to this work, personal fees from Novartis for consulting regarding antibody therapeutics unrelated to this work, stock ownership from AbCellera unrelated to this work, and stock ownership from CareDx unrelated to this work. Dr Chertow reported receiving personal fees from Akebia, Ardelyx, AstraZeneca, Baxter, Cricket, DiaMedica, Gilead, Goldfinch Bio, Miromatrix, Reata, Sanifit, and Vertex; serving on the Angion Data Safety and Monitoring Board, Bayer Data Safety and Monitoring Board, ReCor Data Safety and Monitoring Board, and board of Satellite Healthcare, a not-for-profit dialysis organization; and having stock options from Outset and CloudCath. No other disclosures were reported.

Funding/Support: Ascend Clinical Laboratory funded the remainder plasma sampling.

Role of the Funder/Sponsor: Ascend Clinical Laboratory undertook the assay selection and sample processing for this study. The Additional Information section has more details.

Additional Information: The coauthors (Ms Cadden, Ms Hunsader, Dr Kerschmann, and Mr Beyer) from Ascend Clinical Laboratory performed the assays, prepared the results and electronic health record data, and sent the data to Stanford University investigators in an anonymized fashion.

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