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With a vulnerable population, centralized care, and a strong system in place for other shots, dialysis providers argue that they should be part of the early rollout with higher prioritization for their patients.

"I have talked to dialysis providers large and small across the country, and it is a unanimous opinion that we would like to be able to vaccinate our patients, in our facilities, by our staff," said Jeffrey Silberzweig, MD, co-chair of the American Society of Nephrology (ASN) COVID-19 Response Team.

End-stage renal disease (ESRD) patients are among the most vulnerable populations for poor outcomes of COVID-19. They had the among all Medicare beneficiaries -- four-fold that of other age-matched seniors; their COVID-19 mortality rate was 25-fold that of other Medicare beneficiaries the same age.

"We're advocating for them to get vaccinated really for two reasons," said Jeffrey Giullian, MD, MBA, chief medical officer of DaVita Kidney Care. "First and foremost, because it is the right thing for them, it will protect them. And then secondarily, it is the right thing for our society. Because when we get them protected, then they are less likely to be hospitalized, less likely to put extra pressure on the health system."

CDC priority groupings put kidney disease patients in the 1c group with the tens of millions of patients with other chronic conditions if they don't qualify for a higher-priority group due to age 75 and older, nursing home residency, or employment in healthcare or other essential frontline work. (In some states, however, they may be in phase 1a or 1b.)

The average age of dialysis patients is around 65, so many will not qualify until group 1c's turn comes around, noted Anthony Valeri, MD, a nephrologist at Columbia University Medical Center and medical director of a satellite dialysis unit affiliated with DaVita.

However, he argued that dialysis should be a group 1a criterion. Along with all the comorbidities and modest immunosuppression that go along with ESRD, he told MedPage Today, "you could argue they should be given the same consideration as to nursing home residents, because it's not that dissimilar. ... Having to go to a center three or four times a week and be there for several hours in a large group setting does increase risk."

Some places like Texas and Pennsylvania have already opened vaccination up to people with underlying medical conditions. DaVita and Fresenius both cited some scattered successes in getting into the distribution chain to administer COVID-19 vaccine to their frontline workers and patients in various places.

For example, Louisiana provided thousands of doses to Fresenius' hub there, and Minnesota provided large allocations to both Fresenius and DaVita. But it has been a state-by-state, and in some places county-by-county, effort.

"Every state has a slightly different approach to managing the vaccine," said Kathleen Belmonte, RN, MBA, senior vice president of nursing and clinical services for Fresenius Kidney Care. "Not every state is interested in direct distribution models to dialysis units."

Silberzweig's ASN team has lobbied the federal Department of Health and Human Services along with governors offices and state health departments and has ongoing conversations with the CDC about possible routes for vaccinating kidney disease patients. "We keep trying to find the right people who are the decision-makers to help us accelerate that," he said. "It's a work in progress. I appreciate that there are many people that want to get vaccines for their patients, so we will do our best to keep advocating."

But with the vaccines currently in short supply, it's just not feasible, said Claire Hannan, MPH, executive director of the .

Few states are opting to spread their limited supply out across the tens of thousands of individual providers who have enrolled to administer COVID-19 shots; rather, they are starting with larger scale distribution centers, she told MedPage Today. Refrigeration requirements play a role in that as well as the multi-dose vials that require a number of patients to be ready within the same window of time, she added.

Kidney disease advocates aren't the only ones arguing for higher priority of their target population, she noted, citing jockeying among essential workers groups.

"There's a lot of pressure being put on governors," Hannan told MedPage Today. "One thing about those over 65 or over 75 is it's very easy to prioritize them just by age. So in the interest of efficiency, that seems like a very effective way to get more doses out into the community and get them into arms."

However, end-stage renal disease patients do have some advantages, Hannan noted. For one, this population is united around the dialysis center. "That's a good pathway," she said, whereas many other conditions cut across providers and access points in a way that makes them harder to reach.

Also, dialysis units have honed their systems for vaccine distribution and administration.

"Infection control is what dialysis centers do," said Giullian. "Even in a non-COVID world, dialysis units are used to vaccinating patients. We vaccinate against influenza every year. We vaccinate patients against hepatitis B, we vaccinate against pneumonia. So this is definitely encompassed in our regular care of patients."

Robust mechanisms for efficiency are in place, agreed Jeffrey Hymes, MD, chief medical officer of Fresenius Kidney Care North America.

"We see our patients three times a week, we're broadly distributed throughout the country, we have nurses, we have all the necessary supplies and experience," he told MedPage Today. "As an organization with national distribution we have the ability to move supplies, handle logistics to make sure vaccine that is received is distributed appropriately to the locations that need it, and very robust information systems as well to keep track of the vaccination."

There are logistical hurdles to having outside providers come into the dialysis center to administer vaccine, as with the model of CVS and Walgreens vaccinating in long-term care facilities, said Silberzweig, who oversees nine dialysis units as chief medical officer of the Rogosin Institute in New York City.

For example, dialysis centers run three to four shifts of patients coming in from 5 a.m. to 11 p.m. at night, so an outside provider would have to come in outside of normal business hours and return multiple times a day, he pointed out.

Hannan, though, expressed skepticism that advocacy will have much impact in getting the ESRD population and other high-risk medical groups to the front of the line in many places any time soon.

"We don't see production ramping up like we thought it would. It's going to take us so much longer than we thought to move out of phase 1b, to move into phase 1c, to move into people with high-risk conditions," she said. "Hopefully when we reach that point where there is enough vaccine supply to spread across providers that have very targeted, very specific populations, they [dialysis centers] would be ready to go."

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