Delayed referral of black, Hispanic, and older patients with chronic renal failure

Setting reasonable goals for kidney transplant referral among dialysis facilities

BACKGROUND

Determining whether a patient is eligible for kidney transplantation is complex. In this study, we estimate what proportion of patients with end-stage kidney disease (ESKD) might have been suitable candidates for kidney transplantation but were not referred.

METHODS

We identified 43,952 people initiating dialysis for kidney failure between 2012 and 2017 in the states of Georgia, North Carolina, or South Carolina from the United States Renal Data System and linked to the Early-Steps to Transplant Access Registry to obtain data on referral and waitlisting up until December 2020. We identified 'good transplant candidates' as those who were waitlisted within 2-years of referral, among all patients referred within 1-year of dialysis initiation. Using propensity score cut-offs, logistic regression, and area under the curve (AUC), we then estimated the proportion of individuals who may have been good transplant candidates, but were not referred.

RESULTS

Overall, 42.6% of incident dialysis patients were referred within one year and among them, 32.9% were waitlisted within 2 years of referral. Our model had reasonably good discrimination for identifying good transplant candidates with an AUC of 0.70 (95%CI 0.69-0.71), sensitivity of 0.68 and specificity of 0.61. Overall, 25% of individuals not referred for transplant may have been 'good' transplant candidates. Adding these patients to the existing 18,725 referred patients would increase the proportion of incident ESKD patients being referred within one year from 42.6% to 57.2% (a ~ 14.6% increase).

CONCLUSIONS

In this study, we show that a significant proportion of potentially good transplant candidates are not being referred for transplant. A ~ 14% increase in the proportion of patients being referred from dialysis facilities is both a meaningful and realistic goal and could lead to more qualified patients being referred and subsequently waitlisted for a lifesaving transplant.

Hispanic/Latino Perspectives on Hearing Loss and Hearing Healthcare: Focus Group Results

OBJECTIVES

To better understand the hearing health learning needs of Hispanic/Latino adults by assessing hearing healthcare (HHC) knowledge, attitudes, and behaviors to inform the development of a culturally and linguistically appropriate self-management program. Through a series of focus groups with members of the target audience, this study explored knowledge about hearing loss and interventions, cultural facilitators and barriers to HHC utilization, and preferences for hearing health education and information delivery. Opinions were also received on patient education materials designed to increase self-efficacy for managing hearing loss in daily life.

DESIGN

This work was guided by a practical framework of culturally competent interventions for addressing disparities in health and healthcare, centered on structural, clinical, and organizational barriers to care. A hybrid individualistic social psychology and social constructionist approach was used to build programmatic theory related to the primary research objective. Focus group goals were to generate a combination of personal opinions and collective experiences from participants with an a priori plan to analyze data using combined content analysis/grounded theory methods. Purposive sampling was used to select 31 participants who were Spanish-speaking, identified as Hispanic/Latino, and who had normal hearing or self-reported hearing difficulties. Thirteen focus groups were conducted using Microsoft Teams, and each group was audio and video recorded for later off-line transcription, translation, and analysis. A constant comparison approach was used to systematically organize focus group data into a structured format for interpretation. Transcripts were coded independently by two investigators, and emergent themes were derived and interpreted from the coded data.

RESULTS

Major and minor themes tied to the framework for culturally competent interventions included those related to sociocultural barriers to care. Structural barriers, including inconsistent access to quality care, lack of culturally and linguistically appropriate patient education materials, appointment wait times and intake processes, and referrals to specialty care, were most frequently experienced by participants. Clinical barriers most frequently cited were a lack of culturally and linguistically congruent healthcare providers and lack of language access during healthcare visits. Other major themes included hearing loss lived experiences, family and familism, and hearing-related patient education needs and preferences.

CONCLUSIONS

Focus group results were integrated into a Spanish-language hearing loss self-management program that is currently being evaluated in a randomized controlled trial. The themes uncovered provided insight regarding the knowledge, attitudes, and beliefs about hearing loss and HHC, including hearing-related learning needs, of Hispanic/Latino adults in this sample.

A Cascade of Structural Barriers Contributing to Racial Kidney Transplant Inequities

Stark racial disparities in access to and receipt of kidney transplantation, especially living donor and pre-emptive transplantation, have persisted despite decades of investigation and intervention. The causes of these disparities are complex, are inter-related, and result from a cascade of structural barriers to transplantation which disproportionately impact minoritized individuals and communities. Structural barriers contributing to racial transplant inequities have been acknowledged but are often not fully explored with regard to transplant equity. We describe longstanding racial disparities in transplantation, and we discuss contributing structural barriers which occur along the transplant pathway including pretransplant health care, evaluation, referral processes, and the evaluation of transplant candidates. We also consider the role of multilevel socio-contextual influences on these processes. We believe focused efforts which apply an equity lens to key transplant processes and systems are required to achieve greater structural competency and, ultimately, racial transplant equity.

Infertility in the Midwest: perceptions and attitudes of current treatment

BACKGROUND

Although infertility affects an estimated 6.1 million individuals in the United States, only half of those individuals seek fertility treatment and the majority of those patients are White and of high socioeconomic status. Research has shown that insurance mandates are not enough to ensure equal access. Many workplaces, schools, and medical education programs have made efforts in recent years to improve the cultural humility of providers in efforts to engage more racially and economically underrepresented groups in medical care. However, these efforts have not been assessed on a population of patients receiving fertility care, an experience that is uniquely shaped by individual social, cultural, and economic factors.

OBJECTIVE

This study aimed to better understand the racial, cultural, economic, and religious factors that impact patient experiences obtaining fertility care.

STUDY DESIGN

A cross-sectional self-administered survey was administered at an academic fertility center in Chicago, Illinois. Of 5000 consecutive fertility care patients, 1460 completed the survey and were included in the study sample. No interventions were used. Descriptive univariate frequencies and percentages were calculated to summarize sociodemographic and other relevant patient characteristics (eg, race or ethnicity, age, household income, religious affiliation, insurance coverage). Rates of endorsing perceived physician cultural competency were compared among demographic subgroups using Pearson chi-squared tests with 2-sided P<.05 indicative of statistical significance. To identify the key determinants of patient-reported worry regarding 9 different fertility treatment outcomes and related concerns, a series of multiple logistic regression models were fit to examine factors associated with patient report of being "very worried" or "extremely worried."

RESULTS

Members of our sample (N=1460) were between 20 and 58 years of age (mean_adjusted, 36.2; standard deviation, 4.4). Among Black participants, 42.3% reported that their physician does not understand their cultural background compared with 16.5% of White participants (P<.0001). Participants who identified as Latinx were significantly more likely than White participants to report being very/extremely worried about side effects of treatment, a miscarriage, ectopic pregnancies, and birth defects (P<.05, P=.02, P=.002, P=.001, respectively). Individuals who identify as Hindu were nearly 4 times more likely to report being very/extremely worried about experiencing an ectopic pregnancy than nonreligious participants (P<.0002). Respondents most strongly identified the biology or physiology of the couple (mean_adjusted, 21.6; confidence interval, 20.4-22.7) and timing or age (mean_adjusted, 27.8; confidence interval, 26.5-29.1) as being associated with fertility. Overall, respondents most strongly disagreed that the ability to bear children rests upon God's will (mean_adjusted, 65.4; confidence interval, 63.7-67.1), which differed most significantly by race (P<.0001) and religion (P<.0001).

CONCLUSION

Of the patient characteristics investigated, racial and ethnic subgroups showed the greatest degree of variation in regard to worries and concerns surrounding the experience of fertility treatment. Our findings emphasize a need for improved cultural humility on behalf of physicians, in addition to affordable psychological support for all patients seeking fertility care.

Racial and Ethnic Disparities in Kidney Transplant Access Within a Theoretical Context of Medical Eligibility

BACKGROUND

Non-Hispanic black (NHB) and Hispanic patients have lower access to kidney transplantation compared to non-Hispanic whites (NHWs). We examined whether differences in the prevalence of comorbidities that affect eligibility for transplant contribute to disparities in receipt of transplantation.

METHODS

We performed a retrospective study of 986 019 adults who started dialysis between 2005 and 2014, according to the United States Renal Data System. We compared prevalence of comorbidities that could influence transplant eligibility by race/ethnicity. We examined time to first transplant by race/ethnicity in this overall cohort and in a very healthy sub-cohort without conditions that could be contraindications to transplantation.

RESULTS

During 2.3 years of mean follow-up, 64 892 transplants occurred. NHBs and Hispanics had a lower prevalence of medical barriers to transplantation at the time of dialysis initiation than NHWs, including age >70 years (26% in NHB versus 47% in NHW) and malignancy (4% in Hispanics versus 10% in NHWs). Access to transplant was 65% lower (95% CI, 0.33-0.37) in NHBs and 43% lower (95% CI, 0.54-0.62) in Hispanics (versus NHWs) in the first year after end-stage renal disease, but by Year 4, access to transplantation was not statistically significantly different between Hispanics or NHBs (versus NHWs). In our very healthy cohort, racial and ethnic disparities in access to transplantation persisted up to Year 5 in NHBs and Year 4 in Hispanics after end-stage renal disease onset.

CONCLUSIONS

Differences in medical eligibility do not appear to explain racial/ethnic disparities in receipt of kidney transplantation and may mask the actual magnitude of the inequities that are present.

Achieving equity in dialysis care and outcomes: The role of policies

Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis care and outcomes, how current ESKD and other public policies may influence or exacerbate these inequities, and gaps in the literature needed to inform future policies toward achieving equity in ESKD. We give special attention to the 2019 Advancing American Kidney Health Executive Order, which has high potential to radically transform dialysis care.

Association of Race and Poverty With Mortality Among Nursing Home Residents on Maintenance Dialysis

OBJECTIVES

The association of race, ethnicity, and socioeconomic factors with survival rates of nursing home (NH) residents with treated end-stage renal disease (ESRD) is unclear. We examined whether race/ethnicity, ZIP code-level, and individual-level indicators of poverty relate to mortality of NH residents on dialysis.

DESIGN

Retrospective cohort study.

PARTICIPANTS/SETTING

Using the United States Renal Data System database, we identified 56,194 nursing home residents initiated on maintenance dialysis from January 1, 2007 through December 31, 2013, followed until May 31, 2014.

MEASUREMENTS

We evaluated baseline characteristics of the NH cohort on dialysis, including race and ethnicity. We assessed the Medicare-Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data. We conducted Cox regression analyses with all-cause mortality as the outcome variable, adjusted for clinical and sociodemographic factors including end-of-life preferences.

RESULTS

Adjusted Cox analysis showed a significantly lower risk of death among black vs nonblack NH residents [adjusted hazard ratio (AHR) 0.91, 95% confidence interval (CI) 0.89, 0.94]. Dual-eligibility status was significantly associated with lower risk of death compared to those with Medicare alone (AHR 0.80, 95% CI 0.78, 0.82). Compared to those in higher MHI quintile levels, NH ESRD patients in the lowest quintile were significantly associated with higher risk of death (AHR 1.09, 95% CI 1.06, 1.13).

CONCLUSIONS/IMPLICATIONS

Black and Hispanic NH residents on dialysis had an apparent survival advantage. This "survival paradox" occurs despite well-documented racial/ethnic disparities in ESRD and NH care and warrants further exploration that could generate new insights into means of improving survival of all NH residents on dialysis. Area-level indicator of poverty was independently associated with mortality, whereas dual-eligibility status for Medicare and Medicaid was associated with lower risk of death, which could be partly explained by improved access to care.

Causes and risk factors for acute dialysis initiation among patients with end-stage kidney disease-a large retrospective observational cohort study

Background

Patients who require acute initiation of dialysis have higher mortality rates when compared with patients with planned starts. Our primary objective was to explore the reasons and risk factors for acute initiation of renal replacement therapy (RRT) among patients with end-stage kidney disease (ESKD). Our secondary objective was to determine the difference in glomerular filtration rate (GFR) change in the year preceding RRT between elective and acute dialysis starts.

Methods

We conducted a single-centre retrospective observational study. ESKD patients either started dialysis electively (planned starters) or acutely and were known to renal services for >90 (unplanned starters) or <90 days (urgent starters).

Results

In all, 825 consecutive patients initiated dialysis between January 2013 and December 2015. Of these, 410 (49.7%) patients had a planned start. A total of 415 (50.3%) patients had an acute start on dialysis: 244 (58.8%) unplanned and 171 (41.2%) urgent. The reasons for acute dialysis initiation included acute illness (58%) and unexplained decline to ESKD (33%). Cardiovascular disease [n = 30 (22%)] and sepsis [n = 65 (48%)] accounted for the majority of acute systemic illness. Age and premorbid cardiovascular disease were independent risk factors for acute systemic illness among unplanned starts, whereas autoimmune disease accounted for the majority of urgent starts. The rate of decline in GFR was greater in the month preceding RRT among acute dialysis starters compared with planned starters (P < 0.001).

Conclusions

Cardiovascular disease and advancing age were independent risk factors for emergency dialysis initiation among patients known to renal services for >3 months. The rapid and often unpredictable loss of renal function in the context of acute systemic illness poses a challenge to averting emergency dialysis start.

Association of the kidney allocation system with dialysis exposure before deceased donor kidney transplantation by preemptive wait-listing status

BACKGROUND

It is unknown whether the new kidney transplant allocation system (KAS) has attenuated the advantages of preemptive wait-listing as a strategy to minimize pretransplant dialysis exposure.

METHODS

We performed a retrospective study of adult US deceased donor kidney transplant (DDKT) recipients between December 4, 2011-December 3, 2014 (pre-KAS) and December 4, 2014-December 3, 2017 (post-KAS). We estimated pretransplant dialysis durations by preemptive listing status in the pre- and post-KAS periods using multivariable gamma regression models.

RESULTS

Among 65 385 DDKT recipients, preemptively listed recipients (21%, n = 13 696) were more likely to be white (59% vs 34%, P < 0.001) and have private insurance (64% vs 30%, P < 0.001). In the pre- and post-KAS periods, average adjusted pretransplant dialysis durations for preemptively listed recipients were <2 years in all racial groups. Compared to recipients who were listed after starting dialysis, preemptively listed recipients experienced 3.85 (95% Confidence Interval [CI] 3.71-3.99) and 4.53 (95% CI 4.32-4.74) fewer average years of pretransplant dialysis in the pre- and post-KAS periods, respectively (P < 0.001 for all comparisons).

CONCLUSIONS

Preemptively wait-listed DDKT recipients continue to experience substantially fewer years of pretransplant dialysis than recipients listed after dialysis onset. Efforts are needed to improve both socioeconomic and racial disparities in preemptive wait-listing.

Racial Disparities in Nephrology Consultation and Disease Progression among Veterans with CKD: An Observational Cohort Study

BACKGROUND

Incident rates of ESRD are much higher among black and Hispanic patients than white patients. Access to nephrology care before progression to ESRD is associated with better clinical outcomes among patients with CKD. However, it is unknown whether black or Hispanic patients with CKD experience lower pre-ESRD nephrology consultation rates compared with their white counterparts, or whether such a disparity contributes to worse outcomes among minorities.

METHODS

We assembled a retrospective cohort of patients with CKD who received care through the Veterans Health Administration from 2003 to 2015, focusing on individuals with incident CKD stage 4 who had an initial eGFR≥60 ml/min per 1.73 m² followed by two consecutive eGFRs<30 ml/min per 1.73 m². We repeated analyses among individuals with incident CKD stage 3. Outcomes included nephrology provider referral, nephrology provider visit, progression to CKD stage 5, and mortality.

RESULTS

We identified 56,767 veterans with CKD stage 4 and 640,704 with CKD stage 3. In both cohorts, rates of nephrology referral and visits were significantly higher among black and Hispanic veterans than among non-Hispanic white veterans. Despite this, both black and Hispanic patients experienced faster progression to CKD stage 5 compared with white patients. Black patients with CKD stage 4 experienced slightly lower mortality than white patients, whereas black patients with CKD stage 3 had a small increased risk of death.

CONCLUSIONS

Black or Hispanic veterans with CKD are more likely than white patients to see a nephrologist, yet are also more likely to suffer disease progression. Biologic and environmental factors may play a bigger role than nephrology consultation in driving racial disparities in CKD progression.

Payment Reform and Health Disparities: Changes in Dialysis Modality under the New Medicare Dialysis Payment System

OBJECTIVE

To evaluate the effect of the Medicare dialysis payment reform on potential disparities in the selection of peritoneal dialysis (PD) for the treatment of end-stage renal disease (ESRD).

DATA SOURCES

Centers for Medicare & Medicaid Services (CMS) ESRD Medical Evidence Form, Medicare claims, and other CMS data for 2008-2013.

STUDY DESIGN

We examined the association of patient age, race/ethnicity, urban/rural location, pre-ESRD care, comorbidities, insurance, and other factors with the selection of PD as initial dialysis modality across prereform (2008-2009), interim (2010), and postreform (2011-2013) time periods.

PRINCIPAL FINDINGS

Selection of PD increased among diverse patient subgroups following the payment reform. However, the lower PD selection observed with older age, black race, Hispanic ethnicity, less pre-ESRD care, and Medicaid insurance before the reform largely remained in the initial postreform years.

CONCLUSIONS

Despite recent growth in PD, there may be ongoing disparities in access to PD that have largely not been mitigated by the payment reform. There is potential for modifying provider financial incentives to achieve policy goals related to cost and quality of care. However, even with a substantial shift in financial incentives, separate initiatives to reduce existing disparities in care may be needed.

Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society

End-stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non-Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre-ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.

Compartmentalising time and space: a phenomenological interpretation of the temporal experience of commencing haemodialysis

AIMS AND OBJECTIVES

To interpret the spatio-temporal experience of people with end-stage kidney disease and their families in the first months of haemodialysis.

BACKGROUND

While dialysis is the mainstay of end-stage kidney disease management, the actual initiation of treatment is often unexpected by people and families. Poor biopsychosocial preparation means haemodialysis commencement is experienced as a crisis. While previous phenomenological studies suggest that over time, a habitual incorporation of dialysis into one's self-concept is possible, the spatio-temporal experience of people new to haemodialysis is not well understood.

DESIGN

A phenomenological study.

METHODS

Following purposive sampling, 18 participants were recruited either during an inpatient admission or while attending a public hospital-based haemodialysis unit in Sydney, Australia. Eleven people who had commenced haemodialysis within the previous three months and five close family members were separately engaged in semistructured interviews. Hermeneutic interpretation within a Heideggerian framework occurred through a backward-and-forward analysis between the early haemodialysis experience and its relationship to Being.

RESULTS

Themes that related to a temporal and spatial understanding of Being-in-the-world as a new haemodialysis patient or carer included the following: 'compartmentalising life into dialysis and non-dialysis days' (lost time, clock time and lived time); 'compartmentalising before, now and future' (normalising the 'before', dealing with the 'now' and the 'foreverness' of dialysis); and finally, 'compartmentalising space'.

CONCLUSIONS

In the months after dialysis commencement, patients and family carers compartmentalise time and space with a loss of continuity of meaningful, lived time that had framed people's past sense of normal.

RELEVANCE TO CLINICAL PRACTICE

Resource enhancement activities should focus on social connectivity and provision of personnel and/or infrastructure to reduce boredom, to facilitate engagement with meaningful tasks and, where appropriate, to support the continuation of work activities during the dialysis period.

Chronic kidney disease referral practices among non-nephrology specialists: A single-centre experience

BACKGROUND

Early referral of CKD patients to nephrology teams (NT) is vital to identify patients most likely to progress, delay decline of excretory function, and provide planned RRT. Unfortunately, many are still being referred late.

METHODS

We conducted a retrospective analysis to investigate referral rates, predictors of non-referral, and performed urine investigations in hospitalised CKD patients.

RESULTS

Out of 388 patients studied, 5.6%, 11.4%, and 16.4% in CKD3A, 3B, and 4+5, respectively, were referred to an NT upon discharge (CKD3A vs. CKD4+5, p=0.016). For every additional year of age, the odds of being referred decreased by 5% (OR: 0.95, CI: 0.92-0.98, p=0.003). Patients were more likely to be referred to an NT if they were males (OR: 2.31, CI: 1.09-4.90, p=0.029) and having reached CKD 4+5 (OR: 3.99, CI: 1.58-10.10, p=0.003). Only 28.8%, 43.9%, and 50.7% of patients with CKD3A, 3B, and 4+5 were followed up with urine investigations after discharge (p=0.001). CKD stage 3B (OR: 3.54, CI: 1.23-10.19, p=0.019), CKD stage 4+5 (OR: 6.06, CI: 1.69-21.67, p=0.006), DM (OR: 6.28, CI: 2.38-16.58, p<0.0001), and having been referred to a NT (OR: 20.95, CI: 3.54-123.92, p=0.001) were independent predictors for having urine investigations.

CONCLUSION

The highest rate of referral was achieved in males, younger age group, and those who have reached CKD stage 4+5. Urine tests remain largely underutilised and only a minority (16.4%) of patients with an eGFR <30mL/min/1.73m(2) were referred to a NT.

Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD: Race, Age, and State Characteristics

BACKGROUND AND OBJECTIVES

Although multiple factors influence access to nephrologist care in patients with CKD stages 4-5, the geographic determinants within the United States are incompletely understood. In this study, we examined interstate differences in nephrologist care among patients approaching ESRD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This national, population-based analysis included 373,986 adult patients from the US Renal Data System, who initiated maintenance dialysis between 2005 and 2009. Multilevel logistic regression was used to examine interstate variation in nephrologist care (≥12 months before ESRD) for overall and four race-age subpopulations (black or white and older or younger than 65 years).

RESULTS

The average state-level probability of having received nephrologist care in all states combined was 28.8% (95% confidence interval, 25.2% to 32.7%) overall and was lowest (24.3%) in the younger black subpopulation. Even at these lower levels, state-level probabilities varied considerably across states in overall and subpopulations (all P<0.001). Overall, excluding the states in the upper and lower five percentiles, the remaining states had a probability of receiving care that varied from 18.5% to 41.9%. The lower probability of receiving nephrologist care for blacks than whites among younger patients noted in most states was attenuated in older patients. Geographically, all New England states and most Midwest states had higher than average probability, whereas most Middle Atlantic and Southern states had lower than average probability. After controlling for patient factors, three state-characteristic categories, including general healthcare access measured by percentage of uninsured persons and Medicaid program performance scores, preventive care measured by percentage of receiving recommended preventive care, and socioeconomic status, contributed 55%-66% of interstate variation.

CONCLUSIONS

Patients living in states with better health service and socioeconomic characteristics were more likely to receive predialysis nephrologist care. The reported national black-white difference in nephrologist care was primarily driven by younger black patients being the least likely to receive care.

Survival Disparity of African American Versus Non-African American Patients With ESRD Due to SLE

BACKGROUND

A recent study showed an increased risk of death in African Americans compared with whites with end-stage renal disease (ESRD) due to lupus nephritis (LN). We assessed the impact of age stratification, socioeconomic factors, and kidney transplantation on the disparity in patient survival among African American versus non-African American patients with LN-caused ESRD, compared with other causes.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Using the US Renal Data System database, we identified 12,352 patients with LN-caused ESRD among 1,132,202 patients who initiated maintenance dialysis therapy from January 1, 1995, through December 31, 2006, and were followed up until December 31, 2010.

PREDICTORS

Baseline demographics and comorbid conditions, Hispanic ethnicity, socioeconomic factors (employment status, Medicare/Medicaid insurance, and area-level median household income based on zip code as obtained from the 2000 US census), and kidney transplantation as a time-dependent variable.

OUTCOME

All-cause mortality.

MEASUREMENTS

Multivariable Cox and competing-risk regressions.

RESULTS

Mean duration of follow-up in the LN-caused ESRD and other-cause ESRD cohorts were 6.24±4.20 (SD) and 4.06±3.61 years, respectively. 6,106 patients with LN-caused ESRD (49.43%) and 853,762 patients with other-cause ESRD (76.24%) died during the study period (P<0.001). Patients with LN-caused ESRD were significantly younger (mean age, 39.92 years) and more likely women (81.65%) and African American (48.13%) than those with other-cause ESRD. In the fully adjusted multivariable Cox regression model, African American (vs non-African American) patients with LN-caused ESRD had significantly increased risk of death at age 18 to 30 years (adjusted HR, 1.43; 95% CI, 1.24-1.65) and at age 31 to 40 years (adjusted HR, 1.17; 95% CI, 1.02-1.34). Among patients with other-cause ESRD, African Americans were at significantly increased risk at age 18 to 30 years (adjusted HR, 1.17; 95% CI, 1.11-1.22).

LIMITATIONS

We used zip code-based median household income as a surrogate for patient income. Residual socioeconomic confounders may exist.

CONCLUSIONS

African Americans are at significantly increased risk of death compared with non-African Americans with LN-caused ESRD at age 18 to 40 years, a racial disparity risk that is 10 years longer than that in the general ESRD population. Accounting for area-level median household income and transplantation significantly attenuated the disparity in mortality of African American versus non-African American patients with LN-caused ESRD.

Perceptions about hemodialysis and transplantation among African American adults with end-stage renal disease: inferences from focus groups

Background

Disparities in access to kidney transplantation (KT) remain inadequately understood and addressed. Detailed descriptions of patient attitudes may provide insight into mechanisms of disparity. The aims of this study were to explore perceptions of dialysis and KT among African American adults undergoing hemodialysis, with particular attention to age- and sex-specific concerns.

Methods

Qualitative data on experiences with hemodialysis and views about KT were collected through four age- and sex-stratified (males <65, males ≥65, females <65, and females ≥65 years) focus group discussions with 36 African American adults recruited from seven urban dialysis centers in Baltimore, Maryland.

Results

Four themes emerged from thematic content analysis: 1) current health and perceptions of dialysis, 2) support while undergoing dialysis, 3) interactions with medical professionals, and 4) concerns about KT. Females and older males tended to be more positive about dialysis experiences. Younger males expressed a lack of support from friends and family. All participants shared feelings of being treated poorly by medical professionals and lacking information about renal disease and treatment options. Common concerns about pursuing KT were increased medication burden, fear of surgery, fear of organ rejection, and older age (among older participants).

Conclusions

These perceptions may contribute to disparities in access to KT, motivating granular studies based on the themes identified.

Race/ethnicity, age, and risk of hospital admission and length of stay during the first year of maintenance hemodialysis

BACKGROUND AND OBJECTIVES

Although patients undergoing maintenance hemodialysis have exceptionally high hospitalization rates, the risk factors for hospitalizations are unclear. This study sought to examine hospitalization rates among hemodialysis patients in the United States according to both race/ethnicity and age.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

US Renal Data System data on 563,281 patients beginning maintenance hemodialysis between 1995 and 2009 were analyzed. Rates of hospital admission and number of hospital days for all-cause and cause-specific hospitalizations during the first year of dialysis were compared among blacks, whites, and Hispanics in the entire cohort and subgroups stratified by age.

RESULTS

After multiple adjustments, compared with whites, Hispanics overall had lower rates of both all-cause hospital days (adjusted rate ratio [aRR], 0.91; 95% confidence interval [95% CI], 0.90 to 0.93; P<0.001) and hospital admissions (aRR, 0.89; 95% CI, 0.88 to 0.90; P<0.001), whereas blacks had a lower rate of all-cause admissions (aRR, 0.95; 95% CI, 0.94 to 0.96; P<0.001). The racial/ethnic differences, however, varied by age. Hispanics exhibited the lowest rates of hospital days and admissions for all age groups≤70 years, but those >80 years had higher rates than their white counterparts. The adjusted black-to-white rate ratios exhibited a U-shaped pattern with age, with higher rates for blacks in the younger and older age groups. Hospitalization rates for dialysis-related infections were markedly higher in blacks and Hispanics than whites, which were consistent in all age groups for blacks (aRRs for hospital days ranged from 1.09 to 1.36) and all ages>60 years for Hispanics (aRRs ranged from 1.20 to 1.38).

CONCLUSIONS

There are significant racial/ethnic differences in hospitalization rates within first year of dialysis, which are not consistent across the age groups and also differ by causes of hospitalization. Overall, blacks and Hispanics had lower rates of all-cause hospital admissions than whites. However, younger and older blacks and older Hispanics were at greatest risk.

Controversies in timing of dialysis initiation and the role of race and demographics

Dialysis remains the predominant form of renal replacement therapy in the United States, but the optimal timing for the initiation of dialysis remains poorly defined. Not only clinical factors such as signs/symptoms of uremia, co-existing cardiovascular disease, and presence of diabetes but also key demographic characteristics including age, gender, race/ethnicity, and socioeconomics have all been considered as potential modifying factors in the decision for the timing of dialysis initiation. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of chronic kidney disease (CKD) suggests that dialysis be initiated when signs/symptoms attributable to kidney failure such as serositis, acid-base or electrolyte abnormalities, pruritus, poorly controlled volume status or blood pressure, deteriorating nutritional status despite dietary intervention, or cognitive impairment are visible or noted. These signs/symptoms typically occur when the glomerular filtration rate (GFR) is in the range of 5-10 ml/minute/1.73 m(2) , although they may occur at higher levels of GFR. We review recent data on the timing of dialysis initiation, their implications for managing patients with late-stage CKD, and the important role of considering key demographics in making patient-centered decisions for the timing of dialysis initiation.

The associations between race and geographic area and quality-of-care indicators in patients approaching ESRD

BACKGROUND AND OBJECTIVES

Pre-ESRD care is an important predictor of outcomes in patients undergoing long-term dialysis. This study examined the extent of variation in receiving pre-ESRD care and black-white disparities across urban and rural counties.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Participants were 404,622 non-Hispanic white and black patients aged >18 years who began dialysis between 2005 and 2010 and resided in 3076 counties from the U.S. Renal Data System. The counties were grouped into large metropolitan, medium/small metropolitan, suburban, and rural counties. Pre-ESRD care indicators included receipt of nephrologist care at least 6 or 12 months before ESRD, dietitian care, use of arteriovenous fistula at first outpatient dialysis session, and use of erythropoiesis-stimulating agents (ESAs) in patients with hemoglobin level < 10 g/dl.

RESULTS

Large metropolitan and rural counties had lower percentages of patients who received pre-ESRD nephrologist care (25.7% and 26.9% for nephrologist care > 12 months), compared with the higher percentage in medium/small metropolitan counties (31.6%; both P<0.001). For both races, nonmetropolitan patients had poorer access to dietitian care and lower ESA use than metropolitan patients. Consistently in all four geographic areas, black patients received less care than their white counterparts. The unadjusted odds ratios of black versus white patients in receiving nephrologist care for >12 months before ESRD were 0.66 (95% confidence interval [CI], 0.61-0.72) in large metropolitan counties and 0.79 (95% CI, 0.69-0.90) in rural counties. The patterns remained, albeit attenuated, after adjustment for patient factors.

CONCLUSIONS

The receipt of pre-ESRD care, with blacks receiving less care, varies among geographic areas defined by urban/rural characteristics.

Racial and ethnic differences in mortality of hemodialysis patients: role of dietary and nutritional status and inflammation

BACKGROUND

Racial/ethnic disparities prevail among hemodialysis patients. We hypothesized that significant differences exist between Black and non-Hispanic and Hispanic White hemodialysis patients in nutritional status, dietary intake and inflammation, and that they account for racial survival disparities.

METHODS

In a 6-year (2001-2007) cohort of 799 hemodialysis patients, we compared diet and surrogates of nutritional-inflammatory status and their mortality-predictabilities between 279 Blacks and 520 Whites using matched and regression analyses and Cox with cubic splines.

RESULTS

In age-, gender- and diabetes-matched analyses, Blacks had higher lean body mass and serum prealbumin, creatinine and homocysteine levels than Whites. In case-mix-adjusted analyses, dietary intakes in Blacks versus Whites were higher in energy (+293 ± 119 cal/day) and fat (+18 ± 5 g/day), but lower in fiber (-2.9 ± 1.3 g/day) than Whites. In both races, higher serum albumin, prealbumin and creatinine were associated with greater survival, whereas CRP and IL-6, but not TNF-α, were associated with increased mortality. The highest (vs. lowest) quartile of IL-6 was associated with a 2.4-fold (95% CI: 1.3-3.8) and 4.1-fold (2.2-7.2) higher death risk in Blacks and Whites, respectively.

CONCLUSIONS

Significant racial disparities exist in dietary, nutritional and inflammatory measures, which may contribute to hemodialysis outcome disparities. Testing race-specific dietary and/or anti-inflammatory interventions is indicated.

Racial composition of residential areas associates with access to pre-ESRD nephrology care

Referral to a nephrologist before initiation of chronic dialysis occurs less frequently for blacks than whites, but the reasons for this disparity are incompletely understood. Here, we examined the contribution of racial composition by zip code on access and quality of nephrology care before initiation of renal replacement therapy (RRT). We retrospectively studied a cohort study of 92,000 white and black adults who initiated RRT in the United States between June 1, 2005, and October 5, 2006. The percentage of patients without pre-ESRD nephrology care ranged from 30% among those who lived in zip codes with <5% black residents to 41% among those who lived in areas with >50% black residents. In adjusted analyses, as the percentage of blacks in residential areas increased, the likelihood of not receiving pre-ESRD nephrology care increased. Among patients who received nephrology care, the quality of care (timing of care and proportion of patients who received a pre-emptive renal transplant, who initiated therapy with peritoneal dialysis, or who had a permanent hemodialysis access) did not differ by the racial composition of their residential area. In conclusion, racial composition of residential areas associates with access to nephrology care but not with quality of the nephrology care received.

Predictors and consequences of higher estimated glomerular filtration rate at dialysis initiation

There have been no studies in pediatric dialysis patients to evaluate the impact of higher estimated glomerular filtration rate (eGFR) at dialysis initiation on clinical outcomes. Baseline clinical and demographic information was collected for children aged 1-18 years undergoing incident dialysis from 1995-2002 within the United States Renal Data System. Baseline eGFRs calculated by the Schwartz formula were categorized as high (>15 ml/min/1.73 m(2)) or low (< or = 15 ml/min/1.73 m(2)). We determined predictors of eGFR at baseline, and associations between baseline eGFR and subsequent hospitalization for hypertension (HTN) or pulmonary edema (PE) in a longitudinal nonconcurrent pediatric end-stage renal disease (ESRD) cohort. Twenty percent of children had a high eGFR at initiation. Black children were less likely to initiate dialysis with a high eGFR [adjusted odds ratio (adjOR) 0.71, p < 0.001]. Girls were less likely to have a high eGFR at baseline (adjOR 0.71, p < 0.001). Children who received predialysis erythropoietin therapy were more likely to start dialysis with a high eGFR (adjOR 6.67, p < 0.001). Children with higher baseline eGFR were found to have a 21% decreased risk of hospitalization [adjusted hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.65-0.96, p = 0.02]. It is not known whether this clinical benefit will result in decreased mortality and complication rates from cardiovascular disease.

Chronic kidney disease management in an academic internal medicine clinic

OBJECTIVE

We sought to evaluate the current state of chronic kidney disease (CKD) management in our academic internal medicine clinic.

METHODS

A retrospective review was carried out involving all patients with laboratory evidence of CKD enrolled in our clinic. We evaluated the rate of CKD recognition as well as compliance with standard guidelines. We further subdivided our results based on physician training level, presence of diabetes, recognition of CKD, age, and race.

RESULTS

Factors that significantly improved recognition and treatment of CKD in our study included presence of diabetes (p < 0.001), black race (p = 0.013), younger age (p = 0.004), and treatment by a resident physician (p = 0.009). Recognition of stage 3 CKD was associated with significant increases in urine protein analysis (p < 0.001) and nephrology consultation (p < 0.001).

CONCLUSION

Chronic kidney disease remains under-recognized and undertreated despite well-publicized guidelines and widespread use of routine eGFR reporting.

Access to liver transplantation in the MELD era: role of ethnicity and insurance

Factors contributing to inequitable access to liver transplantation include socioeconomic status, geographic location, and delayed referral. The aim of this study is to identify the factors associated with a high MELD at the time of listing. Using the UNOS database, we identified all adults listed from 2002 to 2006. Data collected included demographics, insurance payor (private and government, i.e., Medicaid and non-Medicaid), diagnosis, and MELD score categorized as low (<20) and high (>or=20). The results obtained show that a high MELD was associated with age, ethnicity, and insurance (P < 0.001). By multivariate analysis, insurance (OR = 1.21, 95% CI = 1.13-1.30, P < 0.001) and ethnicity (OR = 1.55, 95% CI = 1.28-1.88, P < 0.001) were independently associated with high MELD. In conclusion, ethnic minorities and liver transplant candidates with Medicaid are more likely to have a high MELD score at initial listing. The above results suggest that the type of insurance and ethnicity are independently associated with a high MELD (i.e., sicker patients).

Survival of patients from South Asian and Black populations starting renal replacement therapy in England and Wales

Background. South Asian and Black ethnic minorities in the UK have higher rates of acceptance onto renal replacement therapy (RRT) than Caucasians. Registry studies in the USA and Canada show better survival; there are few data in the UK.

Methods. Renal Association UK Renal Registry data were used to compare the characteristics and survival of patients starting RRT from both groups with those of Caucasians, using incident cases accepted between 1997 and 2006. Survival was analysed by multivariate Cox's proportional hazards regression split by haemodialysis and peritoneal dialysis (PD) due to non-proportionality, and without censoring at transplantation.

Results. A total of 2495 (8.2%) were South Asian and 1218 (4.0%) were Black. They were younger and had more diabetic nephropathy. The age-adjusted prevalence of vascular co-morbidity was higher in South Asians and lower in Blacks; other co-morbidities were generally common in Caucasians. Late referral did not differ. They were less likely to receive a transplant or to start PD. South Asians and Blacks had significantly better survival than Caucasians both from RRT start to Day 90 and after Day 90, and for those on HD or PD at Day 90. Fully adjusted hazard ratios after Day 90 on haemodialysis were 0.70 (0.55–0.89) for South Asians and 0.56 (0.41–0.75) for Blacks.

Conclusion. South Asian and Black minorities have better survival on dialysis. An understanding of the mechanisms may provide general insights for all patients on RRT.

Late referral of patients with end-stage renal disease: an in-depth review and suggestions for further actions

Late referral of patients with chronic kidney disease (CKD) is a known problem and a major challenge for practising nephrologists since decades. In this review we report about the reasons for late referral, its epidemiology and socioeconomic impact and the medical particularities of late referred patients. We furthermore highlight on the efforts which have been undertaken so far to avoid late referral and should be undertaken in future to face the ever growing numbers of chronic kidney disease patients.

Differences in mortality among Mexican-American, Puerto Rican, and Cuban-American dialysis patients in the United States

BACKGROUND

The Hispanic ethnic group is heterogeneous, with distinct genetic, cultural, and socioeconomic characteristics, but most prior studies of patients with end-stage renal disease focus on the overall Hispanic ethnic group without further granularity. We examined survival differences among Mexican-American, Puerto Rican, and Cuban-American dialysis patients in the United States.

STUDY DESIGN

Prospective observational study.

SETTING & PARTICIPANTS

Data from individuals randomly selected for the End-Stage Renal Disease Clinical Performance Measures Project (2001 to 2005) were examined. Mexican-American (n = 2,742), Puerto Rican (n = 838), Cuban-American (n = 145), and Hispanic-other dialysis patients (n = 942) were compared with each other and with non-Hispanic (n = 33,076) dialysis patients in the United States.

PREDICTORS

Patient characteristics of interest included ethnicity/race, comorbidities, and specific available laboratory values.

OUTCOMES

The major outcome of interest was mortality.

RESULTS

In the fully adjusted multivariable model, 2-year mortality risk was significantly lower for the Mexican-American and Hispanic-other groups compared with non-Hispanics (adjusted hazard ratio, 0.79; 95% confidence interval, 0.73 to 0.85; adjusted hazard ratio, 0.81; 95% confidence interval, 0.71 to 0.92, respectively). Differences in 2-year mortality rates within the Hispanic ethnic groups were statistically significant (P = 0.004) and ranged from 21% lower mortality in Mexican Americans to 3% higher mortality in Puerto Ricans compared with non-Hispanics.

LIMITATIONS

Include those inherent to an observational study, potential ethnic group misclassification, and small sample sizes for some Hispanic subgroups.

CONCLUSION

Mexican-American and Hispanic-other dialysis patients have a survival advantage compared with non-Hispanics. Furthermore, Mexican Americans, Cuban Americans, and Hispanic others had a survival advantage compared with their Puerto Rican counterparts. Future research should continue to examine subgroups within Hispanic ethnicity to understand underlying reasons for observed differences that may be masked by examining the Hispanic ethnic group as only a single entity.

Access to health care among status Aboriginal people with chronic kidney disease

BACKGROUND

Ethnic disparities in access to health care and health outcomes are well documented. It is unclear whether similar differences exist between Aboriginal and non-Aboriginal people with chronic kidney disease in Canada. We determined whether access to care differed between status Aboriginal people (Aboriginal people registered under the federal Indian Act) and non-Aboriginal people with chronic kidney disease.

METHODS

We identified 106 511 non-Aboriginal and 1182 Aboriginal patients with chronic kidney disease (estimated glomerular filtration rate less than 60 mL/min/1.73 m(2)). We compared outcomes, including hospital admissions, that may have been preventable with appropriate outpatient care (ambulatory-care-sensitive conditions) as well as use of specialist services, including visits to nephrologists and general internists.

RESULTS

Aboriginal people were almost twice as likely as non-Aboriginal people to be admitted to hospital for an ambulatory-care-sensitive condition (rate ratio 1.77, 95% confidence interval [CI] 1.46-2.13). Aboriginal people with severe chronic kidney disease (estimated glomerular filtration rate < 30 mL/min/1.73 m(2)) were 43% less likely than non-Aboriginal people with severe chronic kidney disease to visit a nephrologist (hazard ratio 0.57, 95% CI 0.39-0.83). There was no difference in the likelihood of visiting a general internist (hazard ratio 1.00, 95% CI 0.83-1.21).

INTERPRETATION

Increased rates of hospital admissions for ambulatory-care-sensitive conditions and a reduced likelihood of nephrology visits suggest potential inequities in care among status Aboriginal people with chronic kidney disease. The extent to which this may contribute to the higher rate of kidney failure in this population requires further exploration.

Higher serum creatinine concentrations in black patients with chronic kidney disease: beyond nutritional status and body composition

BACKGROUND AND OBJECTIVES

Serum creatinine concentrations tend to be higher in black than white individuals and people of other races or ethnicities. These differences have been assumed to be largely related to race-related differences in body composition, especially muscle mass.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a diverse population of hemodialysis patients, we compared mean serum creatinine concentrations in black versus nonblack patients, adjusting for case mix (age, gender, diabetes, and dialysis vintage), body size (height, weight), laboratory parameters of nutritional status (albumin, predialysis blood urea nitrogen, transferrin, phosphorus, glucose), dialysis dosage (urea reduction ratio), and parameters of bioelectrical impedance (resistance and reactance), proxies for body composition.

RESULTS

Adjusted mean serum creatinine concentrations were significantly higher in black versus nonblack patients (11.7 versus 10.0 mg/dl; P < 0.0001). Black patients were roughly four-fold more likely to have a serum creatinine concentration >10 mg/dl and six-fold more likely to have a serum creatinine concentration >15 mg/dl. Higher serum creatinine concentrations were associated with a lower relative risk for death (0.93; 95% confidence interval 0.88 to 0.98 per mg/dl); the association was slightly more pronounced among nonblack patients.

CONCLUSIONS

Serum creatinine concentrations are significantly higher in black compared with nonblack hemodialysis patients; these differences are not readily explained by differences in nutritional status or body composition.

A systematic review of patient and health system characteristics associated with late referral in chronic kidney disease

BACKGROUND

To identify patient and health system characteristics associated with late referral of patients with chronic kidney disease to nephrologists.

METHODS

MEDLINE, CENTRAL, and CINAHL were searched using the appropriate MESH terms in March 2007. Two reviewers individually and in duplicate reviewed the abstracts of 256 articles and selected 18 observational studies for inclusion. The reasons for late referral were categorized into patient or health system characteristics. Data extraction and content appraisal were done using a prespecified protocol.

RESULTS

Older age, the existence of multiple comorbidities, race other than Caucasian, lack of insurance, lower socioeconomic status and educational levels were patient characteristics associated with late referral of patients with chronic kidney disease. Lack of referring physician knowledge about the appropriate timing of referral, absence of communication between referring physicians and nephrologists, and dialysis care delivered at tertiary medical centers were health system characteristics associated with late referral of patients with chronic kidney disease. Most studies identified multiple factors associated with late referral, although the relative importance and the combined effect of these factors were not systematically evaluated.

CONCLUSION

A combination of patient and health system characteristics is associated with late referral of patients with chronic kidney disease. Overall, being older, belonging to a minority group, being less educated, being uninsured, suffering from multiple comorbidities, and the lack of communication between primary care physicians and nephrologists contribute to late referral of patients with chronic kidney disease. Both primary care physicians and nephrologists need to engage in multisectoral collaborative efforts that ensure patient education and enhance physician awareness to improve the care of patients with chronic kidney disease.

Racial and ethnic disparities in end-stage kidney failure-survival paradoxes in African-Americans

The risk of death is nearly 45% lower in African-Americans than Caucasians undergoing chronic hemodialysis. In light of the higher mortality rate in African-Americans in the general US population, this paradox requires explanation and further investigation. Factors that may contribute to this survival advantage include a younger age at which African-Americans arrive at end-stage renal disease (ESRD) and the slightly higher body mass index. On the other hand, factors, such as lower residual renal function, lower mean hemoglobin and hematocrit, increased prevalence of hypertension, a higher prevalence of catheter use for initial dialysis, and generally lower dose of dialysis should put African-Americans on dialysis at a higher risk of death. This survival advantage seems to be completely annulled with a successful renal transplant. Finally, it should be noted that ESRD carries with it a very high mortality rate in all racial and ethnic groups. A successful renal transplant improves but does not restore the expected remaining life times. Therefore, aggressive approach is required in investigating the factors that confer such high mortality risk on ESRD patients.

Insurance type and minority status associated with large disparities in prelisting dialysis among candidates for kidney transplantation

BACKGROUND AND OBJECTIVES

Disparities in time to placement on the waiting list on the basis of socioeconomic factors decrease access to deceased-donor renal transplantation for some groups of patients with end-stage renal disease. This study was undertaken to determine candidate factors that influence duration of dialysis before placement on the waiting list among candidates for deceased-donor renal transplantation in the United States from January 2001 to December 2004 and the impact of Medicare eligibility rules on access.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Access to the waiting list was measured as the percentage of all wait-listed candidates in the Scientific Registry of Transplant Recipients database who were listed before dialysis and by the duration of dialysis before placement on the waiting list. Multivariate logistic and linear regressions were used to determine variables that were predictive of preemptive listing and the duration of dialysis before listing.

RESULTS

The odds for preemptive placement on the waiting list improved during the course of the study period, whereas the median duration of prelisting dialysis did not. The candidate factors that were associated with low rates of preemptive listing and prolonged exposure to prelisting dialysis included Medicare insurance, minority race/ethnicity, and low educational attainment. In patients who were listed after the age of 64 yr, the adverse effect of Medicare insurance on access largely disappeared.

CONCLUSIONS

The disparity in dialysis exposure could potentially be diminished by concerted efforts on the part of the nephrology and transplant communities to promote early referral and preemptive placement on the waiting list, by calculating waiting time from the date of initiation of dialysis for patients who are on dialysis at the time of referral, and by relaxing Medicare eligibility requirements.

Building the chronic kidney disease management team

The need to be efficient and the demands for performance-based service are changing how nephrologists deliver care. Chronic kidney disease (CKD) occurs in patients with complex medical and social problems. CKD management requires that multidisciplinary professionals provide patient education, disease management, and psychosocial support. To remain cost-efficient, many physicians are training and supervising midlevel practitioners in the delivery of specialized health care. Specialized care that meets present CKD patient needs is best delivered in a CKD clinic. Three models of CKD clinic are identified: (1) anemia management CKD clinic, (2) the basic CKD clinic, and (3) the comprehensive CKD clinic. Each clinic model is based on critical elements of staffing, billable services, and patient-focused health care. Billable services are anemia-management services, physician services that may be provided by midlevel practitioners, and medical nutrition therapy. In some cases, social worker services may be billable. Building a patient-focused clinic that offers CKD management requires planning, familiarity with federal regulations and statutes, and skillful practitioners. Making services cost-efficient and outcome oriented requires careful physician leadership, talented midlevel practitioners, and billing professionals who understand the goals of the CKD clinic. As Medicare payment reforms evolve, a well-organized CKD program can be well poised to meet the requirements of payers and congressional mandates for performance-based purchasing.

Ethnic disparity in outcomes for pediatric peritoneal dialysis patients in the ESRD Clinical Performance Measures Project

Ethnicity information was collected for all pediatric peritoneal dialysis patients from the End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project for the period October 2004 through March 2005. Associations between intermediate outcomes and Hispanic ethnicity were determined. Thirty percent (207/696) of patients in the final cohort were Hispanic, 24% (165/696) non-Hispanic black, and 46% (324/696) non-Hispanic white. Hispanics were more likely to be female, older, and have a lower mean height standard deviation score (SDS). There were no significant differences among ethnic/racial groups regarding clearance parameters. More Hispanics had a mean hemoglobin > or = 11 g/dl compared with non-Hispanic blacks and non-Hispanic whites (77% vs. 55% and 70%, P < 0.0001). More Hispanics compared with non-Hispanic blacks and non-Hispanic whites had a mean serum albumin > or = 4.0/3.7 g/dl [bromcresol green/bromcresol purple laboratory method (BCG/BCP)] (50% vs. 24% and 27%, respectively, P < 0.0001). In multivariate analyses, Hispanics remained significantly more likely to achieve a mean serum albumin > or = 4.0/3.7 g/dl (BCG/BCP) compared with non-Hispanic whites (referent) and were as likely to achieve clearance and hemoglobin targets. Pediatric Hispanic peritoneal dialysis patients experience equivalent or better intermediate outcomes of dialytic care compared with non-Hispanics. Further study is needed to understand associations of Hispanic ethnicity with outcomes such as hospitalization, transplantation, and mortality.

Prevalence of chronic kidney disease and survival among aboriginal people

Globally, it is known that the incidence of end-stage renal disease is higher among Aboriginals, but it is unknown whether this is due to an increased prevalence of chronic kidney disease or other unidentified factors. We studied 658,664 people of non-First Nations and 14,989 people of First Nations and found that the age- and sex-adjusted prevalence of chronic kidney disease was significantly higher among those of non-First Nations compared to those of First Nations (67.5 versus 59.5 per 1000 population; P < 0.0001). However, severe chronic kidney disease (estimated glomerular filtration rate <30 ml/min per 1.73 m2) was almost two-fold higher among people of First Nations (P < 0.0001). Cox proportional hazards models suggested that compared to people of non-First Nations, those of First Nations with chronic kidney disease had a 77% increased risk of death after adjusting for age, gender, diabetes and baseline eGFR. In conclusion, whether the higher incidence of end-stage renal disease among people of First Nations is due to suboptimal management of chronic kidney disease and its associated comorbidities, more rapid loss of kidney function, or other unidentified factors remains to be determined.

Lack of disparity in lower urinary tract symptom severity between community-dwelling non-Hispanic white, Mexican-American, and African-American men

OBJECTIVES

To determine whether disparities exist in the reporting of lower urinary tract symptoms (LUTS) in non-Hispanic white (NHW), Mexican-American (MA), and African-American (AA) men.

METHODS

Data were collected from a prospective, community-based cohort assembled to study risk factors associated with prostate cancer. Measures included demographics, prostate-specific antigen (PSA), body mass index (BMI), and family history of prostate cancer. Lower urinary tract symptom severity was assessed in 2804 men (1485 NHW, 964 MA, 355 AA) without prostate cancer according to the American Urological Association Symptom Index.

RESULTS

No significant difference (P = 0.998) was seen in the prevalence of moderate or severe LUTS in NHW (34%), MA (34%), and AA (33%) men. No differences were found in either obstructive or irritative symptoms among the three groups. Age, PSA level, BMI, and family history did not affect symptom severity.

CONCLUSIONS

Rates of moderate to severe LUTS symptoms in this cohort were similar to those in other community-based populations of NHW men. Lower rates of moderate or severe symptoms were noted in AA men than previously reported. Mexican-American men had similar degrees of LUTS as the general population, and with their increased risk for diabetes and renal disease, in-depth study of this population is warranted.

Referral to nephrologists for chronic kidney disease care: is non-diabetic kidney disease ignored?

BACKGROUND

Late referral to nephrologists is common and associated with increased morbidity and mortality. We aimed to analyze the prevalence rates, predictors and consequences of late referral to nephrologists by primary care physicians for chronic kidney disease (CKD) care.

METHODS

A retrospective analysis of 204 patients started on dialysis for CKD in two community hospitals between March 2003 and March 2005 was conducted. Relevant clinical and laboratory data were obtained from the patient records of the nephrology clinics and dialysis units. Patients referred in CKD stage 5 (estimated glomerular filtration rate <15 ml/min) were defined as late referral and patients in CKD stage 1-4 (estimated glomerular filtration rate >15 ml/min) as early referral.

RESULTS

Forty-five (22%) of the 204 patients were referred late. In the multivariate analysis, non-diabetic kidney disease (odds ratio = 2.46, p = 0.02) and Charlson comorbidity index (odds ratio = 1.17, p = 0.009) were significantly associated with late referral. The late referral group had lower hematocrit and serum calcium levels, and higher serum phosphorus and parathyroid hormone levels than the early referral group (p < or =0.05) at the time of referral. Late referral resulted in less permanent vascular access for initiation of dialysis (p = 0.03). Even though there was twice the number of deaths in the late referral group in 1 year (18 vs. 9%), this was not statistically significant (p = 0.07).

CONCLUSION

Referring physicians should pay special attention to patients with non-diabetic kidney disease and patients with multiple comorbidities since delayed referral to nephrologists may result in poorer patient-related outcomes. Larger and long-term prospective studies analyzing the long-term consequences of late referral to nephrologists are needed.

Revisiting survival differences by race and ethnicity among hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study

Hemodialysis (HD) patients who are identified as belonging to racial or ethnic minority groups have longer survival than non-Hispanic white HD patients. This study sought to determine to what extent this survival difference is explained by comprehensive adjustment for measurable case-mix and treatment characteristics. A cohort analysis was conducted among 6677 patients between 1996 and 2001 in the American arm of the first phase of the Dialysis Outcomes and Practice Patterns Study, a prospective observational study. Using multivariable proportional hazards analysis, all-cause mortality by racial/ethnic category was compared before and after adjustment for other patient-level variables that are associated with mortality. Factors that influence the statistical associations of race/ethnicity with mortality were explored. The statistically significant (P < 0.001) associations of racial/ethnic minority categories with lower mortality in unadjusted analyses were attenuated or lost in the multivariable model. Compared with non-Hispanic white patients, the adjusted hazard ratio (HR) (95% confidence interval [CI]) for mortality was 0.86 (0.72 to 1.03) for Hispanic patients; among non-Hispanic patients, the HR (95% CI) were 0.97 (0.85 to 1.11) for black patients, 0.82 (0.56 to 1.20) for Asian patients, 0.95 (0.52 to 1.73) for Native American patients, and 0.95 (0.60 to 1.50) for patients of other races (overall P = 0.66). The survival advantages for racial/ethnic minority categories were explained most notably by the combined influence of unbalanced distributions of numerous demographic, morbidity, nutritional, and laboratory variables. The associations of race/ethnicity with survival varied little by duration of ESRD and were not influenced substantially by different rates of kidney transplantation among patients who were on HD. The survival advantages for racial and ethnic minority groups on HD are explained largely by measurable case-mix and treatment characteristics. Individual racial minority group or Hispanic patients should not be expected to survive longer on HD than non-Hispanic white patients with similar clinical attributes.

Enhancing the survival of tunneled haemodialysis catheters using an antibiotic lock in the elderly: A randomised, double-blind clinical trial

BACKGROUND

Tunneled-cuffed catheters (TCC) are often used among the elderly to commence and carry out haemodialysis (HD). Complications like infection and thrombosis frequently reduce the lifespan of TCC. The role of an antibiotic heparin 'lock' in the prevention of thrombotic and infectious complications and enhancement of TCC survival in the elderly has not been investigated previously.

METHODS

In this prospective, double-blind clinical trial, TCC (n = 119, placed among 113 elderly patients requiring HD during March 2002 - February 2003) were randomised to either group I having TCC (n = 59, placed in 58 elderly patients) locked with cefotaxime (10 mg/mL) and heparin (5000 U/mL), or group II with TCC (n = 60, placed in 55 elderly patients) having catheter-restricted filling of heparin (5000 U/mL) alone. Symptomatic catheter-related blood stream infections (CRBSI) and catheter thrombosis were the primary end points in this study. Thrombosis was defined as an inability to use the catheter at a blood flow of 200 mL/min that did not respond to catheter repositioning and/or intraluminal thrombolysis. The incidence of catheter thrombosis, CRBSI and percentage of catheter survival were estimated and statistically compared between the two groups.

RESULTS

Kaplan-Meier survival analysis using log rank test showed higher thrombosis-free TCC survival (84.7%vs 63.3%, P = 0.021), infection-free survival (68.7%vs 31.3%, P < 0.001) and infection and thrombosis-free survival (65.0%vs 35.0%, P = 0.006) at 365 days in group I compared with group II.

CONCLUSION

Cefotaxime and heparin locks safely and effectively enhance the lifespan of TCC by lowering the incidence of thrombotic and infectious complications among elderly end-stage renal failure (ESRD) patients.

The association of poverty with the prevalence of albuminuria: data from the Third National Health and Nutrition Examination Survey (NHANES III)

BACKGROUND

Albuminuria is a major risk factor for the development and progression of chronic kidney disease (CKD) and cardiovascular disease. Socioeconomic factors also have been reported to modify CKD and cardiovascular risk factors and clinical outcomes. The extent to which poverty influences the prevalence of albuminuria, particularly among racial/ethnic minority populations, is not well established. The influence of poverty on the prevalence of albuminuria and the implication of this relationship for the racial and/or ethnic differences in the prevalence of albuminuria were examined.

METHODS

We examined data from 6,850 male and 7,634 female adults from a national probability survey conducted between 1988 and 1994.

RESULTS

In univariate analysis, poverty, defined as less than 200% federal poverty level (FPL), was associated with the presence of both microalbuminuria (odds ratio [OR], 1.35; 95% confidence interval, 1.22 to 1.49) and macroalbuminuria (OR, 1.78; 95% confidence interval, 1.40 to 2.26). The association of less than 200% FPL with microalbuminuria persisted in a multivariate model controlling for age, sex, race, education, obesity, hypertension, diabetes, reduced glomerular filtration rate, and medication use (OR, 1.18; 95% confidence interval, 1.05 to 1.33). FPL less than 200% was not associated with macroalbuminuria in the multivariate model. When multivariate analysis is stratified by FPL (<200% and > or =200%), differences in ORs for microalbuminuria and macroalbuminuria among racial/ethnic minority participants compared with whites were more apparent among the less affluent participants in the FPL-less-than-200% stratum.

CONCLUSION

FPL less than 200% is associated with microalbuminuria, and differences in FPL levels may account for some of the observed differences in prevalence of albuminuria between racial/ethnic minority participants and their white counterparts.

Outcomes for Adolescent Hispanic Hemodialysis Patients: Findings From the ESRD Clinical Performance Measures Project

BACKGROUND

There is limited information regarding outcomes of dialytic care for Hispanic adolescent hemodialysis patients.

METHODS

Ethnicity information was collected for all adolescent in-center hemodialysis patients for the Centers for Medicare & Medicaid Services 2000 End-Stage Renal Disease (ESRD) Clinical Performance Measures Project. Associations between intermediate outcomes and Hispanic ethnicity were determined. Associations of ethnicity and other demographic/clinical variables with hospitalization and transplantation during the 12-month follow-up period were examined.

RESULTS

Twenty-two percent of patients were identified as Hispanic; 40%, as non-Hispanic black; and 32%, as non-Hispanic white. Hispanic patients were younger and more likely to have congenital/urological causes of ESRD. More Hispanic patients had a mean single-pool Kt/V of 1.2 or greater compared with non-Hispanic blacks and non-Hispanic whites (87% versus 73% and 79%; P = 0.036). More Hispanic patients had a mean serum albumin level of 3.5/3.2 g/dL (bromcresol green/bromcresol purple method) or greater (> or = 35/32 g/L; 91% versus 82% and 76%; P = 0.017). More Hispanic patients compared with non-Hispanic blacks and non-Hispanic whites were dialyzed with a catheter for 90 days or longer (30% versus 21% and 23%; P = 0.027). In the final multivariate Cox proportional hazard models, Hispanic patients were at a slightly decreased risk for hospitalization compared with non-Hispanics (adjusted hazard ratio [adjHR], 0.63; P = 0.031) and were as likely to undergo a first transplantation as non-Hispanic whites (adjHR, 0.56; P = 0.099).

CONCLUSION

Adolescent Hispanic hemodialysis patients experience equivalent or better intermediate outcomes of dialytic care than non-Hispanics. They experienced a decreased risk for subsequent hospitalization and are as likely to undergo transplantation within 12 months as non-Hispanic whites.

Unraveling the racial disparities associated with kidney disease

In the United States, chronic kidney disease (CKD), and in particular end-stage renal disease (ESRD), represent a growing problem. Many other countries also have an increasing number of ESRD cases. Racial/ethnic disparities have been documented globally in the prevalence, incidence, and treatment of CKD, most extensively in the United States, but also in the United Kingdom, Australia, and New Zealand, among others. In many circumstances, these disparities are of a negative nature, that is, certain racial/ethnic groups fare worse than their white counterparts with respect to the treatment or outcome of CKD. However, in a few circumstances, they are of a positive nature, such as the survival advantage seen in minorities with ESRD compared with whites. The reasons for racial disparities in the prevalence, incidence, and treatment of CKD are not fully understood, although they are explained partly by coexisting medical conditions and modifiable risk factors, such as socioeconomic, lifestyle, and cultural. It is likely, however, that the complete picture incorporates a complex interaction between these sociocultural, genetic, and environmental factors. In a global society that prides itself on a high level of sensitivity and equality, there is an ethical and moral imperative to address the continuing racial/ethnic disparities in CKD and many of the factors underlying this epidemic. We review data highlighting the racial/ethnic disparities that exist in the incidence and treatment of CKD, with particular emphasis on ESRD. A better understanding of both the negative and positive racial/ethnic disparities may yield important insights, which can inform future research strategies and improve health outcomes for all patients afflicted with CKD.

Perceived discrimination and reported delay of pharmacy prescriptions and medical tests

BACKGROUND

Access to health care varies according to a person's race and ethnicity. Delaying treatment is one measure of access with important health consequences.

OBJECTIVE

Determine whether perceptions of unfair treatment because of race or ethnicity are associated with reported treatment delays, controlling for economic constraints, self-reported health, depression, and demographics.

DESIGN

Cross-sectional, observational study.

PARTICIPANTS

A randomly selected community sample of 181 blacks, 148 Latinos, and 193 whites in Durham County, NC.

MEASUREMENTS

A phone survey conducted in 2002 to assess discrimination, trust in medical care, quality of care, and access to care. Treatment delays were measured by whether or not a person reported delaying or forgoing filling a prescription and delaying or forgoing having a medical test/treatment in the past 12 months. Perceived discrimination was measured as unfair treatment in health care and as racism in local health care institutions.

RESULTS

The odds of delaying filling prescriptions were significantly higher (odds ratio (OR)=2.02) for persons who perceived unfair treatment, whereas the odds of delaying tests or treatments were significantly higher (OR=2.42) for persons who thought racism was a problem in health care locally. People with self-reported depression and people who reported not working had greater odds of delaying both types of care.

CONCLUSIONS

A prospective cohort study with both personal and macro measures of discrimination, as well as more refined measures of treatment delays, would help us better understand the relationship between perceived discrimination and treatment delays.