Reappraisal of the impact of race on survival in patients on dialysis

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.

Trends in African Americans' Attitudes and Behaviors About Living Donor Kidney Transplantation

BACKGROUND

Due to marginal efforts to increase living donor kidney transplantation, it is unclear whether interventions to improve African Americans' interest and pursuit of living donation should be tailored to address patients' exposure to or familiarity with dialysis or transplant settings.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a cross-sectional secondary analysis of baseline data from 3 separate randomized clinical trials among African Americans with varying degrees of experience with dialysis or transplantation (predialysis, on dialysis but not on transplant list, and on transplant wait-list) settings.

METHODS

Interest in living donation was described using a 0 to 10 scale and pursuit of living donor kidney transplantation by achievement of at least 1 pursuant behavior. In multivariable logistic regression analyses, we assessed the association of knowledge, health literacy, and trust in health care with interest in or pursuit of living donation.

RESULTS

Interest among the 3 study cohorts was high (predialysis, 62.9%; dialysis, 67.4%; and transplant wait-list, 74.2%). The dialysis and transplant wait-list study cohorts pursued living donation more readily than those not on dialysis (73%, 92%, and 45%, respectively). Interest and pursuit were not statistically significantly associated with knowledge, health literacy, or the 3 factors reflecting medical mistrust.

CONCLUSION

Interest and pursuit of living donation were greater among study participants with greater exposure to dialysis or transplant settings. Efforts to promote patients' early interest and pursuit of living donor transplants may consider novel strategies to educate patients with less experience about the benefits of living donor kidney transplantation.

Race, Mineral Homeostasis and Mortality in Patients with End-Stage Renal Disease on Dialysis

BACKGROUND

Abnormalities in mineral homeostasis are ubiquitous in patients on dialysis, and influenced by race. In this study, we determine the race-specific relationship between mineral parameters and mortality in patients initiating hemodialysis.

METHODS

We measured the levels of fibroblast growth factor 23 (FGF23) and 25-hydroxyvitamin D (25 D) in 184 African American and 327 non-African American hemodialysis patients who enrolled between 1995 and 1998 in the Choices for Healthy Outcomes in Caring for ESRD Study. Serum calcium, phosphorus, parathyroid hormone (PTH) and total alkaline phosphatase levels were averaged from clinical measurements during the first 4.5 months of dialysis. We evaluated the associated prospective risk of mortality using multivariable Cox proportional hazards models stratified by race.

RESULTS

PTH and total alkaline phosphatase levels were higher, whereas calcium, phosphorus, FGF23 and 25 D levels were lower in African Americans compared to those of non-African Americans. Higher serum phosphorus and FGF23 levels were associated with greater mortality risk overall; however, phosphorus was only associated with risk among African Americans (HR 5.38, 95% CI 2.14-13.55 for quartile 4 vs. 1), but not among non-African Americans (p-interaction = 0.04). FGF23 was associated with mortality in both groups, but more strongly in African Americans (HR 3.91, 95% CI 1.74-8.82 for quartiles 4 vs. 1; p-interaction = 0.09). Serum calcium, PTH, and 25 D levels were not consistently associated with mortality. The lowest and highest quartiles of total alkaline phosphatase were associated with higher mortality risk, but this did not differ by race (p-interaction = 0.97).

CONCLUSIONS

Aberrant phosphorus homeostasis, reflected by higher phosphorus and FGF23, may be a risk factor for mortality in patients initiating hemodialysis, particularly among African Americans.

Neighborhood socioeconomic status, race, and mortality in young adult dialysis patients

Young blacks receiving dialysis have an increased risk of death compared with whites in the United States. Factors influencing this disparity among the young adult dialysis population have not been well explored. Our study examined the relation of neighborhood socioeconomic status (SES) and racial differences in mortality in United States young adults receiving dialysis. We merged US Renal Data System patient-level data from 11,027 black and white patients ages 18-30 years old initiating dialysis between 2006 and 2009 with US Census data to obtain neighborhood poverty information for each patient. We defined low SES neighborhoods as those neighborhoods in U.S. Census zip codes with ≥20% of residents living below the federal poverty level and quantified race differences in mortality risk by level of neighborhood SES. Among patients residing in low SES neighborhoods, blacks had greater mortality than whites after adjusting for baseline demographics, clinical characteristics, rurality, and access to care factors. This difference in mortality between blacks and whites was significantly attenuated in higher SES neighborhoods. In the United States, survival between young adult blacks and whites receiving dialysis differs by neighborhood SES. Additional studies are needed to identify modifiable factors contributing to the greater mortality among young adult black dialysis patients residing in low SES neighborhoods.

The RaDIANT community study protocol: community-based participatory research for reducing disparities in access to kidney transplantation

BACKGROUND

The Southeastern United States has the lowest kidney transplant rates in the nation, and racial disparities in kidney transplant access are concentrated in this region. The Southeastern Kidney Transplant Coalition (SEKTC) of Georgia, North Carolina, and South Carolina is an academic and community partnership that was formed with the mission to improve access to kidney transplantation and reduce disparities among African American (AA) end stage renal disease (ESRD) patients in the Southeastern United States.

METHODS/DESIGN

We describe the community-based participatory research (CBPR) process utilized in planning the Reducing Disparities In Access to kidNey Transplantation (RaDIANT) Community Study, a trial developed by the SEKTC to reduce health disparities in access to kidney transplantation among AA ESRD patients in Georgia, the state with the lowest kidney transplant rates in the nation. The SEKTC Coalition conducted a needs assessment of the ESRD population in the Southeast and used results to develop a multicomponent, dialysis facility-randomized, quality improvement intervention to improve transplant access among dialysis facilities in GA. A total of 134 dialysis facilities are randomized to receive either: (1) standard of care or "usual" transplant education, or (2) the multicomponent intervention consisting of transplant education and engagement activities targeting dialysis facility leadership, staff, and patients within dialysis facilities. The primary outcome is change in facility-level referral for kidney transplantation from baseline to 12 months; the secondary outcome is reduction in racial disparity in transplant referral.

DISCUSSION

The RaDIANT Community Study aims to improve equity in access to kidney transplantation for ESRD patients in the Southeast.

TRIAL REGISTRATION

Clinicaltrials.gov number NCT02092727.

Survival on dialysis among American Indians and Alaska Natives with diabetes in the United States, 1995-2010

OBJECTIVES

We assessed survival in American Indians and Alaska Natives (AI/ANs) with end-stage renal disease attributed to diabetes who initiated hemodialysis between 1995 and 2009.

METHODS

Follow-up extended from the first date of dialysis in the United States Renal Data System until December 31, 2010, kidney transplantation, or death. We used the Kaplan-Meier method to compute survival on dialysis by age and race/ethnicity and Cox regression analysis to compute adjusted hazard ratios (HRs).

RESULTS

Our study included 510,666 persons-48% Whites, 2% AI/AN persons, and 50% others. Median follow-up was 2.2 years (interquartile range = 1.1-4.1 years). At any age, AI/AN persons survived longer on hemodialysis than Whites; this finding persisted after adjusting for baseline differences. Among AI/AN individuals, those with full Indian blood ancestry had the lowest adjusted risk of death compared with Whites (HR = 0.58; 95% confidence interval = 0.55, 0.61). The risk increased with declining proportion of AI/AN ancestry.

CONCLUSIONS

Survival on dialysis was better among AI/AN than White persons with diabetes. Among AI/AN persons, the inverse relationship between risk of death and level of AI/AN ancestry suggested that cultural or hereditary factors played a role in survival.

The impact of chronic kidney disease and cardiovascular comorbidity on mortality in a multiethnic population: a retrospective cohort study

OBJECTIVE

To assess the impact of chronic kidney disease (CKD) and cardiovascular comorbidity on mortality in a multiethnic primary care population.

DESIGN

Retrospective cohort study.

SETTING

Inner-city primary care trust in West Midlands, UK.

PARTICIPANTS

Individuals aged 40 years and older, of South Asian, black or white ethnicity, registered with a general practice and with their kidney function checked within the last 12 months (n=31 254).

OUTCOME MEASURE

All-cause mortality.

RESULTS

Reduced estimated glomerular filtration rate, higher albuminuria, older age, white ethnicity (vs South Asian or black ethnicity) and increasing cardiovascular comorbidities were independent determinants of a higher mortality risk. In the multivariate model including comorbidities and kidney function, the HR for mortality for South Asians was 0.697 (95% CI 0.56 to 0.868, p=0.001) and for blacks it was 0.533 (95% CI 0.403 to 0.704, p<0.001) compared to whites.

CONCLUSIONS

The HR for death is lower for South Asian and black individuals compared to white individuals. This is, in part, independent of age, gender, socioeconomic status, kidney function and comorbidities. Risk of death is higher in individuals with CKD and with a higher cumulative cardiovascular comorbidity.

Predicting palliative care needs and mortality in end stage renal disease: use of an at-risk register

INTRODUCTION

The Gold Standard Frameworks (GSF) Committee devised Prognostic Indicator Guidance in November 2007 to 'aid identification of adult patients with advanced disease, in the last months or year of life, who are in need of supportive or palliative care'.

METHODS

This research used the GSF `surprise question' to formulate a list of patients predicted to die within 1 year with end stage renal failure and to establish the specificity and sensitivity of this register.

RESULTS

58 patients were added to the list during the follow-up period of which 28 (48.3%) died during the same period giving an annual mortality of 32.2%. In comparison with the patients who died during the follow-up period but were not added to the at-risk register, those on the register had a much higher mortality rate (32.2% vs 7.8%). Identification of patients with chronic kidney disease and reduced life expectancy by this method appears to have a high sensitivity (66.7%) and specificity (77.9%). In particular, the negative predictive value for mortality for those on the at-risk register appears to be very high (88.3%), indicating the very low mortality among those not on the register.

CONCLUSIONS

Patients with chronic kidney disease and a reduced life expectancy can be accurately identified by a multi-disciplinary team using the surprise trigger question with a relatively high sensitivity and specificity. The accurate identification of patients with reduced life expectancy allows appropriate end of life care planning to begin in keeping with patients' wishes and within published guidelines.

Effect of race and genetics on vitamin D metabolism, bone and vascular health

The pathophysiology of chronic kidney disease-mineral and bone disorder accounts for an inverse relationship between bone mineralization and vascular calcification in progressive nephropathy. Inverse associations between bone mineral density (BMD) and calcified atherosclerotic plaque are also observed in individuals of European and African ancestry without nephropathy, suggesting a mechanistic link between these processes that is independent of kidney disease. Despite lower dietary calcium intake and serum 25-hydroxyvitamin D (25(OH)D) concentrations, African Americans have higher BMD and develop osteoporosis less frequently than do European Americans. Moreover, despite having more risk factors for cardiovascular disease, African Americans have a lower incidence and severity of calcified atherosclerotic plaque formation than do European Americans. Strikingly, evidence is now revealing that serum 25(OH)D and/or 1,25 dihydroxyvitamin D levels associate positively with atherosclerosis but negatively with BMD in African Americans; by contrast, vitamin D levels associate negatively with atherosclerosis and positively with BMD in individuals of European ancestry. Biologic phenomena, therefore, seem to contribute to population-specific differences in vitamin D metabolism, bone and vascular health. Genetic and mechanistic approaches used to explore these differences should further our understanding of bone-blood vessel relationships and explain how African ancestry protects from osteoporosis and calcified atherosclerotic plaque, provided that access of African Americans to health care is equivalent to individuals of European ethnic origin. Ultimately, in our opinion, a new mechanistic understanding of the relationships between bone mineralization and vascular calcification will produce novel approaches for disease prevention in aging populations.

The role of psychosocial factors in ethnic differences in survival on dialysis in the Netherlands

INTRODUCTION

Ethnic minority patients on dialysis are reported to have better survival rates relative to Caucasians. The reasons for this finding are not fully understood and European studies are scarce. This study examined whether ethnic differences in survival could be explained by patient characteristics, including psychosocial factors.

METHODS

We analysed data of the Netherlands Cooperative Study on the Adequacy of Dialysis study, an observational prospective cohort study of patients who started dialysis between 1997 and 2007 in the Netherlands. Ethnicity was classified as Caucasian, Black or Asian, assessed by local nurses. Data collected at the start of dialysis treatment included demographic, clinical and psychosocial characteristics. Psychosocial characteristics included data on health-related quality of life (HRQoL), mental health status and general health perception. Cox proportional hazards analysis was used to explore ethnic survival differences.

RESULTS

One thousand seven hundred and ninety-one patients were Caucasian, 45 Black and 108 Asian. The ethnic groups differed significantly in age, residual glomerular filtration rate, diabetes mellitus, erythropoietin use, plasma calcium, parathormone and creatinine, marital status and general health perception. No ethnic differences were found in HRQoL and mental health status. Crude hazard ratios (HRs) for mortality for Caucasians compared to Blacks and Asians were 3.1 [95% confidence interval (CI) 1.6-5.9] and 1.1 (95% CI 0.9-1.5), respectively. After adjustment for a range of potential explanatory variables, including psychosocial factors, the HRs were 2.5 (95% CI 1.2-4.9) compared with Blacks and 1.2 (95% CI 0.9-1.6) compared with Asians.

CONCLUSIONS

Although patient numbers were rather small, this study demonstrates, with 95% confidence, better survival for Black compared to Caucasian dialysis patients and equal survival for Asian compared to Caucasian dialysis patients in the Netherlands. This could not be explained by patient characteristics, including psychosocial factors.

Association between GFR, proteinuria, and adverse outcomes among White, Chinese, and South Asian individuals in Canada

BACKGROUND

We investigated the association between proteinuria, estimated glomerular filtration rate (eGFR), and risk of mortality and kidney failure in white, Chinese, and South Asian populations.

STUDY DESIGN

Population-based cohort study.

SETTING & PARTICIPANTS

Participants from Alberta, Canada, with a serum creatinine and urine protein dipstick measurement from January 1, 2005, to December 31, 2005.

PREDICTOR

White, Chinese, or South Asian ethnicity.

OUTCOMES

Prevalence of proteinuria by level of eGFR (estimated using the MDRD [Modification of Diet in Renal Disease] Study equation) and the association between eGFR, proteinuria, and all-cause mortality and kidney failure.

MEASUREMENTS

Rates of all-cause mortality and kidney failure per 1,000 person-years were calculated using Poisson regression by ethnicity, eGFR level, and proteinuria level while adjusting for sociodemographic variables and comorbid conditions.

RESULTS

Of 491,729 participants, 5.3% were Chinese and 4.7% were South Asian. For participants with eGFR <60 mL/min/1.73 m(2), the prevalence of heavy proteinuria was higher in Chinese and South Asians compared with whites. Compared with whites, adjusted rates of death were significantly lower for Chinese and South Asian populations (rate ratios, 0.67 [95% CI, 0.56-0.80] and 0.73 [95% CI, 0.59-0.88], respectively); these rate ratios did not vary by eGFR and proteinuria levels.

LIMITATIONS

Using surname to identify ethnicity has the potential for misclassification due to name changes and identical last names from different ethnic groups. Also, to be eligible for inclusion, participants had to have a measurement of serum creatinine and urine dipstick proteinuria.

CONCLUSIONS

Although increasing proteinuria and lower eGFR predicted mortality and progression to kidney failure in all 3 ethnic groups, both Chinese and South Asian populations experienced a lower risk of death and similar risk of kidney failure compared with whites at all eGFR and proteinuria levels. Studies exploring this association further are required.

End-stage renal disease due to lupus nephritis among children in the US, 1995-2006

OBJECTIVE

To identify predictors of wait-listing for kidney transplantation, kidney transplantation, and mortality among children with lupus nephritis-associated end-stage renal disease (ESRD).

METHODS

Children ages 5-18 years with new-onset lupus nephritis-associated ESRD were identified in the US Renal Data System (1995-2006). Demographic and clinical characteristics, causes of death, and predictors of wait-listing for kidney transplantation, kidney transplantation, and mortality during the first 5 years of ESRD were investigated. Cox proportional hazards models were used.

RESULTS

A total of 583 children had incident lupus nephritis-associated ESRD. The mean ± SD age of the patients at the time of ESRD onset was 16.2 ± 2.4 years; 49% were African American, and 24% were Hispanic. During the 5-year period after the onset of ESRD, 292 (49%) were wait-listed, 193 (33%) received a kidney transplant, and 131 (22%) died. The main causes of death were cardiopulmonary (31%) and infectious (16%). Children living in the northeast and west were more than twice as likely as children in the south to be wait-listed and were >50% more likely than children in the south to undergo transplantation. There were fewer kidney transplants among older versus younger patients (odds ratio [OR] 0.59, P = 0.009), African American versus white patients (OR 0.48, P < 0.001), Hispanic versus non-Hispanic patients (OR 0.63, P = 0.03), and those with Medicaid versus those with private insurance (OR 0.70, P = 0.03). Mortality among African American children was almost double that among white children (OR 1.83, P < 0.001).

CONCLUSION

Among US children with lupus nephritis-associated ESRD, age, race, ethnicity, type of medical insurance, and geographic region were associated with significant variation in 5-year wait-listing for kidney transplantation, kidney transplantation, and mortality.

Association of race and age with survival among patients undergoing dialysis

CONTEXT

Many studies have reported that black individuals undergoing dialysis survive longer than those who are white. This observation is paradoxical given racial disparities in access to and quality of care, and is inconsistent with observed lower survival among black patients with chronic kidney disease. We hypothesized that age and the competing risk of transplantation modify survival differences by race.

OBJECTIVE

To estimate death among dialysis patients by race, accounting for age as an effect modifier and kidney transplantation as a competing risk.

DESIGN, SETTING, AND PARTICIPANTS

An observational cohort study of 1,330,007 incident end-stage renal disease patients as captured in the United States Renal Data System between January 1, 1995, and September 28, 2009 (median potential follow-up time, 6.7 years; range, 1 day-14.8 years). Multivariate age-stratified Cox proportional hazards and competing risk models were constructed to examine death in patients who receive dialysis.

MAIN OUTCOME MEASURES

Death in black vs white patients who receive dialysis.

RESULTS

Similar to previous studies, black patients undergoing dialysis had a lower death rate compared with white patients (232,361 deaths [57.1% mortality] vs 585,792 deaths [63.5% mortality], respectively; adjusted hazard ratio [aHR], 0.84; 95% confidence interval [CI], 0.83-0.84; P <.001). However, when stratifying by age and treating kidney transplantation as a competing risk, black patients had significantly higher mortality than their white counterparts at ages 18 to 30 years (27.6% mortality vs 14.2%; aHR, 1.93; 95% CI, 1.84-2.03), 31 to 40 years (37.4% mortality vs 26.8%; aHR, 1.46; 95% CI, 1.41-1.50), and 41 to 50 years (44.8% mortality vs 38.0%; aHR, 1.12; 95% CI, 1.10-1.14; P <.001 for interaction terms between race and each aforementioned age category), as opposed to patients aged 51 to 60 years (51.5% vs 50.9%; aHR, 0.93; 95% CI, 0.92-0.94), 61 to 70 years (64.9% vs 67.2%; aHR, 0.87; 95% CI, 0.86-0.88), 71 to 80 years (76.1% vs 79.7%; aHR, 0.85; 95% CI, 0.84-0.86), and older than 80 years (82.4% vs 83.6%; aHR, 0.87; 95% CI, 0.85-0.88).

CONCLUSIONS

Overall, among dialysis patients in the United States, there was a lower risk of death for black patients compared with their white counterparts. However, the commonly cited survival advantage for black dialysis patients applies only to older adults, and those younger than 50 years have a higher risk of death.

Racial and ethnic disparities in United States: stillbirth rates: trends, risk factors, and research needs

As with most adverse health outcomes, there has been long standing and persistent racial and ethnic disparity for stillbirth in the United States. In 2005, the stillbirth rate (fetal deaths ≥ 20 weeks' gestation per 1000 fetal deaths and live births) for non-Hispanic blacks was 11.13 compared with 4.79 for non-Hispanic whites. Rates were intermediate for American Indian or Alaska Natives (6.17) and Hispanics (5.44). There is racial disparity for both early (< 28 weeks' gestation) and late stillbirths. We review available data regarding risk factors for stillbirth with a focus on those factors that are more prevalent in certain racial/ethnic groups and those factors that appear to have a more profound effect in certain racial/ethnic groups. Although many factors, including genetics, environment, stress, social issues, access to and quality of medical care and behavior, contribute to racial disparity in stillbirth, the reasons for the disparity remain unclear. Knowledge gaps and recommendations for further research and interventions intended to reduce racial disparity in stillbirth are highlighted.

Dialyzer reuse with peracetic acid does not impact patient mortality

BACKGROUND AND OBJECTIVES

Numerous studies have shown the overall benefits of dialysis filter reuse, including superior biocompatibility and decreased nonbiodegradable medical waste generation, without increased risk of mortality. A recent study reported that dialyzer reprocessing was associated with decreased patient survival; however, it did not control for sources of potential confounding. We sought to determine the effect of dialyzer reprocessing with peracetic acid on patient mortality using contemporary outcomes data and rigorous analytical techniques.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a series of analyses of hemodialysis patients examining the effects of reuse on mortality using three techniques to control for potential confounding: instrumental variables, propensity-score matching, and time-dependent survival analysis.

RESULTS

In the instrumental variables analysis, patients at high reuse centers had 16.2 versus 15.9 deaths/100 patient-years in nonreuse centers. In the propensity-score matched analysis, patients with reuse had a lower death rate per 100 patient-years than those without reuse (15.2 versus 15.5). The risk ratios for the time-dependent survival analyses were 0.993 (per percent of sessions with reuse) and 0.995 (per unit of last reuse), respectively. Over the study period, 13.8 million dialyzers were saved, representing 10,000 metric tons of medical waste.

CONCLUSIONS

Despite the large sample size, powered to detect miniscule effects, neither the instrumental variables nor propensity-matched analyses were statistically significant. The time-dependent survival analysis showed a protective effect of reuse. These data are consistent with the preponderance of evidence showing reuse limits medical waste generation without negatively affecting clinical outcomes.

Effect of gender and race on outcomes in dialysis-dependent patients undergoing percutaneous coronary intervention

We aimed to determine whether gender and race are independently associated with in-hospital major adverse cardiac and cerebrovascular events (MACCE) and hospital length of stay in chronic dialysis patients undergoing percutaneous coronary intervention (PCI). Cardiovascular disease is the leading cause of mortality in patients with end-stage renal disease requiring dialysis. Whether gender or race independently influences the outcomes in patients undergoing PCI is not fully understood. The study population included 474 chronic dialysis patients who underwent PCI at 4 New York State teaching hospitals from January 1, 2004 to December 31, 2007. The primary end point of the study was the composite of in-hospital MACCE, defined as all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke. The secondary end points included in-hospital all-cause mortality and hospital length of stay. Of the 474 chronic dialysis patients, 172 (36.3%) were women. The women undergoing PCI were more likely to be black or Hispanic and had a greater left ventricular ejection fraction. The women had significantly greater rates of in-hospital MACCE (5.8% vs 1.7%, p=0.013) and mortality (4.7% vs 0.7%, p=0.006). No significant difference in the MACCE rates was found between the black and white patients (4.9% vs 2.2%, respectively, p=0.125), although black patients showed a trend toward greater in-hospital mortality (4.1% vs 1.2%, p=0.069). After adjustment for the baseline clinical and procedural characteristics, female gender was an independent predictor of MACCE (odds ratio 7.41, 95% confidence interval 1.81 to 30.27) and all-cause mortality (odds ratio 13.23, 95% confidence interval 1.55 to 113.25), but race was not. No significant difference in the hospital length of stay was observed by either gender or race. In conclusion, in this study, female gender was independently associated with a greater risk of MACCE and all-cause mortality in dialysis-dependent patients undergoing PCI. Although being a black woman was an independent predictor of mortality, race per se was not an independent predictor of in-hospital mortality.

Potential effects of MYH9-associated nephropathy on dialysis and kidney transplant outcomes

Several related disorders comprise the spectrum of nonmuscle myosin heavy chain 9-associated (MYH9) nephropathy. The contribution of variants in this single MYH9 gene to ethnic differences in the incidence rates of end-stage renal disease is now clearly established. The importance of recognizing the role of MYH9 in these inherited kidney disorders goes beyond simple disease association; there may well be effects on clinical outcomes in patients on dialysis and after kidney transplantation. MYH9 polymorphisms may affect treatment outcomes in severe kidney disease and such gene effects are rarely encountered in practice.