Differential mortality and transplantation rates among Asians and Pacific Islanders with ESRD

Association of Race and Ethnicity With High Longevity Deceased Donor Kidney Transplantation Under the US Kidney Allocation System

RATIONALE & OBJECTIVE

The US Kidney Allocation System (KAS) prioritizes candidates with a≤20% estimated posttransplant survival (EPTS) to receive high-longevity kidneys defined by a≤20% Kidney Donor Profile Index (KDPI). Use of EPTS in the KAS deprioritizes candidates with older age, diabetes, and longer dialysis durations. We assessed whether this use also disadvantages race and ethnicity minority candidates, who are younger but more likely to have diabetes and longer durations of kidney failure requiring dialysis.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

Adult candidates for and recipients of kidney transplantation represented in the Scientific Registry of Transplant Recipients from January 2015 through December 2020.

EXPOSURE

Race and ethnicity.

OUTCOME

Age-adjusted assignment to≤20% EPTS, transplantation of a≤20% KDPI kidney, and posttransplant survival in longevity-matched recipients by race and ethnicity.

ANALYTIC APPROACH

Multivariable logistic regression, Fine-Gray competing risks survival analysis, and Kaplan-Meier and Cox proportional hazards methods.

RESULTS

The cohort included 199,444 candidates (7% Asian, 29% Black, 19% Hispanic or Latino, and 43% White) listed for deceased donor kidney transplantation. Non-White candidates had significantly higher rates of diabetes, longer dialysis duration, and were younger than White candidates. Adjusted for age, Asian, Black, and Hispanic or Latino candidates had significantly lower odds of having a ETPS score of≤20% (odds ratio, 0.86 [95% CI, 0.81-0.91], 0.52 [95% CI, 0.50-0.54], and 0.49 [95% CI, 0.47-0.51]), and were less likely to receive a≤20% KDPI kidney (sub-hazard ratio, 0.70 [0.66-0.75], 0.89 [0.87-0.92], and 0.73 [0.71-0.76]) compared with White candidates. Among recipients with≤20% EPTS scores transplanted with a≤20% KDPI deceased donor kidney, Asian and Hispanic recipients had lower posttransplant mortality (HR, 0.45 [0.27-0.77] and 0.63 [0.47-0.86], respectively) and Black recipients had higher but not statistically significant posttransplant mortality (HR, 1.22 [0.99-1.52]) compared with White recipients.

LIMITATIONS

Provider reported race and ethnicity data and 5-year post transplant follow-up period.

CONCLUSIONS

The US kidney allocation system is less likely to identify race and ethnicity minority candidates as having a≤20% EPTS score, which triggers allocation of high-longevity deceased donor kidneys. These findings should inform the Organ Procurement and Transplant Network about how to remedy the race and ethnicity disparities introduced through KAS's current approach of allocating allografts with longer predicted longevity to recipients with longer estimated posttransplant survival.

PLAIN-LANGUAGE SUMMARY

The US Kidney Allocation System prioritizes giving high-longevity, high-quality kidneys to patients on the waiting list who have a high estimated posttransplant survival (EPTS) score. EPTS is calculated based on the patient's age, whether the patient has diabetes, whether the patient has a history of organ transplantation, and the number of years spent on dialysis. Our analyses show that Asian, Black or African American, and Hispanic or Latino patients were less likely to receive high-longevity kidneys compared with White patients, despite having similar or better posttransplant survival outcomes.

Strategies to Guide Preemptive Waitlisting and Equity in Waittime Accrual by Race/Ethnicity

BACKGROUND

Use of eGFR to determine preemptive waitlisting eligibility may contribute to racial/ethnic disparities in access to waitlisting, which can only occur when the eGFR falls to ≤20 ml/min per 1.73 m 2 . Use of an alternative risk-based strategy for waitlisting may reduce these inequities ( e.g. , a kidney failure risk equation [KFRE] estimated 2-year risk of kidney failure) rather than the standard eGFR threshold for determining waitlist eligibility. Our objective was to model the amount of preemptive waittime that could be accrued by race and ethnicity, applying two different strategies to determine waitlist eligibility.

METHODS

Using electronic health record data, linear mixed models were used to compare racial/ethnic differences in preemptive waittime that could be accrued using two strategies: estimating the time between an eGFR ≤20 and 5 ml/min per 1.73 m 2 versus time between a 25% 2-year predicted risk of kidney failure (using the KFRE, which incorporates age, sex, albuminuria, and eGFR to provide kidney failure risk estimation) and eGFR of 5 ml/min per 1.73 m 2 .

RESULTS

Among 1290 adults with CKD stages 4-5, using the Chronic Kidney Disease Epidemiology Collaboration equation yielded shorter preemptive waittime between an eGFR of 20 and 5 ml/min per 1.73 m 2 in Black (-6.8 months; 95% confidence interval [CI], -11.7 to -1.9), Hispanic (-10.2 months; -15.3 to -5.1), and Asian/Pacific Islander (-10.3 months; 95% CI, -15.3 to -5.4) patients compared with non-Hispanic White patients. Use of a KFRE threshold to determine waittime yielded smaller differences by race and ethnicity than observed when using a single eGFR threshold, with shorter time still noted for Black (-2.5 months; 95% CI, -7.8 to 2.7), Hispanic (-4.8 months; 95% CI, -10.3 to 0.6), and Asian/Pacific Islander (-5.4 months; -10.7 to -0.1) individuals compared with non-Hispanic White individuals, but findings only met statistical significance criteria in Asian/Pacific Islander individuals. When we compared potential waittime availability using a KFRE versus eGFR threshold, use of the KFRE yielded more equity in waittime for Black ( P = 0.02), Hispanic ( P = 0.002), and Asian/Pacific Islander ( P = 0.002) patients.

CONCLUSIONS

Use of a risk-based strategy was associated with greater racial equity in waittime accrual compared with use of a standard single eGFR threshold to determine eligibility for preemptive waitlisting.

Racial Disparities in End-Stage Kidney Disease Outcomes among Asians and Native Hawaiians and Other Pacific Islanders across Geographic Residence

INTRODUCTION

While Asian and Native Hawaiian and other Pacific Islander (NHOPI) patients have a high prevalence of kidney disease risk factors, there are sparse data examining their end-stage kidney disease (ESKD) outcomes. As Hawaii has high representation of Asian and NHOPI individuals, we compared their ESKD outcomes based on residence in the mainland USA versus Hawaii/Pacific Islands (PIs).

MATERIALS AND METHODS

Using United States Renal Data System data, we examined the impact of geographic residence in the mainland versus Hawaii/PIs on race-mortality associations among incident ESKD patients transitioning to dialysis over January 1, 2000-December 31, 2016 using Cox regression. We examined likelihood of post-dialysis kidney transplantation using Cox models and cumulative incidence curves.

RESULTS

Compared with White patients in the mainland, Asian and NHOPI patients in the mainland had lower mortality: adjusted HRs (95% CIs) 0.67 (0.66-0.67) and 0.72 (0.70-0.73), respectively. When examining Asian and NHOPI patients in Hawaii/PIs, survival benefit was attenuated in Asian and diminished to the null in NHOPI patients (ref: mainland White patients). Cumulative incidence curves comparing Asian, NHOPI, and White patients showed Asian and NHOPI patients in the mainland had the highest likelihood of transplantation, whereas NHOPI and Asian patients in Hawaii/PIs had the lowest likelihood.

CONCLUSION

In the mainland, Asian and NHOPI patients had lower mortality versus White patients, whereas in Hawaii/PIs, this survival benefit was diminished in Asian and mitigated in NHOPI patients. NHOPI and Asian patients in Hawaii/PIs had less transplantation versus those in the mainland. Further research is needed to uncover factors contributing to differential ESKD outcomes among Asian and NHOPI patients across geographic residence.

Racial and Ethnic Differences in Chronic Kidney Disease and Its Risk Factors among Asian-Americans and Pacific Islanders in Hawaii

BACKGROUND

Several studies suggest that Asian-American and Native Hawaiian and Other Pacific Islander (NHOPI) racial/ethnic groups have a heightened risk of chronic kidney disease (CKD), but provide limited inference due to the aggregation of these groups into a single racial/ethnic category. We thus examined the association of granularly defined racial/ethnic groups with specific CKD indicators among a diverse group of participants from the National Kidney Foundation of Hawaii's Kidney Early Detection Screening (KEDS) Program.

METHODS

Among 1,243 participants enrolled in 19 KEDS screening events over 2006-2009, we examined the association between Asian-American and NHOPI groups and specific CKD indicators, defined as self-reported CKD, microalbuminuria, and macroalbuminuria, using multivariable logistic regression. We then examined associations of race/ethnicity with various CKD risk factors.

RESULTS

The most predominant racial/ethnic groups were White (22.0%), Multiracial (18.9%), Japanese (19.2%), Filipino (13.4%), NHOPI (8.4%), and Chinese (4.5%) participants. NHOPI and Chinese participants had a higher risk of microalbuminuria (adjusted ORs [aORs] [95% CIs] 2.48 [1.25-4.91] and 2.37 [1.07-5.27], respectively), while point estimates for all other minority groups suggested higher risk (reference: Whites). NHOPI participants also had a higher risk of macroalbuminuria and self-reported CKD. While most minorities had a higher risk of diabetes and hypertension, NHOPI and Multiracial participants had a higher risk of obesity, whereas the East Asian groups had a lower risk.

CONCLUSIONS

In this community-based cohort, compared with Whites, Asian-Americans had a higher risk of early CKD indicators, whereas NHOPIs had a higher risk of more severe CKD indicators. Further studies are needed to elucidate the distinct pathways leading to CKD across diverse racial/ethnic groups in Hawaii.

Thrombocytopenia predicts mortality in Chinese hemodialysis patients- an analysis of the China DOPPS

BACKGROUND

Hemodialysis (HD) patients have a higher mortality rate compared with general population. Our previous study revealed that platelet counts might be a potential risk factor. The role of platelets in HD patients has rarely been studied. The aim of this study is to examine if there is an association of thrombocytopenia (TP) with elevated risk of all-cause mortality and cardiovascular (CV) death in Chinese HD patients.

METHODS

Data from a prospective cohort study, China Dialysis Outcomes and Practice Patterns Study (DOPPS) 5, were analyzed. Demographic data, comorbidities, platelet counts and other lab data, and death records which extracted from the medical record were analyzed. TP was defined as the platelet count below the lower normal limit (< 100*109/L). Associations between platelet counts and all-cause and CV mortality were evaluated using Cox regression models. Stepwise multivariate logistic regression was used to identify the independent associated factors, and subgroup analyses were also carried out.

RESULTS

Of 1369 patients, 11.2% (154) had TP at enrollment. The all-cause mortality rates were 26.0% vs. 13.3% (p < 0.001) in patients with and without TP. TP was associated with higher all-cause mortality after adjusted for covariates (HR:1.73,95%CI:1.11,2.71), but was not associated with CV death after fully adjusted (HR:1.71,95%CI:0.88,3.33). Multivariate logistic regression showed that urine output < 200 ml/day, cerebrovascular disease, hepatitis (B or C), and white blood cells were independent impact factors (P < 0.05). Subgroup analysis found that the effect of TP on all-cause mortality was more prominent in patients with diabetes or hypertension, who on dialysis thrice a week, with lower ALB (< 4 g/dl) or higher hemoglobin, and patients without congestive heart failure, cerebrovascular disease, or hepatitis (P < 0.05).

CONCLUSION

In Chinese HD patients, TP is associated with higher risk of all-cause mortality, but not cardiovascular mortality. Platelet counts may be a useful prognostic marker for clinical outcomes among HD patients, though additional study is needed.

Racial and Ethnic Variations in Mortality Rates for Patients Undergoing Maintenance Dialysis Treated in US Territories Compared with the US 50 States

BACKGROUND AND OBJECTIVES

In the United States mortality rates for patients treated with dialysis differ by racial and/or ethnic (racial/ethnic) group. Mortality outcomes for patients undergoing maintenance dialysis in the United States territories may differ from patients in the United States 50 states.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study of using US Renal Data System data included 1,547,438 adults with no prior transplantation and first dialysis treatment between April 1, 1995 and September 28, 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of death for the territories versus 50 states for each racial/ethnic group using the whole cohort and covariate-matched samples. Covariates included demographics, year of dialysis initiation, cause of kidney failure, comorbid conditions, dialysis modality, and many others.

RESULTS

Of 22,828 patients treated in the territories (American Samoa, Guam, Puerto Rico, Virgin Islands), 321 were white, 666 were black, 20,299 were Hispanic, and 1542 were Asian. Of 1,524,610 patients in the 50 states, 838,736 were white, 444,066 were black, 182,994 were Hispanic, and 58,814 were Asian. The crude mortality rate (deaths per 100 patient-years) was lower for whites in the territories than the 50 states (14 and 29, respectively), similar for blacks (18 and 17, respectively), higher for Hispanics (27 and 16, respectively), and higher for Asians (22 and 15). In matched analyses, greater risks of death remained for Hispanics (HR, 1.65; 95% confidence interval, 1.60 to 1.70; P<0.001) and Asians (HR, 2.01; 95% confidence interval, 1.78 to 2.27; P<0.001) living in the territories versus their matched 50 states counterparts. There were no significant differences in mortality among white or black patients in the territories versus the 50 states.

CONCLUSIONS

Mortality rates for patients undergoing dialysis in the United States territories differ substantially by race/ethnicity compared with the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for whites or blacks, but remained much greater for territory-dwelling Hispanics and Asians.

Old age is a positive modifier of renal outcome in Taiwanese patients with stages 3-5 chronic kidney disease

BACKGROUND

The incidence of end-stage renal disease (ESRD) is increasing in elderly patients with chronic kidney disease (CKD). This contradicts the general notion that elderly people are more likely to die than to ever reach ESRD. And racial disparity in relation to age on kidney disease outcomes has always been a subject of research interest.

AIMS

We investigated the effect of age on outcome in a cohort with stages 3-5 CKD patients by age category.

METHODS

A total of 430 patients with a mean age of 65.6 years were enrolled and followed till death, ESRD, or end of 2015. Multivariable Cox regression was used to identify predictors of all-cause mortality. Competing risk-adjusted Cox regression was used to identify determinants of ESRD. The median follow-up was 7.3 (interquartile range 8.8) years.

RESULTS

Cox regression showed old age and low mean arterial pressure were predictors of mortality before and after onset of ESRD. Competing risk analysis revealed patients aged 20-39 years and 40-64 years exhibited greater risks of ESRD, compared to those aged over 75 years. These effects of age on outcomes occurred independently of traditional risk factors such as low estimated glomerular filtration rate and high proteinuria.

CONCLUSIONS

Age over 75 years is associated with decreased risk for ESRD even after adjustment for competing mortality. Given the global trends in population aging, there is a need to develop age-specific strategies, on top of the existing stage-based measures, to optimize the management of CKD in the elderly.

Inequalities and outcomes: end stage kidney disease in ethnic minorities

Background

The international evidence about outcomes of End Stage Kidney Disease (ESKD) for ethnic minorities was reviewed to identify gaps and make recommendations for researchers and policy makers.

Methods

Nine databases were searched systematically with 112 studies from 14 different countries included and analysed to produce a thematic map of the literature.

Results

Reviews (n = 26) highlighted different mortality rates and specific causes between ethnic groups and by stage of kidney disease associated with individual, genetic, social and environmental factors. Primary studies focussing on uptake of treatment modalities (n = 19) found ethnic differences in access. Research evaluating intermediate outcomes and quality of care in different treatment phases (n = 35) e.g. dialysis adequacy, transplant evaluation and immunosuppression showed ethnic minorities were disadvantaged. This is despite a survival paradox for some ethnic minorities on dialysis seen in studies of longer term outcomes (n = 29) e.g. in survival time post-transplant and mortality. There were few studies which focussed on end of life care (n = 3) and ethnicity.

Gaps identified were: limited evidence from all stages of the ESKD pathway, particularly end of life care; a lack of system oriented studies with a reliance on national routine datasets which are limited in scope; a dearth of qualitative studies; and a lack studies from many countries with limited cross country comparison and learning.

Conclusions

Differences between ethnic groups occur at various points and in a variety of outcomes throughout the kidney care system. The combination of individual factors and system related variables affect ethnic groups differently indicating a need for culturally intelligent policy informed by research to prevent disadvantage.

Racial Differences in Home Dialysis Utilization and Outcomes in Canada

BACKGROUND AND OBJECTIVES

Data on racial disparities in home dialysis utilization and outcomes are lacking in Canada, where health care is universally available.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We studied patients starting maintenance dialysis between 1996 and 2012 in the Canadian Organ Replacement Register, stratified by race: white, Asian, black, Aboriginal, Indian subcontinent, and other. The association between race and treatment with home dialysis was examined using generalized linear models. Secondary outcomes assessed racial differences in all-cause mortality and technique failure using a Fine and Gray competing risk model.

RESULTS

66,600 patients initiated chronic dialysis between 1996 and 2012. Compared with whites (n=46,092), treatment with home dialysis was lower among Aboriginals (n=3866; adjusted relative risk, RR, 0.71; 95% confidence interval, CI, 0.66 to 0.76) and higher in Asians (n=4157; adjusted RR, 1.28; 95% CI, 1.22 to 1.35) and others (n=2170; adjusted RR, 1.12; 95% CI, 1.04 to 1.20) but similar in blacks (n=2143) and subcontinent Indians (n=2809). Black (adjusted hazard ratio, HR, 1.31; 95% CI, 1.16 to 1.48) and Aboriginal (adjusted HR, 1.19; 95% CI, 1.06 to 1.33) patients treated with peritoneal dialysis had a significantly higher adjusted risk of technique failure compared with whites, whereas Asians had a lower risk (adjusted HR, 0.89; 95% CI, 0.82 to 0.99). In patients on peritoneal dialysis, the risk of death was significantly lower in Asians (adjusted HR, 0.83; 95% CI, 0.75 to 0.92), blacks (adjusted HR, 0.71; 95% CI, 0.59 to 0.85), and others (adjusted HR, 0.79; 95% CI, 0.68 to 0.92) but higher in Aboriginals (adjusted HR, 1.16; 95% CI, 1.02 to 1.32) compared with whites. Among patients on home hemodialysis, no significant racial differences in patient and technique survival were observed, which may be limited by the low number of events among each subgroups.

CONCLUSIONS

With the exception of Aboriginals, all racial minority groups in Canada were as likely to be treated with home dialysis compared with whites. However, significant racial differences exist in outcomes.

Association Between Overweight and Renal Transplant Outcomes: A Meta-Analysis

OBJECTIVES

As the demand for kidney transplant allografts has increased, many centers are expanding the upper limit of acceptable body mass index for kidney donors. However, obesity is a risk factor for developing renal disease. Our goal was to quantify body mass index trends in donor nephrectomy patients and to institute nutrition counseling to promote sustainable weight loss to reduce the risk of metabolic syndrome-derived renal dysfunction.

MATERIALS AND METHODS

Ninety patients who underwent donor nephrectomy between 2007 and 2012 consented to having height and weight data collected at multiple time points. After data collection, each patient underwent a standardized nutrition counseling session. One year later, body mass index was reassessed.

RESULTS

Preoperatively, 52% of the patients were overweight or obese. The percentage of overweight and obese patients remained stable for 2 years after surgery. However, at 3, 4, and 5 years after surgery, these rates increased to 59%, 69%, and 91%. Each patient was counseled about obesity-related comorbidities and provided information about lifestyle modification. One year later, 94% of previously overweight patients and 82% of previously obese patients had a decrease in mean body mass index from 27.2 ± 4.0 kg/m2 to 25.1 ± 3.6 kg/m2.

CONCLUSIONS

Living-donor nephrectomy patients are at risk of developing obesity, similar to the adult population. Nutrition counseling may be beneficial to help normalize body mass index in patients who have become overweight or obese to potentially prevent obesity-related comorbidities. All patients were evaluated by a nutrition specialist after surgery to review our donor nephrectomy nutrition brochure. Body mass index monitoring and primary care follow-up appear to be appropriate surveillance methods.

Insights from Screening a Racially and Ethnically Diverse Population for Chronic Kidney Disease

BACKGROUND

The value of chronic kidney disease (CKD) screening in the general population remains unclear but may be beneficial in populations with high disease prevalence. We examined risk factors for albuminuria among participants in a state-wide CKD screening program in Hawaii.

METHODS

The National Kidney Foundation of Hawaii Kidney Early Detection Screening (NKFH-KEDS) program held 19 CKD screening events from 2006 to 2012. Participants rotated through 5 stations during which sociodemographic, blood glucose, urine albumin-to-creatinine ratio (ACR), and spot urine albumin data were collected. Multivariate logistic regression analyses (adjusted for age, sex, race/ethnicity, body mass index [BMI]) were used to identify clinical predictors of abnormal ACR (≥30 μg/mg) and abnormal spot urine albumin (>20 mg/L) levels.

RESULTS

Among 1,190 NKFH-KEDS participants who met eligibility criteria, 13 and 49% had abnormal ACR and urine albumin levels, respectively. In multivariate logistic regression analyses, participants of older age (>65 years), Asian and Pacific Islander race/ethnicity, BMI ≥30 kg/m2, and with hypertension had higher risk of abnormal ACR. Being of older age; Asian, Pacific Islander, and Mixed race/ethnicity; and having diabetes was associated with higher risk of abnormal urine albumin levels in adjusted analyses.

CONCLUSIONS

NKFH-KEDS participants of older age; Asian and Pacific Islander race/ethnicity; and with obesity, hypertension, and diabetes had higher risk of kidney damage defined by elevated ACR and urine albumin levels. Further studies are needed to determine whether targeted screening programs can result in timely identification of CKD and implementation of interventions that reduce cardiovascular disease, death, and progression to end-stage renal disease.

Impact of weaning from acute dialytic therapy on outcomes of chronic kidney disease following urgent-start dialysis

Discontinuation of acute, unplanned dialysis is always an important therapeutic goal in dialysis-requiring patients with existing chronic kidney disease. Only a limited proportion of patients could be weaned off dialysis and remained dialysis-free. Here we performed a multicenter, observational study to investigate factors associated with successful weaning from acute dialysis, and to explore the potential impact of weaning itself on outcomes of patients with chronic kidney disease following urgent-start dialysis. We recruited 440 chronic kidney disease patients with a baseline estimated glomerular filtration rate <45 ml/min per 1/73 m2, and used propensity score-adjusted Cox regression analysis to measure the effect of weaning from acute dialysis on death during the index hospitalization and death or readmission after discharge. Over 2 years, 64 of 421 (15.2%) patients who survived >1 month died, and 36 (8.6%) were removed from dialysis, with 26 (6.2%) remaining alive and dialysis-free. Logistic regression analysis found that age ≧ 65 years, ischemic acute tubular necrosis, nephrotoxic exposure, urinary obstruction, and higher predialysis estimated glomerular filtration rate and serum hemoglobin were predictors of weaning off dialysis. After adjustment for propensity scores for dialysis weaning, Cox proportional hazards models showed successful weaning from dialysis (adjusted hazard ratio 0.06; 95% confidence interval 0.01 to 0.35), along with a history of hypertension and serum albumin, were independent protectors for early death. Conversely, a history of stroke, peripheral arterial disease and cancer predicted the occurrence of early mortality. In conclusion, this prospective cohort study shows that compared to patients with chronic kidney disease who became end-stage renal disease after acute dialysis, patients who could be weaned off acute dialytic therapy were associated with reduced risk of premature death over a 2-year observation period.

Characteristics and performance of minority-serving dialysis facilities

OBJECTIVE

To examine the structure, processes, and outcomes of American dialysis facilities that predominantly treat racial-ethnic minority patients.

DATA SOURCES/STUDY SETTING

Secondary analysis of data from all patients who initiated dialysis during 2005-2008 in the United States.

STUDY DESIGN

In this retrospective cohort study, we examined the associations of the racial-ethnic composition of the dialysis facility with facility-level survival and achievement of performance targets for anemia and dialysis adequacy.

DATA COLLECTION/EXTRACTION METHODS

We obtained dialysis facility- and patient-level data from the national data registry of patients with end-stage renal disease. We linked these data with clinical performance measures from the Centers for Medicare and Medicaid Services.

PRINCIPAL FINDINGS

Overall, minority-serving facilities were markedly larger, more often community based, and less likely to offer home dialysis than facilities serving predominantly white patients. A significantly higher proportion of minority-serving dialysis facilities exhibited worse than expected survival as compared with facilities serving predominantly white patients (p < .001 for each). However, clinical performance measures for anemia and dialysis adequacy were similar across minority-serving status.

CONCLUSIONS

While minority-serving facilities generally met dialysis performance targets mandated by Medicare, they exhibited worse than expected patient survival.

Differences in access to kidney transplantation between Hispanic and non-Hispanic whites by geographic location in the United States

BACKGROUND AND OBJECTIVES

Hispanic patients undergoing chronic dialysis are less likely to receive a kidney transplant compared with non-Hispanic whites. This study sought to elucidate disparities in the path to receipt of a deceased donor transplant between Hispanic and non-Hispanic whites.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the US Renal Data System, 417,801 Caucasians who initiated dialysis between January 1, 1995 and December 31, 2007 with follow-up through 2008 were identified. This study investigated time from first dialysis to first kidney transplantation, time from first dialysis to waitlisting, and time from waitlisting to kidney transplantation. Multivariable Cox regression estimated cause-specific hazard ratios (HRCS) and subdistribution (competing risk) hazard ratios (HRSD) for Hispanics versus non-Hispanic whites.

RESULTS

Hispanics experienced lower adjusted rates of deceased donor kidney transplantation than non-Hispanic whites (HRCS, 0.77; 95% confidence interval [95% CI], 0.75 to 0.80) measured from dialysis initiation. No meaningful differences were found in time from dialysis initiation to placement on the transplant waitlist. Once waitlisted, Hispanics had lower adjusted rates of deceased donor kidney transplantation (HRCS, 0.66; 95% CI, 0.64 to 0.68), and the association attenuated once accounting for competing risks (HRSD, 0.79; 95% CI, 0.77 to 0.81). Additionally controlling for blood type and organ procurement organization further reduced the disparity (HRSD, 0.99; 95% CI, 0.96 to 1.02).

CONCLUSIONS

After accounting for geographic location and controlling for competing risks (e.g., Hispanic survival advantage), the disparity in access to deceased donor transplantation was markedly attenuated among Hispanics compared with non-Hispanic whites. To overcome the geographic disparities that Hispanics encounter in the path to transplantation, organ allocation policy revisions are needed to improve donor organ equity.

Geographic information systems and chronic kidney disease: racial disparities, rural residence and forecasting

The dynamics of health and health care provision in the United States vary substantially across regions, and there is substantial regional heterogeneity in population density, age distribution, disease prevalence, race and ethnicity, poverty and the ability to access care. Geocoding and geographic information systems (GIS) are important tools to link patient or population location to information regarding these characteristics. In this review, we provide an overview of basic GIS concepts and provide examples to illustrate how GIS techniques have been applied to the study of kidney disease, and in particular to understanding the interplay between race, poverty, rural residence and the planning of renal services for this population. The interplay of socioeconomic status and renal disease outcomes remains an important area for investigation and recent publications have explored this relationship utilizing GIS techniques to incorporate measures of socioeconomic status and racial composition of neighborhoods. In addition, there are many potential challenges in providing care to rural patients with chronic kidney disease including long travel times and sparse renal services such as transplant and dialysis centers. Geospatially fluent analytic approaches can also inform system level analyses of health care systems and these approaches can be applied to identify an optimal distribution of dialysis facilities. GIS analysis could help untangle the complex interplay between geography, socioeconomic status, and racial disparities in chronic kidney disease, and could inform policy decisions and resource allocation as the population ages and the prevalence of renal disease increases.

Racial differences in determinants of live donor kidney transplantation in the United States

Few studies have compared determinants of live donor kidney transplantation (LDKT) across all major US racial-ethnic groups. We compared determinants of racial-ethnic differences in LDKT among 208 736 patients who initiated treatment for end-stage kidney disease during 2005-2008. We performed proportional hazards and bootstrap analyses to estimate differences in LDKT attributable to sociodemographic and clinical factors. Mean LDKT rates were lowest among blacks (1.19 per 100 person-years [95% CI: 1.12-1.26]), American Indians/Alaska Natives-AI/ANs (1.40 [1.06-1.84]) and Pacific Islanders (1.10 [0.78-1.84]), intermediate among Hispanics (2.53 [2.39-2.67]) and Asians (3.89 [3.51-4.32]), and highest among whites (6.46 [6.31-6.61]). Compared with whites, the largest proportion of the disparity among blacks (20%) and AI/ANs (29%) was attributed to measures of predialysis care, while the largest proportion among Hispanics (14%) was attributed to health insurance coverage. Contextual poverty accounted for 16%, 4%, 18%, and 6% of the disparity among blacks, Hispanics, AI/ANs and Pacific Islanders but none of the disparity among Asians. In the United States, significant disparities in rates of LDKT persist, but determinants of these disparities vary by race-ethnicity. Efforts to expand preESKD insurance coverage, to improve access to high-quality predialysis care and to overcome socioeconomic barriers are important targets for addressing disparities in LDKT.

Trends in relative mortality between Hispanic and non-Hispanic whites initiating dialysis: a retrospective study of the US Renal Data System

BACKGROUND

Hispanic patients undergoing long-term dialysis experience better survival compared with non-Hispanic whites. It is unknown whether this association differs by age, has changed over time, or is due to differential access to kidney transplantation.

STUDY DESIGN

National retrospective cohort study.

SETTING & PARTICIPANTS

Using the US Renal Data System, we identified 615,618 white patients 18 years or older who initiated dialysis therapy between January 1, 1995, and December 31, 2007.

PREDICTORS

Hispanic ethnicity (vs non-Hispanic whites), year of end-stage renal disease incidence, age (as potential effect modifier).

OUTCOMES

All-cause and cause-specific mortality.

RESULTS

We found that Hispanics initiating dialysis therapy experienced lower mortality, but age modified this association (P < 0.001). Compared with non-Hispanic whites, mortality in Hispanics was 33% lower at ages 18-39 years (adjusted cause-specific HR [HRcs], 0.67; 95% CI, 0.64-0.71) and 40-59 years (HRcs, 0.67; 95% CI, 0.66-0.68), 19% lower at ages 60-79 years (HRcs, 0.81; 95% CI, 0.80-0.82), and 6% lower at 80 years or older (HRcs, 0.94; 95% CI, 0.91-0.97). Accounting for the differential rates of kidney transplantation, the associations were attenuated markedly in the younger age strata; the survival benefit for Hispanics was reduced from 33% to 10% at ages 18-39 years (adjusted subdistribution-specific HR [HRsd], 0.90; 95% CI, 0.85-0.94) and from 33% to 19% among those aged 40-59 years (HRsd, 0.81; 95% CI, 0.80-0.83).

LIMITATIONS

Inability to analyze Hispanic subgroups that may experience heterogeneous mortality outcomes.

CONCLUSIONS

Overall, Hispanics experienced lower mortality, but differential access to kidney transplantation was responsible for much of the apparent survival benefit noted in younger Hispanics.

Advanced kidney failure and hyperuricemia

Metabolic end products accumulate in kidney failure, including uric acid (UA), a terminal product of purine catabolism. Hyperuricemia (HUA) can cause gout and has been increasingly linked with cardiovascular (CV) morbidity and mortality, outcomes that are highly prevalent in patients with kidney disease. Serum UA levels rise as glomerular filtration declines, whereas the frequency of gouty attacks declines and the incidence of CV death rises precipitously. Herein, we review the kinetics of UA metabolism in CKD and dialysis and discuss the possible mechanisms of gout mitigation in kidney failure and the potential contribution of hyperuricemic milieu to CV outcomes in patients with kidney disease.

Review of ethnic disparities in access to renal transplantation

Renal transplantation is the gold standard treatment for patients with end-stage renal disease and is associated with several advantages over dialysis, including increased quality of life, reduced morbidity and mortality, and lower healthcare costs. Barring the constraints of a limited organ supply, the goals of the patient care should focus on attaining renal transplantation while minimizing, or even eliminating, time spent on dialysis. Disparities in access to renal transplantation between African Americans and Caucasians have been extensively documented, with African Americans having significantly poorer access. There is a growing corpus of literature examining the determinants of reduced access among other racial ethnic minority groups, including Hispanics. These determinants include patient and physician preference, socioeconomic status, insurance type, patient education, and immunologic factors. We review these determinants in access to renal transplantation in the United States among all races and ethnicities.

Understanding and overcoming barriers to living kidney donation among racial and ethnic minorities in the United States

In the United States, racial-ethnic minorities experience disproportionately high rates of ESRD, but they are substantially less likely to receive living donor kidney transplants (LDKT) compared with their majority counterparts. Minorities may encounter barriers to LDKT at several steps along the path to receiving it, including consideration, pursuit, completion of LDKT, and the post-LDKT experience. These barriers operate at different levels related to potential recipients and donors, health care providers, health system structures, and communities. In this review, we present a conceptual framework describing various barriers that minorities face along the path to receiving LDKT. We also highlight promising recent and current initiatives to address these barriers, as well as gaps in initiatives, which may guide future interventions to reduce racial-ethnic disparities in LDKT.

Understanding Racial Differences in Deceased-Donor Kidney Transplantation: Geography, Poverty, Language, and Health Insurance Coverage

Despite the continued growth of diverse populations on dialysis, no prior studies have comprehensively compared the barriers to kidney transplantation among different racial and ethnic groups. This brief review summarizes key findings from a recent study that examined specific determinants of diminished access to, or delayed completion of, deceased-donor kidney transplantation among major racial-ethnic groups in the United States. In particular, we focus on the relative influence on transplantation rates of clinical factors, such as histocompatibility, residential geography, health insurance coverage, poverty, and other socioeconomic factors according to patient race or ethnicity.

Outcomes following dialysis for acute kidney injury among different stages of chronic kidney disease

BACKGROUND

Information is limited regarding the outcomes of patients with preexisting chronic kidney disease (CKD) who develop dialysis-requiring acute kidney injury.

METHODS

131 adult patients with advanced CKD who received emergent hemodialysis from January to June in 2002 were recruited and monitored for all-cause mortality and end-stage renal disease until the end of 2007.

RESULTS

Among patients investigated, 21 (16%) were successfully withdrawn from acute hemodialysis after an average of 8 sessions of dialysis therapy (range: 1-44). Multivariate analysis revealed that larger kidney size (odds ratio, OR = 1.755, p = 0.018), lower predialysis creatinine (OR = 0.722, p = 0.002), and non-diabetes (OR = 0.271, p = 0.037) were predictors for withdrawal. After 5 years, all patients in the non-withdrawal group remained on chronic dialysis, whereas only 8/21 (38%) patients in the withdrawal group developed end-stage renal disease. Cox's analysis showed that age (hazard ratio, HR = 1.043, p < 0.0001), prerenal azotemia (HR = 1.040, p = 0.002), and adjusted propensity score for assigning to dialysis withdrawal (HR = 6.819, p = 0.008) were associated with mortality. Withdrawal from acute dialysis was not related to long-term mortality (p = 0.34).

CONCLUSIONS

Among the advanced CKD patients, predictors of the successful weaning from acute dialysis were non-diabetes, larger kidney size and lower serum creatinine levels. The strategy of removal from emergent dialysis was not related to long-term mortality.

Racial ethnic differences in rates and determinants of deceased donor kidney transplantation

Contemporary studies have not comprehensively compared waiting times and determinants of deceased donor kidney transplantation across all major racial ethnic groups in the Unites States. Here, we compared relative rates and determinants of waitlisting and deceased donor kidney transplantation among 503,090 nonelderly adults of different racial ethnic groups who initiated hemodialysis between1995 and 2006 with follow-up through 2008. Annual rates of deceased donor transplantation from the time of dialysis initiation were lowest in American Indians/Alaska Natives (2.4%) and blacks (2.8%), intermediate in Pacific Islanders (3.1%) and Hispanics (3.2%), and highest in whites (5.9%) and Asians (6.4%). Lower rates of deceased donor transplantation among most racial ethnic minority groups appeared primarily to reflect differences in time from waitlisting to transplantation, but this was not the result of higher rates of waitlist inactivity or removal from the waitlist. The fraction of the reduced transplant rates attributable to measured factors (e.g., demographic, clinical, socioeconomic, linguistic, and geographic factors) varied from 14% in blacks to 43% in American Indians/Alaska Natives compared with whites. In conclusion, adjusted rates of deceased donor kidney transplantation remain significantly lower among racial ethnic minorities compared with whites; generally, differences in time to waitlisting were not as pronounced as differences in time between waitlisting and transplantation. Determinants of delays in time to transplantation differed substantially by racial ethnic group. Area-based efforts targeted to address racial- and ethnic-specific delays in transplantation may help to reduce overall disparities in deceased donor kidney transplantation in the United States.

How do communities want their information? Designing educational outreach on organ donation for Asian Americans

CONTEXT

Support of organ donation among Asian Americans has been limited, but lack of access to information and prevalence of misinformation are 2 barriers that might be counteracted by public education.

OBJECTIVE

To solicit advice from 4 Asian American communities on the design of a culturally appropriate educational campaign on organ donation and transplantation.

DESIGN AND SETTING

Cross-sectional, multilingual survey administered at community festivals and supermarkets.

PARTICIPANTS

201 Asian American respondents.

MAIN OUTCOME MEASURES

The components of an effective public education outreach campaign on organ donation were defined for 4 Asian American communities.

RESULTS

Media venues ranked highest for information dissemination on organ donation/transplantation were, in descending order, mainstream television, ethnic newspapers, mainstream newspapers, and ethnic television. Most respondents preferred a spokesperson of Asian American descent, but opinions differed by ethnicity as to whether an effective spokesperson needed to be of the same Asian ethnicity as the respondents. Respondents were further divided by ethnicity on their preference for a locally or nationally well-known spokesperson. The most compelling scenario to promote organ donation was an Asian American waiting for a transplant, followed by an organ donor family or individual, and, last, a transplant recipient. Different advertisements for organ donation appealed to different Asian ethnic groups.

CONCLUSIONS

Community-based research gives communities the opportunity to collaborate with health professionals in designing health education programs that target their own populations. Because key aspects influencing campaign efficacy can vary by ethnicity, these important differences need to be taken into account in outreach planning.

An Overview of Transplantation in Culturally Diverse Regions

Transplantation is one of the most progressive areas of medicine. Following its rapid development, organ transplantation has become part of the globalisation process, and is now available in all corners of the world in different social and cultural environments. Almost a decade into a new century, transplantation faces new challenges, with record numbers of patients on the waiting list, a scarcity of donor organs, inequity in access to transplantation, organ commercialisation, increasing living donation and the use of marginal donors. Probably more than in any other field of medicine, the cultural influences are very prominent in transplantation due to the complexity of the process and the ethical issues surrounding every step from donation, access to transplantation to outcome. These influences have led to different practical approaches around the world, which aim to be in agreement with the respective societal principles and moral values. Herein, we provide an overview of some of these challenges and their possible resolution in culturally diverse areas of the world. Key words: Access to transplantation, Living donor, Organ donation, Religion, Transplant laws, Transplant tourism

How Do Communities Want Their Information? Designing Educational Outreach on Organ Donation for Asian Americans

Context

Support of organ donation among Asian Americans has been limited, but lack of access to information and prevalence of misinformation are 2 barriers that might be counteracted by public education.

Objective

To solicit advice from 4 Asian American communities on the design of a culturally appropriate educational campaign on organ donation and transplantation.

Design and Setting

Cross-sectional, multilingual survey administered at community festivals and supermarkets.

Participants

201 Asian American respondents.

Main Outcome Measures

The components of an effective public education outreach campaign on organ donation were defined for 4 Asian American communities.

Results

Media venues ranked highest for information dissemination on organ donation/transplantation were, in descending order, mainstream television, ethnic newspapers, mainstream newspapers, and ethnic television. Most respondents preferred a spokesperson of Asian American descent, but opinions differed by ethnicity as to whether an effective spokesperson needed to be of the same Asian ethnicity as the respondents. Respondents were further divided by ethnicity on their preference for a locally or nationally well-known spokesperson. The most compelling scenario to promote organ donation was an Asian American waiting for a transplant, followed by an organ donor family or individual, and, last, a transplant recipient. Different advertisements for organ donation appealed to different Asian ethnic groups.

Conclusions

Community-based research gives communities the opportunity to collaborate with health professionals in designing health education programs that target their own populations. Because key aspects influencing campaign efficacy can vary by ethnicity, these important differences need to be taken into account in outreach planning.

Neighborhood poverty and kidney transplantation among US Asians and Pacific Islanders with end-stage renal disease

The degree to which low transplant rates among Asians and Pacific Islanders in the United States are confounded by poverty and reduced access to care is unknown. We examined the relationship between neighborhood poverty and kidney transplant rates among 22 152 patients initiating dialysis during 1995-2003 within 1800 ZIP codes in California, Hawaii and the US-Pacific Islands. Asians and whites on dialysis were distributed across the spectrum of poverty, while Pacific Islanders were clustered in the poorest areas. Overall, worsening neighborhood poverty was associated with lower relative rates of transplant (adjusted HR [95% CI] for areas with > or =20% vs. <5% residents living in poverty, 0.41 [0.32-0.53], p < 0.001). At every level of poverty, Asians and Pacific Islanders experienced lower transplant rates compared with whites. The degree of disparity increased with worsening neighborhood poverty (adjusted HR [95% CI] for Asians-Pacific Islanders vs. whites, 0.64 [0.51-0.80], p < 0.001 for areas with <5% and 0.30 [0.21-0.44], p < 0.001 for areas with > or =20% residents living in poverty; race-poverty level interaction, p = 0.039). High levels of neighborhood poverty are associated with lower transplant rates among Asians and Pacific Islanders compared with whites. Our findings call for studies to identify cultural and local barriers to transplant among Asians and Pacific Islanders, particularly those residing in resource-poor neighborhoods.

Increased survival of immigrant compared to native dialysis patients in an urban setting in the Netherlands

BACKGROUND

Data from the United States and Canada suggest that survival rates of Caucasian dialysis patients are lower compared to those of black patients and patients from Asian regions. Information regarding the survival rate of immigrant dialysis patients in Europe is scarce.

METHODS

We retrospectively analysed incident haemodialysis (HD) and peritoneal dialysis (PD) patients who entered an Amsterdam renal service between January 1996 and December 2005. To explore the origin of differences in survival between natives and immigrants, we ran a series of Cox models with adjustment for demographic, clinical and laboratory variables at baseline and initial adequacy variables.

RESULTS

Of 303 incident dialysis patients, 58% were natives and 42% were immigrants. Fifty-nine percent of natives and 54% of immigrants had HD as initial treatment modality. At initiation of dialysis, native patients were older and had higher rates of vascular and coronary artery diseases and malignancies and a lower prevalence of hypertension. Glomerulonephritis was more common among immigrants as primary kidney disease. Mean haematocrit and calcium levels for natives were higher compared to immigrants. Cox proportional hazards analysis revealed an increased relative mortality risk (RR) of 2.7 [95% confidence interval (CI) 1.9-3.9] for natives compared to immigrants. Adjustment for age at the start of dialysis attenuated the RR to 1.9 (CI 1.3-2.7). Adjustment for the other variables did not materially influence this RR.

CONCLUSIONS

We demonstrate increased survival for immigrant compared to native dialysis patients in an urban setting in the Netherlands. This survival advantage is only partly explained by younger age of immigrants at the start of dialysis compared to native patients.

Racial and survival paradoxes in chronic kidney disease

Most of the 20 million people in the US with chronic kidney disease (CKD) die before commencing dialysis. One of every five dialysis patients dies each year in the US. Although cardiovascular disease is the most common cause of death among patients with CKD, conventional cardiovascular risk factors such as hypercholesterolemia, hypertension and obesity are paradoxically associated with better survival in hemodialysis populations. Emerging data indicate the existence of this 'reverse epidemiology' in earlier stages of CKD. There are also paradoxical relationships between outcomes and race and ethnicity. For example, the survival rate of African American dialysis patients seems to be superior to that of whites on dialysis. Paradoxes-within-paradoxes have been detected among Hispanic and Asian American CKD patients. These survival paradoxes might evolve and change over the natural course of CKD progression as a result of the time differentials of competing risk factors and the overwhelming impact of malnutrition, inflammation and wasting. Reversal of the reverse epidemiology as a result of successful kidney transplantation underscores the role of nutritional status and kidney function in engendering these paradoxes. The observation of paradoxes and their reversal might lead to the formulation of new paradigms and management strategies to improve the survival of patients with CKD. Such movement away from the use of targets set on the basis of data gathered in general populations (e.g. the Framingham cohort) would be a major paradigm shift in clinical medicine and public health.

Epidemiologic and clinical factors associated with chronic kidney disease among Asian Americans and Native Hawaiians

OBJECTIVE

To examine the association between key susceptibility factors and measures of chronic kidney disease in Asian American and Native Hawaiian participants enrolled in the Hawai'i site of the national Kidney Early Evaluation Program (KEEP-2) study community screening program.

DESIGN

In 2001-2003, 793 participants from five ethnic groups (Japanese, Native Hawaii an, Chinese, Filipino and Caucasian) were enrolled in the Hawai'i KEEP-2 program. Odds ratios were used as the measure of association and were computed using unconditional logistic regression. Renal susceptibility factors for chronic kidney disease were included in a multivariable model if found to be statistically significant in univariate analysis. The proportion of Hawai'i KEEP-2 study participants manifesting various clinical characteristics were compared by ethnicity with Japanese as the referent group.

RESULTS

Significant ethnic differences in the occurrence of chronic kidney disease were found, with Japanese having the lowest occurrence of chronic kidney disease (18%) and Native Hawaiians the highest (40%). Within each ethnic group, the occurrence of chronic kidney disease was associated with a different ethnic-specific clustering of susceptibility factors. Hypertension was associated with chronic kidney disease among four of the five ethnic groups: Japanese, Caucasian, Native Hawaiian and Filipino. Overweight was associated with a decreased occurrence of chronic kidney disease among Caucasians, while diabetes and lower educational attainment were associated with increased occurrence of chronic kidney disease among Native Hawaiians. For Filipinos, diabetes and age 65 years and older were both associated with an increased occurrence for chronic kidney disease while lower educational attainment was associated with a reduced occurrence of chronic kidney disease. Among Chinese, no factors were significantly associated with chronic kidney disease, although trends for all factors paralleled those of the overall study group.

CONCLUSIONS

The occurrence of chronic kidney disease in the Hawai'i KEEP-2 study was nearly fourfold greater compared with the general US population. The clustering of susceptibility factors for chronic kidney disease occurrence was found to differ for all five ethnic groups.

Differences in Use of Peritoneal Dialysis and Survival Among East Asian, Indo Asian, and White ESRD Patients in Canada

BACKGROUND

Racial differences in health outcomes in general are well documented; however, few studies examined the impact of East Asian and Indo Asian race on choice of dialytic modality and survival among patients with end-stage renal disease (ESRD).

METHODS

We compared the use of peritoneal dialysis (PD) and survival among East Asian, Indo Asian, and white patients with ESRD initiating dialysis therapy in Canada between January 1, 1990, and December 31, 2000.

RESULTS

Of 10,338 patients, 5.7% were East Asian, 3.2% were Indo Asian, and 91% were white. After controlling for sociodemographics and comorbidities, East Asian and Indo Asian patients were significantly more likely to initiate dialysis therapy on PD compared with white patients (odds ratio, 1.63; 95% confidence interval [CI], 1.36 to 1.96; odds ratio, 1.52; 95% CI, 1.21 to 1.93, respectively), with no difference in likelihood of technique failure. East Asian and Indo Asian patients had a lower risk for death after the initiation of dialysis therapy (irrespective of modality) compared with white patients, with adjusted hazard ratios of 0.66 (95% CI, 0.58 to 0.76) for East Asian patients and 0.63 (95% CI, 0.53 to 0.75) for Indo Asian patients. The survival benefit for East Asian and Indo Asian patients was similar in the subgroup that initiated dialysis therapy with PD.

CONCLUSION

We found that Asian patients with ESRD were more likely to initiate dialysis therapy using PD, with improved survival after the initiation of dialysis therapy, compared with white patients. Elucidation of factors in East Asian and Indo Asian ESRD populations that result in improved outcomes may have implications for ESRD treatment for other racial groups.

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.

New insights into the epidemiology of chronic kidney disease in US Asians and Pacific Islanders

PURPOSE OF REVIEW

In contrast to advances in our understanding of health disparities in other ethnic groups within the US, differential outcomes associated with chronic kidney disease among US Asians have gone largely unexamined. Until recently, risk estimates for chronic kidney disease outcomes among US Pacific Islanders were virtually unknown. This review highlights recent contributions to our understanding of chronic kidney disease outcomes in US Asians and Pacific Islanders.

RECENT FINDINGS

Asians in the US appear to have a higher risk of end-stage renal disease relative to US whites after accounting for baseline kidney disease and many of the known risk factors for end-stage renal disease. The origins of the discrepancy in risk for end-stage renal disease between US Asians and whites do not appear to be explained by the socioeconomic and comorbidity disparities paradigm present in the US black vs. white model. Mounting evidence suggests that US Asians and Pacific Islanders receive substantially less predialysis care and proportionally fewer kidney transplants compared with US whites. Paradoxically, these populations have equivalent or better survival on dialysis.

SUMMARY

These data highlight the need for studies to elucidate the mechanisms underlying the differential outcomes observed among US Asians and Pacific Islanders. Efforts to identify ethnicity-specific risk factors for kidney disease and interventions aimed at promoting predialysis care and kidney transplantation among US Asians and Pacific Islanders could substantially reduce morbidity, mortality, and costs.