Regional differences in dialysis care and mortality among American Indians and Alaska Natives

Adequacy of haemodialysis and associated factors among patients with end-stage kidney disease in Tanzania

Objectives

Adequate haemodialysis helps maintain normal renal function by removing toxins and other waste products in patients with end-stage kidney disease. This study was aimed at determining the prevalence and predictors of adequacy of haemodialysis and outcomes in patients with end-stage kidney disease.

Methods

This longitudinal analytical hospital-based study was conducted at two dialysis centres in Dodoma city, Tanzania, between February and July of 2020. Adequacy of haemodialysis was measured with single-pool (sp) Kt/V and urea reduction rate (URR) formulae. Binary logistic regression and multivariable analysis were used to assess the independent predictors of adequacy of haemodialysis.

Results

The analysis included 100 patients with a mean age of 50.6 ± 15.0 years. The prevalence of adequacy of haemodialysis according to URR and sp-Kt/V was 72 % and 75 %, respectively. Having <12 months since dialysis initiation (AOR = 7.3, 95 % CI = 0.11-0.90, p = 0.032), fewer than three dialysis sessions per week (AOR = 6.9, 95 % CI = 1.52-31.49, p = 0.013) and severe anaemia (AOR = 2.2, 95 % CI = 0.26-0.93, p = 0.033) were predictors of inadequate haemodialysis, according to the URR formula. Having fewer than three dialysis sessions per week was significantly associated with inadequate haemodialysis (AOR = 5.6, 95 % CI = 1.47-19.66, p = 0.011), according to the sp-Kt/V formula. The mortality rate was 11.2 %, and cardiovascular disease and uremic syndrome were responsible for most deaths.

Conclusion

This study indicated a high percentage of adequacy of haemodialysis among patients with end-stage kidney disease. Having fewer than three dialysis sessions per week, late initiation of dialysis after diagnosis of end-stage kidney disease and severe anaemia were predictors of inadequate haemodialysis among patients.

Uranium Exposure in American Indian Communities: Health, Policy, and the Way Forward

BACKGROUND

Uranium contamination of drinking-water sources on American Indian (AI) reservations in the United States is a largely ignored and underfunded public health crisis. With an estimated 40% of the headwaters in the western U.S. watershed, home to many AI reservation communities, being contaminated with untreated mine waste, the potential health effects have largely been unexplored. With AI populations already facing continued and progressive economic and social marginalization, higher prevalence of chronic disease, and systemic discrimination, associations between various toxicant exposures, including uranium, and various chronic conditions, need further examination.

OBJECTIVES

Uranium's health effects, in addition to considerations for uranium drinking-water testing, reporting, and mitigation in reference to AI communities through the lens of water quality, is reviewed.

DISCUSSION

A series of environmental health policy recommendations are described with the intent to proactively improve responsiveness to the water quality crisis in AI reservation communities in the United States specific to uranium. There is a serious and immediate need for better coordination of uranium-related drinking-water testing and reporting on reservations in the United States that will better support and guide best practices for uranium mitigation efforts. https://doi.org/10.1289/EHP7537.

The Role of Place in Disparities Affecting Black Men Receiving Hemodialysis

INTRODUCTION

Black men are over-represented in the end stage kidney disease population and are at disproportionate risk of unfavorable outcomes. There is a paucity of investigation to elucidate the mediators of this risk. This study attempts to identify residential community attributes as a possible contributor.

METHODS

A post-hoc analysis of prospectively collected data from a cohort of Black men enrolled in the US Dialysis Outcomes and Practice Patterns Study (DOPPS), 2010--2015, linked to the American Community Survey, by dialysis facility zip codes was undertaken. The exposure variable was the dialysis facility community composition as defined by percent Black residents. Negative binomial regression was used to estimate incidence rate ratio (IRR) of hospitalization (first outcome) for Black men in crude and adjusted models. Similarly, Cox proportional hazards modeling was used to estimate mortality (second outcome) for Black men by type of community.

RESULTS

A total of 702 Black men receiving chronic hemodialysis were included in the study. Black men receiving hemodialysis in communities with greater proportions of Black residents had lower Charlson scores and fewer comorbidities, but a higher rate of hypertension. They had equivalent adherence to dialysis treatments, but a lower rate of arteriovenous fistula use and fewer dialysis minutes prescribed. Black men receiving dialysis in communities with a greater proportion of Black residents (per 10% increase) had higher adjusted hospitalization rates (IRR 1.09, 95% confidence interval [CI] 1.00-1.19) and mortality (hazard ratio [HR] 1.29, 95% CI 1.05-1.59).

CONCLUSIONS

This study supports the unique role of residential community as a risk factor for Black men with end stage kidney disease, showing higher hospitalization and mortality in those treating in Black versus non-Black communities, despite equivalent adherence and fewer comorbidities.

Assessment of hemodialysis adequacy in patients with chronic kidney disease in the hemodialysis unit at Tanta University Hospital in Egypt

Worldwide, hemodialysis (HD) constitutes the most common form of renal replacement therapy. Many studies have shown strong correlation between HD dose and clinical outcome. The cross-sectional study was conducted on 100 patients in Hemodialysis Unit at Tanta University Hospital, Egypt. Data were collected using a reliable questionnaire (including clinical, demographic, dialysis, laboratory, and radiological data). SpKt/V was used to assess the adequacy of HD. The results revealed inadequate HD dose among 60% of the study population. The results also showed that increasing time and frequency of dialysis, blood flow rates, low recirculation percentages, reduction of intradialytic complaints, and well-functioning vascular access are associated with better HD adequacy. Our findings showed a positive correlation between dialysis dose and hemoglobin, serum albumin, normalized protein catabolic rate, and physical health. A great percentage of patients had inadequate HD. HD adequacy was influenced by several factors such as duration and frequency of dialysis session, patients' complaints, and well-functioning vascular access.

Relationships of clinic size, geographic region, and race/ethnicity to the frequency of missed/shortened dialysis treatments

BACKGROUND

Significant international differences abound in the adherence of hemodialysis (HD) patients to prescribed treatments. Unfortunately, factors influencing adherence within the United States (US) are not well understood. This study explores the hypothesis that race/ethnicity, geographic region and clinic size are associated with differences in the frequency of missed/shortened treatments.

METHODS

A retrospective analysis on all prevalent chronic HD patients treated at Dialysis Clinics Inc. facilities between January 2007 and June 2008. Logistic regression models were computed in which the outcome measures were the odds for missing or shortening treatments.

RESULTS

The cohort consisted of 15,340 HD patients of whom 48% were non-Hispanic whites (NHW), 41% African Americans (AA), 6% Hispanics, 2% Native Americans, 2% Asians, and 1% unknown. Patients were older in the Northeast than in the South (p < 0.001) or West (p = 0.0052). The frequency of missed and shortened treatments was lower in the Northeast than other regions, p < 0.0001. Hospitalization rates were lower in the West than the Northeast (p < 0.01) but mortality rates were similar across all regions. The odds ratio and 95% confidence interval for missed [1.31 (1.14-1.52)] and shortened treatments [1.86 (1.73-2.0)] were greater in clinics with >100 patients than in those with <50 patients. Compared to NHW, the frequencies of missed and shortened treatments were higher in AA, Hispanics and Native Americans (p < 0.001) but lower among Asians (p < 0.001).

CONCLUSION

The frequency of missed and shortened HD varies significantly by race/ethnicity, geographic region and clinic size. The relationship of clinic size to missed/shortened treatments may warrant consideration when planning new HD facilities.

Association of modality with mortality among Canadian Aboriginals

BACKGROUND AND OBJECTIVES

Previous studies have shown that Aboriginals and Caucasians experience similar outcome on dialysis in Canada. Using the Canadian Organ Replacement Registry, this study examined whether dialysis modality (peritoneal or hemodialysis) impacted mortality in Aboriginal patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study identified 31,576 adult patients (hemodialysis: Aboriginal=1839, Caucasian=21,430; peritoneal dialysis: Aboriginal=554, Caucasian=6769) who initiated dialysis between January of 2000 and December of 2009. Aboriginal status was identified by self-report. Dialysis modality was determined 90 days after dialysis initiation. Multivariate Cox proportional hazards and competing risk models were constructed to determine the association between race and mortality by dialysis modality.

RESULTS

During the study period, 939 (51.1%) Aboriginals and 12,798 (53.3%) Caucasians initiating hemodialysis died, whereas 166 (30.0%) and 2037 (30.1%), respectively, initiating peritoneal dialysis died. Compared with Caucasians, Aboriginals on hemodialysis had a comparable risk of mortality (adjusted hazards ratio=1.04, 95% confidence interval=0.96-1.11, P=0.37). However, on peritoneal dialysis, Aboriginals experienced a higher risk of mortality (adjusted hazards ratio=1.36, 95% confidence interval=1.13-1.62, P=0.001) and technique failure (adjusted hazards ratio=1.29, 95% confidence interval=1.03-1.60, P=0.03) than Caucasians. The risk of technique failure varied by patient age, with younger Aboriginals (<50 years old) more likely to develop technique failure than Caucasians (adjusted hazards ratio=1.76, 95% confidence interval=1.23-2.52, P=0.002).

CONCLUSIONS

Aboriginals on peritoneal dialysis experience higher mortality and technique failure relative to Caucasians. Reasons for this race disparity in peritoneal dialysis outcomes are unclear.