ESRD among Immigrants to Ontario, Canada: A Population-Based Study

Racialized and Immigrant Status and the Pursuit of Living Donor Kidney Transplant - a Canadian Cohort Study

Introduction

Both immigrant and racialized status may be associated with the pursuit of living donor kidney transplant (LDKT).

Methods

This study was a secondary analysis of a convenience cross-sectional sample of patients with kidney failure in Toronto, obtained from our "Comprehensive Psychosocial Research Data System" research database. The exposures included racialized, immigrant, and combined immigrant and racialized status (White nonimmigrant, racialized nonimmigrant, White immigrant and racialized immigrant). Outcomes include the following: (i) having spoken about LDKT with others, (ii) having a potential living donor (LD) identified, (iii) having allowed others to share the need for LDKT, (iv) having directly asked a potential donor to be tested, and (v) accept a hypothetical LDKT offer. We assessed the association between exposure and outcomes using univariable, and multivariable binary or multinominal logistic regression (reference: White or White nonimmigrant participants).

Results

Of the 498 participants, 281 (56%) were immigrants; 142 (28%) were African, Caribbean, and Black (ACB); 123 (25%) were Asian; and 233 (47%) were White. Compared to White nonimmigrants, racialized immigrants (relative risk ratio [RRR]: 2.98; 95% confidence interval [CI]: 1.76-5.03) and racialized nonimmigrants (RRR: 2.84; 95% CI: 1.22-6.65) were more likely not to have spoken about LDKT with others (vs. having spoken or planning to do so). Both racialized immigrant (odds ratio [OR]: 4.07; 95% CI: 2.50-6.34), racialized nonimmigrants (OR: 2.68; 95% CI: 1.31-5.51) and White immigrants (OR: 2.68; 95% CI: 1.43-5.05) were more likely not to have a potential LD identified.

Conclusion

Both racialized and immigrant status are associated with less readiness to pursue LDKT. Supporting patients to communicate their need for LDKT may improve equitable access to LDKT.

Differences in Outcomes by Place of Origin among Hispanic Patients with Kidney Failure

SIGNIFICANCE STATEMENT

Hispanic patients are known to have a higher risk of kidney failure and lower rates of home dialysis use and kidney transplantation than non-Hispanic White patients. However, it is unknown whether these outcomes differ within the Hispanic community, which is heterogeneous in its members' places of origins. Using United States Renal Data System data, the authors found similar adjusted rates of home dialysis use for patients originating from places outside the United States and US-born Hispanic patients, whereas the adjusted risk of mortality and likelihood of transplantation differed depending on place (country or territory) of origin. Understanding the heterogeneity in kidney disease outcomes and treatment within the Hispanic community is crucial in designing interventions and implementation strategies to ensure that Hispanic individuals with kidney failure have equitable access to care.

BACKGROUND

Compared with non-Hispanic White groups, Hispanic individuals have a higher risk of kidney failure yet lower rates of living donor transplantation and home dialysis. However, how home dialysis, mortality, and transplantation vary within the Hispanic community depending on patients' place of origin is unclear.

METHODS

We identified adult Hispanic patients from the United States Renal Data System who initiated dialysis in 2009-2017. Primary exposure was country or territory of origin (the United States, Mexico, US-Puerto Rico, and other countries). We used logistic regression to estimate differences in odds of initiating home dialysis and competing risk models to estimate subdistribution hazard ratios (SHR) of mortality and kidney transplantation.

RESULTS

Of 137,039 patients, 44.4% were US-born, 30.9% were from Mexico, 12.9% were from US-Puerto Rico, and 11.8% were from other countries. Home dialysis rates were higher among US-born patients, but not significantly different after adjusting for demographic, medical, socioeconomic, and facility-level factors. Adjusted mortality risk was higher for individuals from US-Puerto Rico (SHR, 1.04; 95% confidence interval [CI], 1.01 to 1.08) and lower for Mexico (SHR, 0.80; 95% CI, 0.78 to 0.81) and other countries (SHR, 0.83; 95% CI, 0.81 to 0.86) compared with US-born patients. The adjusted rate of transplantation for Mexican or US-Puerto Rican patients was similar to that of US-born patients but higher for those from other countries (SHR, 1.22; 95% CI, 1.15 to 1.30).

CONCLUSIONS

Hispanic people from different places of origin have similar adjusted rates of home dialysis but different adjusted rates of mortality and kidney transplantation. Further research is needed to understand the mechanisms underlying these observed differences in outcomes.

Nursing Countermeasures of Continuous Renal Replacement Treatment in End-Stage Renal Disease with Refractory Hypotension in the Context of Smart Health

This work is aimed at exploring the nursing strategies and effects of continuous renal replacement therapy (CRRT) for end-stage renal disease (ESRD) with refractory hypotension under the background of smart health. 40 ESRD patients with refractory hypotension who received CRRT treatment were enrolled as the research objects and were randomly rolled into the intervention group and the control group, with 20 cases in each group. Patients in the control group received routine nursing, and those in the intervention group received individualized nursing. The incidence of hypotension, dry body weight, serous cavity effusion, renal function indicators (blood urea nitrogen (BUN) and creatinine (Cre)), and patient satisfaction were compared between the two groups. The results showed that the probability of hypotension in the intervention group was 9.38%, which was lower than that in the control group (34.38%). The probability of early termination of dialysis in the intervention group was 0%, which was lower than that in the control group (18.75%), and the difference was statistically significant (P < 0.05). The decreases of BUN and Cre in the intervention group were significantly greater than those in the control group, and the differences were statistically significant (P < 0.05). The proportion of water growth less than 10% during dialysis in the intervention group was 98.44%, which was greater than that in the control group (93.45%), and the difference was statistically significant (P < 0.05). The ultrafiltration volume after dialysis in the intervention group was 2850 ± 400 mL, which was greater than that in the control group 2350 ± 350 mL. After intervention, the proportion of patients with pleural effusion in the intervention group was 10% less than that in the control group (20%), and the difference was statistically significant (P < 0.05). The satisfaction rate of the intervention group was 97.66%, which was higher than that of the control group (65.63%). In conclusion, individualized nursing was more helpful to the recovery of ESRD patients with refractory hypotension treated with CRRT than routine nursing.

Effects of Uremic Clearance Granules on p38 MAPK/NF-κB Signaling Pathway, Microbial and Metabolic Profiles in End-Stage Renal Disease Rats Receiving Peritoneal Dialysis

Background

Methods

Results

Conclusion

Epidemiology of pediatric chronic kidney disease/kidney failure: learning from registries and cohort studies

Although the concept of chronic kidney disease (CKD) in children is similar to that in adults, pediatric CKD has some peculiarities, and there is less evidence and many factors that are not clearly understood. The past decade has witnessed several additional registry and cohort studies of pediatric CKD and kidney failure. The most common underlying disease in pediatric CKD and kidney failure is congenital anomalies of the kidney and urinary tract (CAKUT), which is one of the major characteristics of CKD in children. The incidence/prevalence of CKD in children varies worldwide. Hypertension and proteinuria are independent risk factors for CKD progression; other factors that may affect CKD progression are primary disease, age, sex, racial/genetic factors, urological problems, low birth weight, and social background. Many studies based on registry data revealed that the risk factors for mortality among children with kidney failure who are receiving kidney replacement therapy are younger age, female sex, non-White race, non-CAKUT etiologies, anemia, hypoalbuminemia, and high estimated glomerular filtration rate at dialysis initiation. The evidence has contributed to clinical practice. The results of these registry-based studies are expected to lead to new improvements in pediatric CKD care.

Ethnic Differences in Health Literacy, Self-Efficacy, and Self-Management in Patients Treated With Maintenance Hemodialysis

Background:

There is a gap in research investigating the potential impact of ethnicity on health literacy, self-efficacy, and self-management in patients treated with maintenance hemodialysis (MHD).

Objective:

To explore (1) the associations between health literacy, self-efficacy, and self-management among outpatients with kidney failure receiving treatment with MHD, and (2) the differences in health literacy and self-efficacy based on characteristics of ethnicity (ie, physical resemblance and proficiency in the language of the host population), known to be associated with health care access and health outcomes.

Design:

Cross-sectional

Setting:

Outpatients receiving MHD at 7 adult hemodialysis centers in Calgary, Alberta from September 2014 to December 2014.

Patients:

Participants were grouped into 2 groups based on a proposed 4-quadrant framework of a multicultural society. Quadrant 1 comprised outpatients with physical resemblance and first language of the host population (ie, white and English as a first language), whereas quadrant 4 participants comprised outpatients with physical resemblance and first language not of the host population (ie, non-white and first language other than English). A total of 78 patients (n_Q1 = 44, n_Q4 = 34) were included.

Measurements:

Heath literacy, self-efficacy, and self-management were measured using the Health Literacy Questionnaire (HLQ), Strategies Used by People to Promote Health (SUPPH), and Patient Activation Measure-13 (PAM-13), respectively.

Methods:

Convenience sampling was used to recruit participants at each of the 7 adult hemodialysis centers. All participants completed a study package, which included a demographic questionnaire, HLQ, SUPPH, and PAM-13. Spearman rho was calculated to identify correlations between patient activation level and HLQ and SUPPH scores. Independent t tests were performed to identify differences in HLQ and SUPPH scores between Q1 and Q4 participants. Stepwise regression was performed in other analyses to identify predictor variables of patient activation level.

Results:

Statistically significant correlations were identified between patient activation level and the health literacy domains of “ability to actively engage with health care providers” (r_HLQ6= .535, P < .001), “ability to find good health information” (r_HLQ8 = .611, P < .001), and “understanding health information well enough to know what to do” (r_HLQ9 = .712, P < .001). There was a statistically significant difference between Q1 and Q4 participants in the health literacy domain of “ability to find good health information” (P = .048). “Understanding health information well enough to know what to do” and “actively managing health” were included in the final stepwise regression model, F(2, 72) = 32.232, P < .001.

Limitations:

The cross-sectional design limits the generalizability of the results. The small sample size limits the power to identify significant associations and differences. Although English was not the first language of Q4 participants, all were proficient in English, meaning potential differences of a key subgroup of Q4 (ie, those who did not speak any English) were not captured.

Conclusion:

The HLQ allowed for the creation of a health literacy profile of patients with end-stage kidney disease receiving treatment with MHD. The findings suggest possible associations between specific domains of health literacy and patient activation. Outpatients’ representative of Q4 receiving treatment with MHD appear to struggle more with finding good health information, which may leave them at a disadvantage in the early phases of their self-management efforts. The findings highlight potential opportunities to better tailor patient care to support patients in their self-management, particularly for patients from ethnic minority backgrounds.

Health Outcomes of Immigrants in Nursing Homes: A Population-Based Retrospective Cohort Study in Ontario, Canada

OBJECTIVE

Older adults account for a significant portion of Canadian immigrants, yet characteristics and health outcomes of older immigrants in nursing homes have not been studied. We aimed to describe the prevalence of immigrants living in nursing homes, their characteristics, and their hospitalization and mortality rates compared to long-term residents in the first year of entry to nursing homes.

DESIGN

Population-based, retrospective cohort study using linked health administrative databases.

SETTING AND PARTICIPANTS

We assessed all incident admissions into publicly funded nursing homes in Ontario between April 2013 and March 2016. Immigrants were defined as those who arrived in Canada after 1985; long-term residents are those who arrived before 1985 or are Canadian-born.

METHODS

The primary outcome was all-cause hospitalization and mortality rates within 1 year of nursing home entry. Nested Cox proportional hazards models were estimated to explore the associations of facility, demographic, and clinical characteristics to the primary outcomes.

RESULTS

Immigrants comprised 4.4% of residents in Ontario's nursing homes, compared to 13.9% in the general population. The majority were from East and Southeast Asia (52.2%), and more than half (53.9%) had no competency in either official language on arrival in Canada. At the time of nursing home entry, immigrants were younger than long-term residents but had greater functional and cognitive impairments. Immigrants had a lower rate of mortality [hazard ratio 0.58, 95% confidence interval (CI) 0.51, 0.68; P < .001] but were more likely to be hospitalized (hazard ratio 1.14, 95% CI 1.06, 1.23; P < .001). Adjusting for language ability, the effect of immigrant status on hospitalization was not statistically significant.

CONCLUSIONS AND IMPLICATIONS

Despite greater functional and cognitive impairments, immigrants in nursing homes had lower mortality than long-term residents, potentially reflecting the "healthy immigrant effect." Inability to speak English was associated with increased risk of hospitalization, highlighting the need for strategies to overcome communication barriers.

End-Stage Kidney Diseases in Immigrant Groups: A Nationwide Cohort Study in Sweden

BACKGROUND

Our aim was to study the association between the country of birth and incident end-stage kidney disease (ESKD) in several immigrant groups in Sweden, using individuals born in Sweden or with Swedish-born parents as referents.

METHODS

A cohort study of first- and second-generation immigrants residing in Sweden between January 1, 1998 and December 31, 2012 was performed. Outcomes were defined as having at least one registered diagnosis of ESKD in the National Patient Register. The incidence of ESKD in different immigrant groups was used in the Cox regression models to estimate hazard ratios (HRs) and 95% CIs. All models were stratified by sex and adjusted for age, geographical residence, educational level, marital status, and neighbourhood socioeconomic status.

RESULTS

Compared to their referents, higher incidence rates and HRs of ESKD (HR; 95% CI) were observed in general among foreign-born men (1.10; 1.04-1.16) and women (1.12; 1.04-1.21) but not among second-generation immigrants (persons born in Sweden with foreign-born parents). A particularly high -incidence was noted among men and women from -East-European countries, as well as from non-European regions. A lower incidence of ESKD was noted among men from Finland.

CONCLUSIONS

We observed substantial differences in incidence of ESKD between immigrant groups and the Swedish-born population, which may be clinically relevant when monitoring preventive measures in patient subgroups with a higher risk of deteriorating kidney disease, and suggest higher attention to hypertension and diabetes control in immigrants. Mechanisms attributable to the migration process or ethnic differences may lead to an increased risk of ESKD.