Differences in Mortality Among Mexican-American, Puerto Rican, and Cuban-American Dialysis Patients in the United States (original) (raw)
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Survival Advantage of Hispanic Patients Initiating Dialysis in the United States Is Modified by Race
Journal of the American Society of Nephrology, 2005
Differences in survival have been reported among ethnic groups in the general population. Whether these extend to patients with ESRD is unclear. Using national data, mortality risks of ethnic groups who began dialysis treatment in the United States between May 1, 1995, and July 31, 1997, were compared over 2 yr. Patients were classified as Hispanic or non-Hispanic and then subclassified by race forming six race-specific subgroups: Hispanic white, black, and other and non-Hispanic white, black, and other. Mortality rates for Hispanics compared with non-Hispanics were 19.2 versus 26 per 100 patient-years at risk for those with diabetes and were 14.7 versus 22.7 per 100 patient-years at risk for those without diabetes. For those with diabetes, adjusted mortality risks for Hispanics versus non-Hispanics were 30% lower (95% confidence interval [CI], 26 to 34%). In subgroup analysis, mortality risks for Hispanic whites and Hispanic blacks were 35% (95% CI, 31 to 39%) and 33% (95% CI, 12 to 48%) lower than non-Hispanic whites and were similar in magnitude to those of non-Hispanic blacks (32% lower; 95% CI, 29 to 35%) and non-Hispanic other (33% lower; 95% CI, 28 to 39%). Interestingly, mortality risks for Hispanic others were not significantly different from non-Hispanic whites. For those without diabetes, adjusted mortality risks for Hispanics versus non-Hispanics were 17% lower (95% CI, 9 to 23%), and subgroup analysis yielded similar patterns to those of individuals with diabetes. The survival advantage of Hispanic over non-Hispanic patients who receive chronic dialysis treatment in the United States is not consistent across subgroups and is modified by race. Cultural and genetic differences as well as variation in the access and delivery of care before and while on dialysis may account for these differences.
Journal of the American Society of Nephrology, 2006
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.
American Journal of Kidney Diseases, 1999
Principal goals of the End-Stage Renal Disease (ESRD) Core Indicators Project are to improve the care provided to ESRD patients and to identify categorical variability in intermediate outcomes of dialysis care. The purpose of the current analysis is to extend our observations about the variability of intermediate outcomes of ESRD care among different racial and gender groups to a previously unreported group, Hispanic Americans. This group is a significant and growing minority segment of the ESRD population. A random sample of Medicare-eligible adult, in-center, hemodialysis patients was selected and stratified from an end-of-year ESRD patient census for 1996. Of the 6,858 patients in the final sample, 45% were non-Hispanic whites, 36% were non-Hispanic blacks, and 11% were Hispanic. Whites were older than blacks or Hispanics (P F 0.001). Hispanics were more likely to have diabetes mellitus as a primary diagnosis than either blacks or whites (P F 0.001). Even though they received longer hemodialysis times and were treated with high-flux hemodialyzers, blacks had significantly lower hemodialysis doses than white or Hispanic patients (P F 0.001). The intradialytic weight losses were greater for blacks (P F 0.05). The delivered hemodialysis dose was lower for blacks than for whites or Hispanics whether measured as a urea reduction ratio (URR) or as the Kt/V calculated by the second generation formula of Daugirdas (median 1.32, 1.36, and 1.37, respectively, P F 0.001). Hispanics and whites had modestly higher hematocrits than blacks (33.2, 33.2, and 33.0%, respectively, P F 0.01). There was no significant difference among groups in the weekly prescribed epoetin alfa dose (D172 units/kg/week). A significantly greater proportion of Hispanic patients had transferrin saturations H20% compared with the other two groups (P F 0.001). Logistic regression modeling revealed that whites were significantly more likely to have serum albumin F3.5(BCG)/3.2(BCP) gm/dL (OR 1.4, p F 0.01); blacks were significantly more likely to have a delivered Kt/V F 1.2 (OR 1.4, P F 0.001) and hematocrit F30%, (OR 1.2; P F 0.05) and both blacks and Hispanics were significantly more likely to have a delivered URR F 65% (OR 1.5, P F 0.001 and 1.2, P F 0.05, respectively). This is a US government work. There are no restrictions on its use.
Journal of the American Society of Nephrology, 2006
Rates of ESRD are rising faster in Hispanic than non-Hispanic white individuals, but reasons for this are unclear. Whether rates of cardiovascular events and mortality differ among Hispanic and non-Hispanic white patients with chronic kidney disease (CKD) also is not well understood. Therefore, this study examined the associations between Hispanic ethnicity and risks for ESRD, cardiovascular events, and death in patients with CKD. A total of 39,550 patients with stages 3 to 4 CKD from Kaiser Permanente of Northern California were included. Hispanic ethnicity was obtained from self-report supplemented by surname matching. GFR was estimated from the abbreviated Modification of Diet in Renal Disease equation, and clinical outcomes, patient characteristics, and longitudinal medication use were ascertained from health plan databases and state mortality files. After adjustment for sociodemographic characteristics, Hispanic ethnicity was associated with an increased risk for ESRD (hazard ratio [HR] 1.93; 95% confidence interval [CI] 1.72 to 2.17) when compared with non-Hispanic white patients, which was attenuated after controlling for diabetes and insulin use (HR 1.50; 95% CI 1.33 to 1.69). After further adjustment for potential confounders, Hispanic ethnicity remained independently associated with an increased risk for ESRD (HR 1.33; 95% CI 1.17 to 1.52) as well as a lower risk for cardiovascular events (HR 0.82; 95% CI 0.76 to 0.88) and death (HR 0.72; 95% CI 0.66 to 0.79). Among a large cohort of patients with CKD, Hispanic ethnicity was associated with lower rates of death and cardiovascular events and a higher rate of progression to ESRD. The higher prevalence of diabetes among Hispanic patients only partially explained the increased risk for ESRD. Further studies are required to elucidate the cause(s) of ethnic disparities in CKD-associated outcomes.
American Journal of Kidney Diseases, 2003
Background: In the United States, an association between mortality risk and ethnicity has been observed among hemodialysis patients. This study was developed to assess whether health-related quality of life (HRQOL) scores also vary among patients of different ethnic backgrounds. Associations between HRQOL and adverse dialysis outcomes (ie, death and hospitalization) also were assessed for all patients and by ethnicity. Methods: Data are from the Dialysis Outcomes and Practice Patterns Study for 6,151 hemodialysis patients treated in 148 US dialysis facilities who filled out the Kidney Disease Quality of Life Short Form. We determined scores for three components of HRQOL: Physical Component Summary (PCS), Mental Component Summary (MCS), and Kidney Disease Component Summary (KDCS). Patients were classified by ethnicity as Hispanic and five non-Hispanic categories: white, African American, Asian, Native American, and other. Multiple linear regression models were used to estimate differences in HRQOL scores among ethnic groups, using whites as the referent category. Cox regression models were used for associations between HRQOL and outcomes. Regression models were adjusted for sociodemographic variables, delivered dialysis dose (equilibrated Kt/V), body mass index, years on dialysis therapy, and several laboratory/comorbidity variables. Results: Compared with whites, African Americans showed higher HRQOL scores for all three components (MCS, PCS, and KDCS). Asians had higher adjusted PCS scores than whites, but did not differ for MCS or KDCS scores. Compared with whites, Hispanic patients had significantly higher PCS scores and lower MCS and KDCS scores. Native Americans showed significantly lower adjusted MCS scores than whites. The three major components of HRQOL were significantly associated with death and hospitalization for the entire pooled population, independent of ethnicity. Conclusion: The data indicate important differences in HRQOL among patients of different ethnic groups in the United States. Furthermore, HRQOL scores predict death and hospitalization among these patients. Am J Kidney Dis 41:605-615.
Clinical Journal of the American Society of Nephrology
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.
Chronic kidney disease in African American and Mexican American populations
Kidney International, 2005
African Americans and Mexican Americans suffer from disproportionately high rates of end-stage renal disease in comparison with whites from the United States. An improved understanding of both classic and novel chronic kidney disease risk factors among racial/ethnic minorities may help to facilitate improved prevention, screening, and early intervention strategies for all patients at risk for chronic kidney disease-not only in the United States, but on a global level. The economic implications are equally important to inform health policy recommendations and ensure cost-effective allocation of limited resources.
Journal of The American Society of Nephrology, 2020
Background Although Hispanics/Latinos in the United States are often considered a single ethnic group, they represent a heterogenous mixture of ancestries who can self-identify as any race defined by the U.S. Census. They have higher ESKD incidence compared with non-Hispanics, but little is known about the CKD incidence in this population. Methods We examined rates and risk factors of new-onset CKD using data from 8774 adults in the Hispanic Community Health Study/Study of Latinos. Incident CKD was defined as eGFR ,60 ml/min per 1.73 m 2 with eGFR decline 1ml/minper1.73m2peryear,orurinealbumin/creatinineratio1 ml/min per 1.73 m 2 per year, or urine albumin/creatinine ratio 1ml/minper1.73m2peryear,orurinealbumin/creatinineratio30 mg/g. Rates and incidence rate ratios were estimated using Poisson regression with robust variance while accounting for the study's complex design. Results Mean age was 40.3 years at baseline and 51.6% were women. In 5.9 years of follow-up, 648 participants developed CKD (10.6 per 1000 person-years). The age-and sex-adjusted incidence rates ranged from 6.6 (other Hispanic/mixed background) to 15.0 (Puerto Ricans) per 1000 person-years. Compared with Mexican background, Puerto Rican background was associated with 79% increased risk for incident CKD (incidence rate ratios, 1.79; 95% confidence interval, 1.33 to 2.40), which was accounted for by differences in sociodemographics, acculturation, and clinical characteristics. In multivariable regression analysis, predictors of incident CKD included BP .140/90 mm Hg, higher glycated hemoglobin, lower baseline eGFR, and higher baseline urine albumin/creatinine ratio. Conclusions CKD incidence varies by Hispanic/Latino heritage and this disparity may be in part attributed to differences in sociodemographic characteristics. Culturally tailored public heath interventions focusing on the prevention and control of risk factors might ameliorate the CKD burden in this population.
Association of Race and Age With Survival Among Patients Undergoing Dialysis
JAMA, 2011
LACKS ARE SIGNIFICANTLY overrepresented in the endstage renal disease (ESRD) population. Of more than 500 000 individuals with ESRD in the United States, approximately one-third are black, and the relative incidence of ESRD is 3.6 times higher among black than white patients. 1 Moreover, racial disparities in quality of and access to care for patients with kidney disease are well-documented. 2-4 Compared with white patients, fewer black patients with chronic kidney disease (CKD) are under the care of a nephrologist, and their rates of referral for peritoneal dialysis and kidney transplantation are significantly lower. 5,6 Black patients who receive dialysis are less likely to receive an adequate dialysis dose, 7,8 have a fistula placed, 9,10 and achieve target hemoglobin levels-all metrics associated with decreased dialysis survival. 11 Despite the disparity in care, current thinking, supported by more than 30 previous studies, is that black patients receiving dialysis survive longer than their white counterparts. 2,3,8,12-42 Black patients with ESRD are reported to have 13% to 45% lower mortality when receiving dialysis than their white counterparts, a finding that persists in both unadjusted analysis and after adjustment for comorbidities and socioeconomic status. Varying postulations for this counterintuitive observation have included differential sensitivity to dialysis dose, 8 racial differences in nutritional status, or racial differences in inflammation 39-the biological or sociological mechanisms for which remain unclear. Moreover, the perception of enhanced dialysis survival seems to have affected clinical decision making and engendered complacency about the low rates of transplantation among black patients. 2,43 Although kidney trans
Racial differences in survival of patients on dialysis
Kidney International, 2000
Racial differences in survival of patients on dialysis. tality rate (adjusted for age, gender, and renal disease Background. Recent studies have documented racial differdiagnosis) in Caucasian patients was consistently higher ences in the crude mortality rates of patients on dialysis. Howthan black patients and patients from the Asia-Pacific ever, proper interpretation of these findings requires adjustregions [1, 2]. Similarly, the crude mortality rate of hemoment for potential confounders and comorbid risk factors dialysis patients in the age range of 45 to 54 years was 5 between the racial groups. Methods. We examined the clinical data on 3752 Caucasian to 10% higher in Europe than in Japan [3, 4]. However, patients, 451 Southeast Asian patients, 322 South Asian pawithout adjusting for differences in dialysis accessibility tients, and 319 black patients who were treated with hemodialyand other comorbid risk factors for survival between sis or peritoneal dialysis under a Universal Health Care system racial groups, proper interpretation of these findings rein Toronto and prospectively followed between 1981 and 1995. mains uncertain. In all patients, a number of comorbid risk factors for survival was assessed at the start of dialysis and was reassessed with Treatment of ESRD in Canada consists of a compretheir outcome status (that is, continued dialysis, transplantahensive and integrated system of government-funded protion, death, or loss to follow-up) at least every six months. grams in hemodialysis, peritoneal dialysis, and renal trans-Cox proportional hazards analysis was used to fit multivariate plantation, which is universally accessible to all Canadians models predicting patient survival. Pairwise comparisons of [5]. Since 1981, the Toronto Regional Dialysis Registry the relative hazards of death between the racial groups were performed after stratifying for cardiovascular disease, diabetes has been collecting data on demographics and comorbid mellitus, and hypertension at the start of dialysis, and were risk factors in all patients at start of their ESRD treatadjusted for differences in other comorbid risk factors. ment program (Methods section). This database reflects Results. The risk of death in Caucasian patients was signifia regional experience of a population of 4.5 million, as cantly increased when compared with Southeast Asian patients, well as a diverse mixture of ethnic groups (that is, 80% South Asian patients, and black patients [multivariate relative hazards (95% CI): 1.63 (1.36 to 1.97), 1.36 (1.07 to 1.73), 1.34 Caucasian, 10% Southeast Asian, 5% South Asian, and (1.07 to 1.67), respectively]. Additionally, we detected an inter-5% blacks) unique to the Metropolitan Toronto area [6]. action between race and cigarette smoking (P Ͻ 0.004), suggesting that in the dialysis patients who smoked, whites had a higher mortality risk compared with non-whites. METHODS Conclusions. Differences in patient survival on dialysis exist Study design and data collection between racial groups. However, the genetic and environmental determinants that underlie these differences are presently This is a prospective cohort study. Since January of unknown.