Do Income Level and Race Influence Survival in Patients Receiving Hemodialysis? (original) (raw)
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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.
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
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.
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.
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.
Risk Adjustment and the Assessment of Disparities in Dialysis Mortality Outcomes
Journal of the American Society of Nephrology : JASN, 2015
Standardized mortality ratios (SMRs) reported by Medicare compare mortality at individual dialysis facilities with the national average, and are currently adjusted for race. However, whether the adjustment for race obscures or clarifies disparities in quality of care for minority groups is unknown. Cox model-based SMRs were computed with and without adjustment for patient race for 5920 facilities in the United States during 2010. The study population included virtually all patients treated with dialysis during this period. Without race adjustment, facilities with higher proportions of black patients had better survival outcomes; facilities with the highest percentage of black patients (top 10%) had overall mortality rates approximately 7% lower than expected. After adjusting for within-facility racial differences, facilities with higher proportions of black patients had poorer survival outcomes among black and non-black patients; facilities with the highest percentage of black patie...
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.
Racial/Ethnic Disparities Associated With Initial Hemodialysis Access
JAMA Surgery, 2015
IMPORTANCE Superior outcomes have been established with the use of an arteriovenous fistula (AVF) at first hemodialysis. However, considering the influence of comorbidities, medical insurance, and specialist care, racial/ethnic differences in the patterns of utilization of AVFs are unknown and deserve evaluation.
Kidney International, 2003
Differences in intermediate outcomes for Asian and non-Asian adult hemodialysis patients in the United States. Background. There is a paucity of information regarding the clinical experience of Asian hemodialysis patients. This paper describes intermediate outcomes for adult Asian hemodialysis patients compared to Caucasians and African Americans. Methods. Dialysis facility staff abstracted clinical information on a national random sample of adult hemodialysis patients from October through December 2000. Associations of race with intermediate outcomes were tested by bivariate analyses and multivariable logistic regression modeling. Results. A total of 429 patients were identified as Asian, 4403 as Caucasians, and 3103 as African Americans. Asian and Caucasian patients were older than African Americans [mean 63.2 (Ϯ15.6), 63.9 (Ϯ15.2), and 57.7 (Ϯ14.7) years, P Ͻ 0.001], and had fewer years on dialysis [mean 3.5 (Ϯ3.8), 3.1 (Ϯ3.8), and 4.1 (Ϯ4.1) years, P Ͻ 0.001]. Ninety three percent of Asians, 87% of Caucasians, and 84% of African Americans had a mean Kt/V Ն1.2 (P Ͻ 0.001). In addition, 36% of Asians, 32% of Caucasians, and 26% of African Americans had an arteriovenous (AV) fistula as their vascular access (P Ͻ 0.001). Hemoglobin profiles were only slightly different among the three racial groups. More Asians and African Americans had a mean serum albumin Ն4.0/3.7 g/dL compared to Caucasians (33% and 31% compared to 27%, respectively, P Ͻ 0.001). In the final multivariable logistic regression model, Asians were twice as likely to have a mean Kt/V Ն1.2 compared to Caucasians (the referent group) [odds ratio (OR) (95% CI) 2.10 (1.33, 3.32), P Ͻ 0.01]. They experienced similar intermediate outcomes for vascular access, anemia management, and serum albumin compared to the majority racial group. Conclusion. These findings indicate that adult hemodialysis Asian patients experience similar or better intermediate outcomes compared to the majority racial group. Further study is needed to determine if these results are associated with improved survival and less morbidity in this minority group.