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

Effect of Race on Transplantation in Autosomal Dominant Polycystic Kidney Disease

Key Points

Despite overall superior outcomes, transplant outcomes of patients with autosomal dominant polycystic kidney disease are heavily influenced by race. Access to living donor and preemptive transplantation partly explains these racial disparities. Favorable Expected Post-Transplant Survival scores suggest that promoting equity would result in improved survival for patients with ADPKD.

Background

Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic cause of ESKD and occurs without racial predilection. In general, non-White patients with ESKD have less access to transplantation, especially living donor transplantation. We examined long-term outcomes of patients with ADPKD-ESKD by self-reported race, with attention to the trajectory of Estimated Post-Transplant Survival (EPTS) scores over time.

Methods

United Network for Organ Sharing Standard Transplant Analysis and Research files were used to identify 32,611 ADPKD transplant recipients between January 2000 and December 2022. EPTS scores were calculated from the date of waitlisting until transplantation occurred. Cumulative incidences of living and deceased transplantation were calculated and plotted. Cox models were made for graft failure and death, and a subdistribution hazards model for graft failure accounted for death as a competing outcome, with adjustment for patient, donor, and transplant factors.

Results

Compared with White patients with ADPKD, all other groups had more dialysis years, more delayed graft function, and fewer living and preemptive transplants; mean EPTS scores were lower in Black and Hispanic patients at each time point on the waitlist. However, EPTS scores at the time of transplant was less likely to be <20% in Black and Hispanic patients because of longer waiting time. Black patients had a significantly higher risk of graft failure with death as competing risk compared with White patients. Asian and Hispanic patients had similar graft survivals but better patient survival compared with White patients.

Conclusions

Waitlist experience, allograft quality, and post-transplant outcomes of patients with ADPKD are influenced by patient race.

Renal Disease and Kidney Transplantation in Hispanic American Persons

The Hispanic population of the United States is the second largest racial or ethnic group, comprising 18.7% of the population. However, this population is incredibly heterogeneous differing in genetic traits, cultural upbringing, educational backgrounds, and financial status. The impact of this heterogeneity on the prevalence and outcomes of renal disease and kidney transplantation is understudied compared with non-Hispanic White and Black populations. What is known appears to be underrecognized. This review aims to critically assess current medical literature on Hispanic individuals, focusing on etiological factors, disease progression, and outcomes related to CKD and kidney transplantation. By doing so, we aim to underscore key areas for further in-depth investigation.

Favorable outcomes in Hispanic recipients receiving simultaneous pancreas kidney transplantation

The objective of this study was to compare the long-term outcomes of Hispanic versus white recipients who underwent simultaneous pancreas kidney transplantation (SPKT). This single-center study, conducted from 2003 to 2022, had a median follow-up of 7.5 years. The study included 91 Hispanic and 202 white SPKT recipients. The mean age (44 vs. 46 years), percentage of males (67% vs. 58%), and body mass index (BMI) (25.6 vs. 25.3 kg/m2 ) were similar between the Hispanic and white groups. The Hispanic group had more recipients with type 2 diabetes (38%) compared to the white group (5%, p < .001). The duration of dialysis was longer in Hispanics (640 vs. 473 days, p = .02), and fewer patients received preemptive transplants (10% vs. 29%, p < .01) compared to whites. Hospital length of stay, rates of BK Viremia, and acute rejection episodes within 1 year were similar between the groups. The estimated 5-year kidney, pancreas, and patient survival rates were also similar between the groups, 94%, 81%, and 95% in Hispanics, compared to 90%, 79%, and 90% in whites. Increasing age and longer duration of dialysis were risk factors for death. Although Hispanic recipients had a longer duration on dialysis and fewer preemptive transplants, the survival rates were similar to those of white recipients. However, referring providers and many transplant centers continue to overlook pancreas transplants for appropriately selected patients with type 2 diabetes, particularly among minority populations. As a transplant community, it is crucial that we make efforts to comprehend and tackle these obstacles to transplantation.

Association of Hyperkalemia and Hypokalemia with Patient Characteristics and Clinical Outcomes in Japanese Hemodialysis (HD) Patients

This study aimed to examine the characteristics and clinical outcomes of Japanese hemodialysis patients with dyskalemia. A retrospective study was conducted using a large Japanese hospital group database. Outpatients undergoing thrice-a-week maintenance hemodialysis were stratified into hyperkalemia, hypokalemia, and normokalemia groups based on their pre-dialysis serum potassium (sK) levels during the three-month baseline period. Baseline characteristics of the three groups were described and compared for the following outcomes during follow-up: all-cause mortality, all-cause hospitalization, major adverse cardiovascular events (MACE), cardiac arrest, fatal arrythmia, and death related to arrhythmia. The study included 2846 eligible patients, of which 67% were men with a mean age of 65.65 (SD: 12.63) years. When compared with the normokalemia group (n = 1624, 57.06%), patients in the hypokalemia group (n = 313, 11.00%) were older and suffered from malnutrition, whereas patients in the hyperkalemia group (n = 909, 31.94%) had longer dialysis vintage. The hazard ratios for all-cause mortality and MACE in the hypokalemia group were 1.47 (95% confidence interval [CI], 1.13–1.92) and 1.48 (95% CI, 1.17–1.86), respectively, whereas that of death related to arrhythmia in the hyperkalemia group was 3.11 (95% CI, 1.03–9.33). Thus, dyskalemia in maintenance hemodialysis patients was associated with adverse outcomes, suggesting the importance of optimized sK levels.

New eGFR equations: Implications for cardiologists and racial inequities

Recently, a new equation to predict estimated glomerular filtration rate (eGFR) that does not include a variable for race has been endorsed by professional organizations and increasingly adopted by clinical laboratories. We discuss the reasoning behind the development of the new equation, implications for cardiologists, and how the new eGFR equation could impact disparities in the cardiovascular care of these patients. Race, a social construct, is a poor proxy for biological variability. Clinical trials which recruit underrepresented minorities and advances in genomic medicine could accelerate the development of personalized medicine and help decrease inequalities in clinical outcomes.

Sex and Racial/Ethnic Differences in Home Hemodialysis Mortality

Key Points

Women on home hemodialysis have higher 1-year mortality than men, and women and men have comparable survival on long-term follow-up. Compared with White patients on home hemodialysis, there was no difference in all-cause mortality for Black patients, Hispanics, or Native Americans. Among patients undergoing home hemodialysis, Asians had a lower risk of all-cause mortality than White patients.

Background

Women and minorities constitute substantial portions of the prevalent population of patients with kidney failure. Little is known about sex and racial/ethnic differences in mortality among patients with kidney failure on home hemodialysis in the United States.

Methods

Using the United States Renal Data System, we retrospectively evaluated a cohort of 42,849 patients who started home hemodialysis between January 1, 2005, and December 31, 2015. We examined the association of sex and race/ethnicity with the outcome of all-cause mortality using adjusted Cox proportional hazard models and logistic regression models.

Results

In the study cohort, 40.4% were women, and 57.4% were White. Women on home hemodialysis had higher unadjusted death rates (26.9 versus 22.4 per 100 person-years) compared with men. There was no difference in adjusted all-cause mortality between men and women, but women had an 8% higher adjusted risk of all-cause mortality at 1 year after initiating home hemodialysis (odds ratio 1.08, 95% confidence interval [CI], 1.01 to 1.15). Regarding race/ethnicity, Hispanic, White, and Black patients had higher unadjusted death rates compared with Asians and Native Americans (25.1 versus 24.8 versus 23.2 versus 17.4 versus 16.6 per 100 person-years). There was no difference in adjusted all-cause mortality in Black, Hispanic, and Native Americans compared with White patients, while Asians had a lower risk of all-cause mortality than did White patients (hazard ratio, 0.81; 95% CI, 0.72 to 0.92). There was no difference in adjusted 1-year mortality for Asian, Black, Hispanic, and Native American patients compared with White patients.

Conclusions

Among patients undergoing home hemodialysis, women have higher 1-year mortality than men, and women and men have comparable survival on long-term follow-up after adjusting for other covariates. Compared with White patients, there was no difference in adjusted survival on long-term follow-up for Black patients, Hispanics, or Native Americans, while Asians had better survival. Our results suggest the need for population-wide strategies to overcome differences in home hemodialysis care.

The Impact of Race and Ethnicity Upon Health-Related Quality of Life and Mortality in Dialysis Patients

RATIONALE & OBJECTIVE

Health-related quality of life (HRQoL) has been recognized as a strong predictor of mortality among hemodialysis patients. However, differences in the association of HRQoL with survival across diverse racial/ethnic groups have not been well studied in this population.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

We examined the relationship between HRQoL and mortality in a prospective cohort of racially/ethnically diverse hemodialysis patients recruited from 18 outpatient dialysis units during 2011 to 2016.

EXPOSURE

Using the 36-Item Short Form Health Survey (SF-36) administered every 6 months, HRQoL was ascertained by 36 questions summarized as 2 Physical and Mental Component and 8 subscale scores.

OUTCOME

All-cause mortality.

ANALYTICAL APPROACH

Associations of time-varying SF-36 scores with mortality were estimated using Cox models in the overall cohort and within racial/ethnic subgroups.

RESULTS

Among 753 hemodialysis patients who met eligibility criteria, expanded case-mix analyses showed that the lowest quartiles of time-varying Physical and Mental Component scores were associated with higher mortality in the overall cohort (reference: highest quartile): adjusted HRs, 2.30 (95% CI, 1.53-3.47) and 1.54 (95% CI, 1.05-2.25), respectively. In analyses stratified by race/ethnicity, the lowest quartile of Physical Component scores was significantly associated with higher mortality across all groups: adjusted HRs, 2.64 (95% CI, 1.31-5.29), 1.84 (95% CI, 1.01-3.38), and 3.18 (95% CI, 1.13-8.91) for Hispanic, African American, and other race/ethnicity patients, respectively. The lowest quartile of time-varying physical functioning, role limitations due to physical health, role limitations due to emotional problems, social functioning, and pain subscale scores were associated with higher mortality in the overall cohort and particularly in Hispanics and blacks.

LIMITATIONS

Residual confounding cannot be excluded.

CONCLUSIONS

Lower SF-36 Physical Component and subscale scores were associated with higher mortality in hemodialysis patients, including those of minority background. Further studies are needed to determine whether interventions that augment physical health might improve the survival of these diverse populations.

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.

CKD and ESRD in US Hispanics

Hispanics are the largest racial/ethnic minority group in the United States, and they experience a substantial burden of kidney disease. Although the prevalence of chronic kidney disease (CKD) is similar or slightly lower in Hispanics than non-Hispanic whites, the age- and sex-adjusted prevalence rate of end-stage renal disease is almost 50% higher in Hispanics compared with non-Hispanic whites. This has been attributed in part to faster CKD progression among Hispanics. Furthermore, Hispanic ethnicity has been associated with a greater prevalence of cardiovascular disease risk factors, including obesity and diabetes, as well as CKD-related complications. Despite their less favorable socioeconomic status, which often leads to limited access to quality health care, and their high comorbid condition burden, the risk for mortality among Hispanics appears to be lower than for non-Hispanic whites. This survival paradox has been attributed to a complex interplay between sociocultural and psychosocial factors, as well as other factors. Future research should focus on evaluating the long-term impact of these factors on patient-centered and clinical outcomes. National policies are needed to improve access to and quality of health care among Hispanics with CKD.

Racial and Ethnic Differences in Mortality Associated with Serum Potassium in a Large Hemodialysis Cohort

BACKGROUND

Hyperkalemia is observed in chronic kidney disease patients and may be a risk factor for life-threatening arrhythmias and death. Race/ethnicity may be important modifiers of the potassium-mortality relationship in maintenance hemodialysis (MHD) patients given that potassium intake and excretion vary among minorities.

METHODS

We examined racial/ethnic differences in baseline serum potassium levels and all-cause and cardiovascular mortality using Cox proportional hazard models and restricted cubic splines in a cohort of 102,241 incident MHD patients. Serum potassium was categorized into 6 groups: ≤3.6, >3.6 to ≤4.0, >4.0 to ≤4.5 (reference), >4.5 to ≤5.0, >5.0 to ≤5.5, and >5.5 mEq/L. Models were adjusted for case-mix and malnutrition-inflammation cachexia syndrome (MICS) covariates.

RESULTS

The cohort was composed of 50% whites, 34% African-Americans, and 16% Hispanics. Hispanics tended to have the highest baseline serum potassium levels (mean ± SD: 4.58 ± 0.55 mEq/L). Patients in our cohort were followed for a median of 1.3 years (interquartile range 0.6-2.5). In our cohort, associations between higher potassium (>5.5 mEq/L) and higher mortality risk were observed in African-American and whites, but not Hispanic patients in models adjusted for case-mix and MICS covariates. While in Hispanics only, lower serum potassium (<3.6 mEq/L) levels were associated with higher mortality risk. Similar trends were observed for cardiovascular mortality.

CONCLUSIONS

Higher potassium levels were associated with higher mortality risk in white and African-American MHD patients, whereas lower potassium levels were associated with higher death risk in Hispanics. Further studies are needed to determine the underlying mechanisms for the differential association between potassium and mortality across race/ethnicity.

Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society

End-stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non-Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre-ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.

Racial-ethnic disparities in mortality and kidney transplant outcomes among pediatric dialysis patients

BACKGROUND

Previous studies in adult hemodialysis patients have shown that African-American and Hispanic patients have a lower risk of mortality in addition to a lower likelihood of kidney transplantation. However, studies of the association between race and outcomes in pediatric dialysis are sparse and often do not examine outcomes in Hispanic children. The objective was to determine if racial-ethnic disparities in mortality and kidney transplantation outcomes exist in pediatric dialysis patients.

METHODS

This was a retrospective cohort analysis of 2,697 pediatric dialysis patients (aged 0-20 years) from a large national dialysis organization (entry period 2001-2011) of non-Hispanic white, African-American, and Hispanic race-ethnicity. Associations between race-ethnicity with mortality and kidney transplantation outcomes were examined separately using competing risks methods. Logistic regression analyses were used to examine the association between race-ethnicity, with outcomes within 1 year of dialysis initiation.

RESULTS

Of the 2,697 pediatric patients in this cohort, 895 were African-American, 778 were Hispanic, and 1,024 were non-Hispanic white. After adjusting for baseline demographics, competing risk survival analysis revealed that compared with non-Hispanic whites, African-Americans had a 64 % higher mortality risk (hazards ratio [HR] = 1.64; 95 % CI 1.24-2.17), whereas Hispanics had a 31 % lower mortality risk (HR = 0.69; 95 % CI 0.47-1.01) that did not reach statistical significance. African-Americans also had higher odds of 1-year mortality after starting dialysis (odds ratio [OR] = 2.08; 95 % CI 0.95-4.58), whereas both African-Americans and Hispanics had a lower odds of receiving a transplant within 1 year of starting dialysis (OR = 0.28; 95 % CI 0.19-0.41 and OR = 0.43; 95 % CI 0.31-0.59 respectively).

CONCLUSION

In contrast to adults, African-American pediatric dialysis patients have worse survival than their non-Hispanic white counterparts, whereas Hispanics have a similar to lower mortality risk. Both African-American and Hispanic pediatric dialysis patients had a lower likelihood of kidney transplantation than non-Hispanic whites, similar to observations in the adult dialysis population.

Association of Growth Differentiation Factor 15 with Mortality in a Prospective Hemodialysis Cohort

BACKGROUND/AIMS

Cardiovascular disease and protein-energy wasting are among the strongest predictors of the high mortality of dialysis patients. In the general population, the novel cardiovascular and wasting biomarker, growth differentiation factor 15 (GDF15), is associated with decreased survival. However, little is known about GDF15 in dialysis patients.

METHODS

Among prevalent hemodialysis patients participating in a prospective study (October 2011 to August 2015), we examined the association of baseline GDF15 levels with all-cause mortality using unadjusted and case mix-adjusted death hazard ratios (HRs) that controlled for age, sex, race, ethnicity, diabetes, and dialysis vintage.

RESULTS

The mean age ± SD of the 203 patients included in the study was 53.2 ± 14.5 years, and the cohort included 41% females, 34% African-Americans, and 48% Hispanics. GDF15 levels (mean ± SD 5.94 ± 3.90 ng/mL; range 1.58-39.8 ng/mL) were higher among older patients and were inversely associated with serum creatinine concentrations as a surrogate for muscle mass. Each 1.0 ng/mL increase in GDF15 was associated with an approximately 17-18% higher mortality risk in the unadjusted and case mix models (p < 0.05). Increments of about 1 SD (a 4.0 ng/mL increase in GDF15) were associated with a nearly 2-fold higher death risk. The highest GDF15 tertile was associated with higher mortality risk (reference: lowest tertile): the HRs (95% CI) were 3.19 (1.35-7.55) and 2.45 (1.00-6.00) in the unadjusted and the case mix-adjusted model, respectively. These incremental death trends were confirmed in cubic spline models.

CONCLUSION

Higher circulating GDF15 levels are associated with higher mortality risk in hemodialysis patients. Future studies are needed to determine whether GDF15 may represent a novel therapeutic target for cardiovascular disease, wasting, and death in this population.

Race/Ethnicity and Cardiovascular Outcomes in Adults With CKD: Findings From the CRIC (Chronic Renal Insufficiency Cohort) and Hispanic CRIC Studies

BACKGROUND

Non-Hispanic blacks and Hispanics with end-stage renal disease have a lower risk for death than non-Hispanic whites, but data for racial/ethnic variation in cardiovascular outcomes for non-dialysis-dependent chronic kidney disease are limited.

STUDY DESIGN

Prospective cohort.

SETTING & PARTICIPANTS

3,785 adults with entry estimated glomerular filtration rates of 20 to 70mL/min/1.73m(2) enrolled in the CRIC (Chronic Renal Insufficiency Cohort) Study.

PREDICTORS

Race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic).

OUTCOMES

Cardiovascular outcomes (atherosclerotic events [myocardial infarction, stroke, or peripheral arterial disease] and heart failure) and a composite of each cardiovascular outcome or all-cause death.

MEASUREMENTS

Multivariable Cox proportional hazards.

RESULTS

During a median follow-up of 6.6 years, we observed 506 atherosclerotic events, 551 heart failure events, and 692 deaths. In regression analyses, there were no significant differences in atherosclerotic events among the 3 racial/ethnic groups. In analyses stratified by clinical site, non-Hispanic blacks had a higher risk for heart failure events (HR, 1.59; 95% CI, 1.29-1.95), which became nonsignificant after adjustment for demographic factors and baseline kidney function. In contrast, Hispanics had similar risk for heart failure events as non-Hispanic whites. In analyses stratified by clinical site, compared with non-Hispanic whites, non-Hispanic blacks were at similar risk for atherosclerotic events or death. However, after further adjustment for cardiovascular risk factors, medications, and mineral metabolism markers, non-Hispanic blacks had 17% lower risk for the outcome (HR, 0.83; 95% CI, 0.69-0.99) than non-Hispanic whites, whereas there was no significant association with Hispanic ethnicity.

LIMITATIONS

Hispanics were largely recruited from a single center, and the study was underpowered to evaluate the association between Hispanic ethnicity and mortality.

CONCLUSIONS

There were no significant racial/ethnic differences in adjusted risk for atherosclerotic or heart failure outcomes. Future research is needed to better explain the reduced risk for atherosclerotic events or death in non-Hispanic blacks compared with non-Hispanic whites.

The Hispanic health paradox: From epidemiological phenomenon to contribution opportunities for psychological science

Similar to non-Hispanic Blacks, Hispanics/Latinos experience a range of psychosocial and physical health challenges, including high rates of poverty, neighborhood segregation, discrimination, poor healthcare access, and high rates of obesity, diabetes, and undiagnosed and late-stage diagnosed diseases. Despite such risks, Hispanics generally experience better physical health and lower mortality than non-Hispanic Whites, an epidemiological phenomenon commonly referred to as the Hispanic or Latino health paradox. With the basic phenomenon increasingly well-established, attention now turns to the sources of such resilience. The current aims are to briefly examine the epidemiological paradox and highlight potential sociocultural resilience factors that may contribute to the paradoxical effects. We conclude with presentation of a framework for modeling sociocultural resilience and discuss future directions for psychological contributions.

Kidney transplantation in the Hispanic population

Hispanic race and low socioeconomic status are established predictors of disparity in access to kidney transplantation. This single-center retrospective review was undertaken to determine whether Hispanic race predicted kidney transplant outcomes. A total of 720 patients underwent kidney transplantation from January 1, 2004 to December 31, 2013, including 398 Hispanic patients and 322 non-Hispanic patients. Hispanic patients were significantly younger (p < 0.0001), on hemodialysis for longer (p = 0.0018), had a greater percentage with public insurance (p < 0.0001), more commonly had diabetes as the cause of end-stage renal disease (p = 0.0167), and had a lower percentage of living donors (p = 0.0013) compared to non-Hispanic patients. There was no difference in one-, five-, and 10-yr graft (97%, 81%, and 61% vs. 95%, 76%, and 42% p = 0.18) or patient survival (98%, 90%, and 84% vs. 97%, 87%, and 69% p = 0.11) between the Hispanic and non-Hispanic recipients. Multivariate analysis identified increased recipient age and kidney donor profile index to be predictive of lower graft survival and increasing recipient age to be predictive of lower patient survival. In the largest single-center study on kidney transplantation outcomes in Hispanic patients, there is no difference in graft and recipient survival between Hispanic and non-Hispanic kidney transplant patients, and in multivariate analysis, Hispanic race is not a risk factor for graft or patient survival.

Racial and Ethnic Differences in Mortality and Cardiovascular Events Among Patients With End-Stage Renal Disease Due to Lupus Nephritis

OBJECTIVE

To identify racial and ethnic differences in mortality and cardiovascular (CV) risk among patients with end-stage renal disease (ESRD) due to lupus nephritis (LN).

METHODS

Within the US ESRD registry (1995-2008), we identified individuals ages >17 years with incident ESRD due to systemic lupus erythematosus. We ascertained demographics, clinical factors, and deaths from registry patient files and CV events (myocardial infarction, heart failure, and hemorrhagic and ischemic strokes) from inpatient Medicare claims. We calculated incidence rates (95% confidence intervals [95% CIs]) per 1,000 person-years for study events, stratified by race and ethnicity. We compared probabilities of the events among racial and ethnic groups using cumulative incidence function curves and multivariable-adjusted subdistribution proportional hazard ratios (HRsd), taking into account the competing events of kidney transplantation and death (for nonfatal CV events).

RESULTS

Of 12,533 patients with LN-associated ESRD, the mean ± SD age was 40.7 ± 14.9 years, 82% were women, and 49% were African American. The overall mortality rate was 98.1/1,000 person-years (95% CI 95.3-100.9). In multivariable models, Asian and Hispanic LN-associated ESRD patients had lower mortality than whites (HRsd 0.70 [95% CI 0.58-0.84] and 0.79 [95% CI 0.71-0.88], respectively), whereas African Americans had higher mortality (HRsd 1.27 [95% CI 1.18-1.36]). African American patients >40 years old had higher mortality than their white counterparts (HRsd 1.67 [95% CI 1.44-1.93]). African Americans were more likely to be admitted for heart failure or hemorrhagic stroke.

CONCLUSION

Among patients with LN-associated ESRD, Asians and Hispanics experienced lower mortality and CV event risks than whites, and African Americans had higher mortality and CV event risks than whites.

Racial and Ethnic Disparities in Use of and Outcomes with Home Dialysis in the United States

Home dialysis, which comprises peritoneal dialysis (PD) or home hemodialysis (home HD), offers patients with ESRD greater flexibility and independence. Although ESRD disproportionately affects racial/ethnic minorities, data on disparities in use and outcomes with home dialysis are sparse. We analyzed data of patients who initiated maintenance dialysis between 2007 and 2011 and were admitted to any of 2217 dialysis facilities in 43 states operated by a single large dialysis organization, with follow-up through December 31, 2011 (n =: 162,050, of which 17,791 underwent PD and 2536 underwent home HD for ≥91 days). Every racial/ethnic minority group was significantly less likely to be treated with home dialysis than whites. Among individuals treated with in-center HD or PD, racial/ethnic minorities had a lower risk for death than whites; among individuals undergoing home HD, only blacks had a significantly lower death risk than whites. Blacks undergoing PD or home HD had a higher risk for transfer to in-center HD than their white counterparts, whereas Asians or others undergoing PD had a lower risk than whites undergoing PD. Blacks irrespective of dialysis modality, Hispanics undergoing PD or in-center HD, and Asians and other racial groups undergoing in-center HD were significantly less likely than white counterparts to receive a kidney transplant. In conclusion, there are racial/ethnic disparities in use of and outcomes with home dialysis in the United States. Disparities in kidney transplantation evident for blacks and Hispanics undergoing home dialysis are similar to those with in-center HD. Future studies should identify modifiable causes for these disparities.

Race and ethnicity influences on cardiovascular and renal events in patients with diabetes mellitus

BACKGROUND

The incidence of end-stage renal disease (ESRD) has been consistently shown to be higher among blacks and Hispanics compared to whites with unmeasured risk factors and access to care as suggested explanations. In a high-risk cohort with frequent protocol-directed follow-up, we evaluated the influence of race on cardiovascular (CV) outcomes and incidence of ESRD.

METHODS

TREAT was a randomized, double-blind, placebo-controlled study. This secondary analysis focused on role of race on outcomes. TREAT enrolled 4,038 patients with type 2 diabetes, chronic kidney disease (estimated glomerular filtration rate 20-60 mL/min per 1.73 m(2)), and anemia (hemoglobin level ≤11 g/dL) treated with either darbepoetin alfa or placebo. We compared self-described black and Hispanic patients to white patients with regard to baseline characteristics and outcomes, including mortality, CV outcomes (myocardial infarction, stroke, heart failure, resuscitated sudden death, and coronary revascularization), and incident ESRD. Multivariate adjusted Cox models were developed for these outcomes.

RESULTS

Black and Hispanic patients were younger, more likely women, had less prior CV disease, and higher blood pressure. During a mean follow-up of 2.4 years with comparable access to care, blacks and Hispanics had a greater risk of ESRD but a significant lower risk of myocardial infarction and coronary revascularization than whites. After adjusting for confounders, blacks remained at significantly greater risk of ESRD than whites (hazard ratio 1.53, 95% CI 1.26-1.85, P < .001), whereas this ESRD risk did not persist among Hispanics.

CONCLUSION

Despite similar access to care and lower CV event rates, the risk of ESRD was higher among blacks and Hispanics than whites. For blacks, but not Hispanics, this increase was independent of known attributable risk factors.

Effect of dialysis initiation timing on clinical outcomes: a propensity-matched analysis of a prospective cohort study in Korea

BACKGROUND

Controversy persists regarding the appropriate initiation timing of renal replacement therapy for patients with end-stage renal disease. We evaluated the effect of dialysis initiation timing on clinical outcomes. Initiation times were classified according to glomerular filtration rate (GFR).

METHODS

We enrolled a total of 1691 adult patients who started dialysis between August 2008 and March 2013 in a multi-center, prospective cohort study at the Clinical Research Center for End Stage Renal Disease in the Republic of Korea. The patients were classified into the early-start group or the late-start group according to the mean estimated GFR value, which was 7.37 ml/min/1.73 m2. The primary outcome was patient survival, and the secondary outcomes were hospitalization, cardiovascular events, vascular access complications, change of dialysis modality, and peritonitis. The two groups were compared before and after matching with propensity scores.

RESULTS

Before propensity score matching, the early-start group had a poor survival rate (P<0.001). Hospitalization, cardiovascular events, vascular access complications, changes in dialysis modality, and peritonitis were not different between the groups. A total of 854 patients (427 in each group) were selected by propensity score matching. After matching, neither patient survival nor any of the other outcomes differed between groups.

CONCLUSIONS

There was no clinical benefit after adjustment by propensity scores comparing early versus late initiation of dialysis.

Impact of age, race and ethnicity on dialysis patient survival and kidney transplantation disparities

BACKGROUND

Prior studies show that African-American and Hispanic dialysis patients have lower mortality risk than whites. Recent age-stratified analyses suggest this survival advantage may be limited to younger age groups, but did not concurrently compare Hispanic, African-American, and white patients, nor account for differences in nutritional and inflammatory status as potential confounders. Minorities experience inequities in kidney transplantation access, but it is unknown whether these racial/ethnic disparities differ across age groups.

METHODS

The associations between race/ethnicity with all-cause mortality and kidney transplantation were separately examined among 130,909 adult dialysis patients from a large national dialysis organization (entry period 2001-2006, follow-up through 2009) within 7 age categories using Cox proportional hazard models adjusted for case-mix and malnutrition and inflammatory surrogates.

RESULTS

African-Americans had similar mortality versus whites in younger age groups (18-40 years), but decreased mortality in older age groups (>40 years). In contrast, Hispanics had lower mortality versus whites across all ages. In sensitivity analyses using competing risk regression to account for differential kidney transplantation rates across racial/ethnic groups, the African-American survival advantage was limited to >60-years age categories. African-Americans and Hispanics were less likely to undergo kidney transplantation from all donor types versus whites across all ages, and these disparities were even more pronounced for living donor kidney transplantation (LDKT).

CONCLUSIONS

Hispanic dialysis patients have greater survival versus whites across all ages; in African-Americans, this survival advantage is limited to patients >40 years of age. Minorities are less likely to undergo kidney transplantation, particularly LDKT, across all ages.

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.