Reappraisal of the impact of race on survival in patients on dialysis.
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ABSTRACT:
SUBMITTER: Buckalew VM
PROVIDER: S-EPMC2876222 | biostudies-literature | 2010 Jun
REPOSITORIES: biostudies-literature
Publications
Reappraisal of the impact of race on survival in patients on dialysis.
Buckalew Vardaman M VM Freedman Barry I BI
American journal of kidney diseases : the official journal of the National Kidney Foundation 20100601 6
Racial differences in the cause, natural history, and effects of chronic kidney disease have long been the subject of investigation. Dialysis-dependent kidney failure occurs nearly 4 times more often in African Americans than European Americans. Despite this observation, studies repeatedly show that African Americans have a significant survival advantage after initiating dialysis therapy. Although this phenomenon has been attributed to environmental and socioeconomic factors, recent studies show ...[more]
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Project description: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.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.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).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.
| S-EPMC4024458 | biostudies-literature
Project description: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.
| S-EPMC7380436 | biostudies-literature
Project description:BackgroundAccess to nephrology care prior to end-stage renal disease (ESRD) is significantly associated with lower rates of morbidity and mortality. We assessed the association of area-level and individual-level indicators of poverty and race/ethnicity on pre-ESRD care provided by nephrologists.MethodsIn this retrospective cohort study using the US Renal Data System database, we identified 739 537 patients initiated on maintenance dialysis from 1 January 2007 through 31 December 2012. We assessed the Medicare-Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data obtained from the 2010 US census. We conducted multivariable logistic regression of pre-ESRD nephrology care as the outcome variable.ResultsAmong patients in the lowest area-level MHI quintile, 61.28% received pre-ESRD nephrology care versus 67.68% among those in higher quintiles (P < 0.001). Similarly, the proportions of dual-eligible and nondual-eligible patients who had pre-ESRD nephrology care were 61.49 and 69.84%, respectively (P < 0.001). Patients in the lowest area-level MHI quintile were associated with significantly lower likelihood of pre-ESRD nephrology care (adjusted odds ratio [aOR] 0.86 [95% confidence interval (CI) 0.85-0.87]) compared with those in higher quintiles. Both African American (AA) and Hispanic patients were significantly less likely to have received pre-ESRD nephrology care [aOR 0.85 (95% CI 0.84-0.86) and aOR 0.72 (95% CI 0.71-0.74), respectively].ConclusionsIndividual- and area-level measures of poverty, AA race and Hispanic ethnicity were independently associated with a lower likelihood of pre-ESRD nephrology care. Efforts to improve pre-ESRD nephrology care may require focusing on the poor and minority groups.
| S-EPMC5469551 | biostudies-literature
Project description:Young blacks receiving dialysis have an increased risk of death compared with whites in the United States. Factors influencing this disparity among the young adult dialysis population have not been well explored. Our study examined the relation of neighborhood socioeconomic status (SES) and racial differences in mortality in United States young adults receiving dialysis. We merged US Renal Data System patient-level data from 11,027 black and white patients ages 18-30 years old initiating dialysis between 2006 and 2009 with US Census data to obtain neighborhood poverty information for each patient. We defined low SES neighborhoods as those neighborhoods in U.S. Census zip codes with ?20% of residents living below the federal poverty level and quantified race differences in mortality risk by level of neighborhood SES. Among patients residing in low SES neighborhoods, blacks had greater mortality than whites after adjusting for baseline demographics, clinical characteristics, rurality, and access to care factors. This difference in mortality between blacks and whites was significantly attenuated in higher SES neighborhoods. In the United States, survival between young adult blacks and whites receiving dialysis differs by neighborhood SES. Additional studies are needed to identify modifiable factors contributing to the greater mortality among young adult black dialysis patients residing in low SES neighborhoods.
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Project description:Blacks have high rates of chronic kidney disease, are overrepresented among the US dialysis patients, have higher parathyroid hormone levels, but greater survival compared to nonblacks. We hypothesized that mineral and bone disorders (MBDs) have a bearing on survival advantages of black hemodialysis patients. In 139,328 thrice-weekly treated hemodialysis patients, including 32% blacks, in a large dialysis organization, where most laboratory values were measured monthly for up to 60 months (July 2001 to June 2006), we examined differences across races in measures of MBDs and survival predictabilities of these markers and administered the active vitamin D medication paricalcitol. Across each age increment, blacks had higher serum calcium and parathyroid hormone (PTH) levels and almost the same serum phosphorus and alkaline phosphatase levels and were more likely to receive injectable active vitamin D in the dialysis clinic, mostly paricalcitol, at higher doses than nonblacks. Racial differences existed in mortality predictabilities of different ranges of serum calcium, phosphorus, and PTH but not alkaline phosphatase. Blacks who received the highest dose of paricalcitol (>10?µg/week) had a demonstrable survival advantage over nonblacks (case-mix-adjusted death hazard ratio?=?0.87, 95% confidence level 0.83-0.91) compared with those who received lower doses (<10?µg/week) or no active vitamin D. Hence, in black hemodialysis patients, hyperparathyroidism and hypercalcemia are more prevalent than in nonblacks, whereas hyperphosphatemia or hyperphosphatasemia are not. Survival advantages of blacks appear restricted to those receiving higher doses of active vitamin D. Examining the effect of MBD modulation on racial survival disparities of hemodialysis patients is warranted.
| S-EPMC3179282 | biostudies-literature
Project description:Abnormalities in mineral homeostasis are ubiquitous in patients on dialysis, and influenced by race. In this study, we determine the race-specific relationship between mineral parameters and mortality in patients initiating hemodialysis.We measured the levels of fibroblast growth factor 23 (FGF23) and 25-hydroxyvitamin D (25 D) in 184 African American and 327 non-African American hemodialysis patients who enrolled between 1995 and 1998 in the Choices for Healthy Outcomes in Caring for ESRD Study. Serum calcium, phosphorus, parathyroid hormone (PTH) and total alkaline phosphatase levels were averaged from clinical measurements during the first 4.5 months of dialysis. We evaluated the associated prospective risk of mortality using multivariable Cox proportional hazards models stratified by race.PTH and total alkaline phosphatase levels were higher, whereas calcium, phosphorus, FGF23 and 25 D levels were lower in African Americans compared to those of non-African Americans. Higher serum phosphorus and FGF23 levels were associated with greater mortality risk overall; however, phosphorus was only associated with risk among African Americans (HR 5.38, 95% CI 2.14-13.55 for quartile 4 vs. 1), but not among non-African Americans (p-interaction = 0.04). FGF23 was associated with mortality in both groups, but more strongly in African Americans (HR 3.91, 95% CI 1.74-8.82 for quartiles 4 vs. 1; p-interaction = 0.09). Serum calcium, PTH, and 25 D levels were not consistently associated with mortality. The lowest and highest quartiles of total alkaline phosphatase were associated with higher mortality risk, but this did not differ by race (p-interaction = 0.97).Aberrant phosphorus homeostasis, reflected by higher phosphorus and FGF23, may be a risk factor for mortality in patients initiating hemodialysis, particularly among African Americans.
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Project description:BACKGROUND: This study was aimed at determining the outcome and examining the association between comorbidities and mortality after intracerebral hemorrhage in chronic dialysis patients. METHODS: We used the Taiwan National Health Insurance Research Database and enrolled patients who underwent maintenance dialysis between 2000 and 2007. Annual incidence of intracerebral hemorrhage in patients receiving dialysis from 2000 to 2007 was determined. To identify predictors of hemorrhagic stroke, we used logistic regression model to estimate the relative ratio of factors for intracerebral hemorrhage in the most recent cohort (2007). The cumulative survival rate and comorbid conditions associated with mortality after intracerebral hemorrhage among all dialysis patients between 2000 and 2007 was calculated using the Kaplan-Meier method and Cox regression analysis. RESULTS: We identified 57,261 patients on maintenance dialysis in the cohort of 2007, and 340 patients had history of intracerebral hemorrhage among them. Hypertension was the most common comorbidity of dialysis patients. The incidence rate of intracerebral hemorrhage among dialysis patients was about 0.6%. Adjusted logistic regression model showed that male gender, middle age (45-64 years), hypertension, and previous history of stroke were the independent predictors for the occurrence of intracerebral hemorrhage among chronic dialysis patients. 1,939 dialysis patients with development of intracerebral hemorrhage in the analysis period from 2000 to 2007 were identified. In-hospital mortality was high (36.15%) following intracerebral hemorrhage. They were followed up after intracerebral hemorrhage for a mean time of 41.56 months. Adjusted Cox regression analyses demonstrated that the factors independently associated with mortality after intracerebral hemorrhage among dialysis patients included diabetes mellitus, malignancy and a history of prior stroke. CONCLUSIONS: Dialysis patients who have history of prior stroke, diabetes and malignancy have worse survival than patients without these comorbidities. Attention must focus on providing optimal medical care after hemorrhagic stroke for these target groups to reduce mortality.
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Project description:BACKGROUND:The prevalence of severe obesity, often considered a contraindication to peritoneal dialysis (PD), has increased over time. However, mortality has decreased more rapidly in the PD population than the hemodialysis (HD) population in the United States. The association between obesity and clinical outcomes among patients with end-stage kidney disease remains unclear in the current era. STUDY DESIGN:Historical cohort study. SETTING & PARTICIPANTS:15,573 incident PD patients from a large US dialysis organization (2007-2011). PREDICTOR:Body mass index (BMI). OUTCOMES:Modality longevity, residual renal creatinine clearance, peritonitis, and survival. RESULTS:Higher BMI was significantly associated with shorter time to transfer to HD therapy (P for trend < 0.001), longer time to kidney transplantation (P for trend < 0.001), and, with borderline significance, more frequent peritonitis-related hospitalization (P for trend = 0.05). Compared with lean patients, obese patients had faster declines in residual kidney function (P for trend < 0.001) and consistently achieved lower total Kt/V over time (P for trend < 0.001) despite greater increases in dialysis Kt/V (P for trend < 0.001). There was a U-shaped association between BMI and mortality, with the greatest survival associated with the BMI range of 30 to < 35kg/m2 in the case-mix adjusted model. Compared with matched HD patients, PD patients had lower mortality in the BMI categories of < 25 and 25 to < 35kg/m2 and had equivalent survival in the BMI category ? 35kg/m2 (P for interaction = 0.001 [vs < 25 kg/m2]). This attenuation in survival difference among patients with severe obesity was observed only in patients with diabetes, but not those without diabetes. LIMITATIONS:Inability to evaluate causal associations. Potential indication bias. CONCLUSIONS:Whereas obese PD patients had higher risk for complications than nonobese PD patients, their survival was no worse than matched HD patients.
| S-EPMC5970950 | biostudies-literature
Project description:BackgroundResults concerning the association between peritoneal dialysis-related peritonitis and mortality in peritoneal dialysis patients are inconclusive, with one potential reason being that the time-dependent effect of peritonitis has rarely been considered in previous studies. This study aimed to evaluate whether peritonitis has a negative impact on mortality in a large cohort of peritoneal dialysis patients. We also assessed the changing impact of peritonitis on patient mortality with respect to duration of follow-up.MethodsThis retrospective cohort study included incident patients who started peritoneal dialysis from 1 January 2006 to 31 December 2011. Episodes of peritonitis were recorded at the time of onset, and peritonitis was parameterized as a time-dependent variable for analysis. We used the Cox regression model to assess whether peritonitis has a negative impact on mortality.ResultsA total of 1321 patients were included. The mean age was 48.1 ± 15.3 years, 41.3% were female, and 23.5% with diabetes mellitus. The median (interquartile) follow-up time was 34 (21-48) months. After adjusting for confounders, peritonitis was independently associated with 95% increased risk of all-cause mortality (hazard ratio, 1.95; 95% confidence interval: 1.46-2.60), 90% increased risk of cardiovascular mortality (hazard ratio, 1.90; 95% confidence interval: 1.28-2.81) and near 4-fold increased risk of infection-related mortality (hazard ratio, 4.94; 95% confidence interval: 2.47-9.86). Further analyses showed that peritonitis was not significantly associated with mortality within 2 years of peritoneal dialysis initiation, but strongly influenced mortality in patients dialysed longer than 2 years.ConclusionsPeritonitis was independently associated with higher risk of all-cause, cardiovascular and infection-related mortality in peritoneal dialysis patients, and its impact on mortality was more significant in patients with longer peritoneal dialysis duration.
| S-EPMC5460447 | biostudies-literature
Project description:BACKGROUND:End-of-life care is a prominent consideration in patients on maintenance dialysis, especially when death appears imminent and quality of life is poor. To date, examination of race- and ethnicity-associated disparities in end-of-life care for patients with ESRD has largely been restricted to comparisons of white and black patients. METHODS:We performed a retrospective national study using United States Renal Data System files to determine whether end-of-life care in United States patients on dialysis is subject to racial or ethnic disparity. The primary outcome was a composite of discontinuation of dialysis and death in a nonhospital or hospice setting. RESULTS:Among 1,098,384 patients on dialysis dying between 2000 and 2014, the primary outcome was less likely in patients from any minority group compared with the non-Hispanic white population (10.9% versus 22.6%, P<0.001, respectively). We also observed similar significant disparities between any minority group and non-Hispanic whites for dialysis discontinuation (16.7% versus 31.2%), as well as hospice (10.3% versus 18.1%) and nonhospital death (34.4% versus 46.4%). After extensive covariate adjustment, the primary outcome was less likely in the combined minority group than in the non-Hispanic white population (adjusted odds ratio, 0.55; 95% confidence interval, 0.55 to 0.56; P<0.001). Individual minority groups (non-Hispanic Asian, non-Hispanic black, non-Hispanic Native American, and Hispanic) were significantly less likely than non-Hispanic whites to experience the primary outcome. This disparity was especially pronounced for non-Hispanic Native American and Hispanic subgroups. CONCLUSIONS:There appear to be substantial race- and ethnicity-based disparities in end-of-life care practices for United States patients receiving dialysis.
| S-EPMC6115657 | biostudies-literature