Racial disparities exist in access to home dialysis among us patients with kidney failure

There are substantial racial/ethnic differences in use of home dialysis and the health outcomes of US patients who use it, according to a study appearing in an upcoming issue of the Journal of the American Society of Nephrology (JASN). With an unprecedented growth in the number of patients undergoing home dialysis in the United States, ensuring equitable access and improving health outcomes for patients is imperative.

Patients with kidney failure who are treated with dialysis need to make considerable lifestyle changes to accommodate the dialysis schedule. Patients have several options on how to undergo long-term dialysis, however: they can receive in-center hemodialysis (HD) during the day or night or undergo treatment at home with peritoneal dialysis (PD) or home HD. It is important to ensure equal access to different dialysis modalities in the interest of equity and fiscal responsibility. (Societal costs for patients dialyzing at home are considerably lower than for in-center hemodialysis.)

To examine whether there are racial/ethnic differences in the use of home dialysis, length of time patients are able to be treated at home, and risk for premature death, Rajnish Mehrotra, MD (University of Washington) and his colleagues analyzed data on 162,050 patients who initiated 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 2011. Of these patients, 17,791 underwent PD and 2536 underwent home HD for at least 91 days.

Among the major findings:

• Every racial/ethnic minority group was significantly less likely to be treated with home dialysis compared with whites. (For blacks, PD was 47% lower and home HD was 51% lower; for Hispanics, PD was 43% lower and home HD was 75% lower; for Asians, PD was 18% lower and home HD was 47% lower; and for others, PD was 40% lower and home HD was 56% lower).
• Among individuals treated with PD or in-center HD, racial/ethnic minorities had a lower risk of dying than whites. Among individuals undergoing home HD, only blacks had a significantly lower risk of dying 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 treated with PD had a lower risk.
• 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 their white counterparts to receive a kidney transplant.

"There are many potential reasons for lower use of home dialysis among racial/ethnic minorities," said Dr. Mehrotra. These might include lack of availability of home dialysis in certain communities; insurance barriers for availability of home dialysis; inability of healthcare teams to discuss various options for treatment because of delayed referral and emergent need for dialysis; provider bias in not offering home dialysis to racial/ethnic minorities; availability of social support or space at home; and patient preference on how treatment should be delivered.

"The challenges with access to transplantation could arise from delayed or no referral by physicians to transplant centers, challenges in completing the work-up related to kidney transplant, and longer time on waiting lists because of limitations with finding an appropriate match," Dr. Mehrotra explained.