Available treatments to prevent kidney disease or slow the progression of the disease have improved greatly over the past decade. Intensive blood glucose control and blood pressure control, use of angiotensin-converting enzyme (ACE) inhibitors, early referral to a renal team, preparation for dialysis, and dietary protein reduction can all markedly improve the outlook for those at risk for ESRD.
Table 1. Racial Comparison of Clinical Data at Referral and During Follow-Up
|Nonwhites (n=155)||Whites (n=61)||P|
|Mean age (years)||52 ± 1.1||51 ± 2.4||0.67|
|Sex, n (%) Women Men||89 (57) 66 (43)||28 (46) 33 (54)||0.13|
|Cause of kidney failure, n (%) Diabetes mellitus Hypertension||70 (45) 49 (32)||23 (38) 14 (23)||0.36|
|Systolic blood pressure (mmHg)||156 ±4.9||153 ±4.4||0.47|
|Mean body weight (lb)||168 ±7.7||161 ±5.2||0.24|
|Blood urea nitrogen concentration (mg/dL)||58 ± 5.4||54 ± 3.7||0.35|
|Serum creatinine concentration (mg/dL)||4.3 ± 0.38||3 ± 0.24||0.001|
|Serum albumin concentration (g/dL)||3.6 ±0.09||3.7 ± 0.09||0.28|
|Hematocrit (%)||31.7 ± 1.3||34.7 ± 0.9||0.001|
|Interval from referral to dialysis (months)||13 ±0.8||43.5 ± 4.8||0.001|
|Number of clinic visits*||19 ± 2||33 ±3.1||0.001|
|Frequency of clinic visits*||0.87 ± 0.08||0.85 ± 0.06||0.63|
|*Total number of clinic visits and frequency of clinic visits from referral to initiation of dialysis. Adopted from Ifudu et a/. /999.|
Despite being increasingly recognized as high-risk groups for ESRD, minority populations, such as Hispanics, do not receive the same standard of care as their white non-Hispanic counterparts. For Hispanics, there is less provision of renal replacement therapy, limited referral for home dialysis, underpre-scription of dialysis, increased use of synthetic grafts rather than fistulas as permanent angioaccess, and delayed placement on the waiting list for kidney transplantation.
Racial disparities in healthcare provisions have been demonstrated by several reports in the literature. A retrospective analysis of 220 patients showed that, even among those with medical insurance, delayed referral to a hospital nephrologist was almost six times more likely to occur in nonwhite patients (i.e., African Americans and Hispanics) than in white patients with chronic kidney disease (Table 1). Delayed referral greatly limits opportunities for such patients to receive interventions that slow the progression of kidney failure and/or manage complications of the condition. Late referral is also associated with longer hospital stays, increased expense, and a higher mortality rate.
Table 2. Factors Associated with Late Initiation of Dialysis (Glomerular Filtration Rate of <5 mL/min/1.73 m2) in the United States
|Odds Ratio||95% CI||Odds Ratio||95% CI|
|0.38, 0.42||0.69||0.64, 0.73|
|1.50, 1.60||1.70||1.65, 1.76|
|1.33, 1.43||1.01||0.97, 1.06|
|1.44, 1.59||1.47||1.38, 1.56|
|1.86, 2.26||1.66||1.49, 1.85|
|1.87, 2.20||1.88||1.72, 2.05|
|Diabetes as cause of ESRD|
|0.46, 0.49||0.44||0.42, 0.45|
|0.74, 0.82||1.03||0.97, 1.09|
|1.15, 1.27||0.94||0.88, 1.00|
|0.73, 0.82||0.88||0.82, 0.94|
|VA and other||
|0.75, 0.81||0.98||0.93, 1.03|
|1.96, 2.20||1.55||1.46, 1.66|
|0.84, 0.92||0.83||0.79, 0.88|
|or medical leave|
|0.48, 0.51||0.76||0.73, 0.80|
|CI: confidence interval; VA: Veterans Affairs.|
Adapted from Kousz et a/. 2000.
A cross-sectional analysis of patients starting dialysis in the United States between 1995 and 1997 showed that, compared with whites, Hispanics were more likely to start dialysis late (multivariate odds ratio 1.47), as indicated by their glomerular filtration rate (Table 2).
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Similar inequalities are also apparent in the kidney transplant service. Transplantation is the treatment of choice for patients with ESRD, being associated with better patient survival than dialysis. Hispanic patients with ESRD are less likely to be referred for transplantation and so can remain on dialysis for longer than the general white population. This was demonstrated by Kasiske et al. using univariate and multivariate analyses of 41,596 patients from all 238 United Network for Organ Sharing (UNOS) kidney transplant centers in the United States between 1994 and 1996. They found that patients from ethnic minorities, along with those who were less educated and less financially secure, were less likely than their white counterparts to be listed for transplantation before initiation of dialysis. Compared with white non-Hispanic patients, Hispanics had an odds ratio for early transplant registration of 0.59. Similar results were found even when the cohort was controlled for possible bias for general access to healthcare and referral for transplantation.
Table 3. Racial Differences in the Waiting List and Transplantation Rates in the United States
|Racial Group||Waiting List for Kidney Alone (%) (n=46,799)||Total Kidney-Alone Transplant (%) (n=87,824)||Waiting List for SPK (%) (n=1,839)||Total SPK Transplants (%) (n=3,298)|
For patients with type-1 diabetes, simultaneous pancreas-kidney (SPK) transplantation has become established as an excellent alternative to kidney transplants and can prevent or possibly even reverse diabetic complications. In a retrospective analysis carried out from 1988 to 1996, Isaacs et al. found striking racial differences in the rates of access to SPK transplants in all 562,814 patients with diabetes-related ESRD (Tables 3 and 4) Although racial minorities represented 30% of type-1 diabetics with ESRD, they received only 8% of all SPK transplants in the United States. Whites were 35 times more likely to receive a SPK transplant than Hispanics, and three-and-a-half times more likely to have a kidney transplant than Hispanics.
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Table 4. Risk Ratios for Transplantation in the United States
Racial Comparisons Risk Ratio* for
|Risk Ratio* for Kidney Transplant||
|Whites vs Hispanics 34.86||12.63-109.17||
|Whites vs African Americans 5.84||5.00-6.83||
|Whites vs Asian Americans 17.49||6.32-54.91||
|Whites vs Native Americans 21.51||7.78-67.48||
|CI: confidence interval.*For total ESRD caused by type-] diabetes mellitus. *Рог total ESRD.|
|Adapted from Isaacs et al. 2000.|
This situation appears to be part of a general picture. Data from the Healthcare Cost and Utilization Project State Inpatient Database for California, Florida, and New York (covering half of the Hispanic population in the country) revealed that Hispanics were less likely than non-Hispanic whites to receive major therapeutic procedures for more than one-third of the 63 conditions examined. Hispanics were more likely to be hospitalized for a preventable condition compared with white patients, even after controlling for differences in healthcare needs, socioeconomic status, insurance coverage, and the availability of primary care. Apcalis Oral Jelly
Possible reasons for these inequalities include inadequate patient education on the available treatment options; and financial, cultural, religious, and spiritual issues, combined with a lack of physician awareness of the effect of racial disparities on the presentation and management of illness.