Race- and Ethnicity-Related Disparities in Predialysis Nephrology Care, Kidney Disease Education, and Home Dialysis Utilization.

Abstract

Pre-dialysis nephrology care and kidney replacement therapy (KRT)-directed education (KDE) are essential for incident home dialysis use. However, there are substantial disparities in these care parameters among patients with advanced CKD. The impact of these disparities on home dialysis underuse has not been examined. We analyzed the 2021 US Renal Database System to identify all adult kidney failure patients with over six months of pre-dialysis Medicare coverage initiating their first-ever dialysis between 2010 and 2019. We used a mediation analysis to dissect the attributable influence of disparities in pre-dialysis nephrology care and KDE on incident home dialysis use. Additionally, we conducted sensitivity analyses using graded levels of mediators and sustained impact on home dialysis outcomes. We identified 464,310 Medicare recipients: 428,301 using incenter hemodialysis and 35,416 using home dialysis as their first-ever dialysis modality during the study period. Compared to non-Hispanic White patients (n=294,914), adjusted odds ratio (95% confidence intervals) for receiving pre-dialysis nephrology care, KDE service, and incident home dialysis were 0.62(0.61, 0.64), 0.58(0.52, 0.63) and 0.76(0.73, 0.79) respectively among Hispanic individuals (n=49,734), and 0.74(0.73, 0.76), 0.84(0.79, 0.89), and 0.63(95%CI:0.61, 0.65) respectively among Black individuals (n=98,992). Mediation analyses showed that compared to non-Hispanic White individuals, lack of nephrology care explained 30% and 14% of incident home dialysis underuse among Hispanic and Black individuals, respectively (p<0.001). Sensitivity analyses using a longer duration of nephrology care and KDE services and the sustained impact on home dialysis underuse through the first-year post-kidney failure showed congruent and consolidating findings. Disparities in pre-dialysis nephrology care were significantly associated with lower home dialysis among Hispanic and Black individuals.