Unmasking Disparities in Kidney Replacement Therapy Among Young Patients—A Call to Action

Abstract

Related Article, p. 9 Decades of medical literature have demonstrated large, persistent racial and ethnic disparities in kidney replacement therapies (KRT) and clinical outcomes for persons with kidney failure.1Reddan D.N. Szczech L.A. Klassen P.S. Owen W.F. Racial inequity in America's ESRD program.Semin Dial. 2000; 13: 399-403Crossref PubMed Scopus (47) Google Scholar,2Johansen K.L. Chertow G.M. Gilbertson D.T. et al.US Renal Data System 2021 Annual Data Report: epidemiology of kidney disease in the United States.Am J Kidney Dis. 2022; 79 (Sviii-Sxi; S1-S575)Google Scholar Despite national efforts to improve the quality of dialysis delivery, including the Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease (ESRD) Quality Improvement Program and Prospective Payment System (PPS)3Mendu M.L. Weiner D.E. Health policy and kidney care in the United States: Core Curriculum 2020.Am J Kidney Dis. 2020; 76: 720-730Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar as well as United Network for Organ Sharing changes in kidney allocation,4Melanson T.A. Hockenberry J.M. Plantinga L. et al.New kidney allocation system associated with increased rates of transplants among black and hispanic patients.Health Aff (Millwood). 2017; 36: 1078-1085Crossref PubMed Scopus (58) Google Scholar significant gaps in care persist for minority persons. Black and Hispanic individuals experience a disproportionate burden across the spectrum of kidney disease. Black and Hispanic patients have 2- to 4-fold greater lifetime risk of developing kidney failure5Albertus P. Morgenstern H. Robinson B. Saran R. Risk of ESRD in the United States.Am J Kidney Dis. 2016; 68: 862-872Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar but are less likely to receive pre-KRT care compared to White persons (64% and 61% vs 73%).2Johansen K.L. Chertow G.M. Gilbertson D.T. et al.US Renal Data System 2021 Annual Data Report: epidemiology of kidney disease in the United States.Am J Kidney Dis. 2022; 79 (Sviii-Sxi; S1-S575)Google Scholar Black and Hispanic patients are also less likely than White patients to receive peritoneal dialysis (PD; 6% and 7% vs 9%) or kidney transplant (21% and 26% vs 36%).2Johansen K.L. Chertow G.M. Gilbertson D.T. et al.US Renal Data System 2021 Annual Data Report: epidemiology of kidney disease in the United States.Am J Kidney Dis. 2022; 79 (Sviii-Sxi; S1-S575)Google Scholar Black patients also experience a longer time on the waiting list than White patients (77 more days per 5 years).6Taber D.J. Gebregziabher M. Hunt K.J. et al.Twenty years of evolving trends in racial disparities for adult kidney transplant recipients.Kidney Int. 2016; 90: 878-887Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar A myriad of interrelated factors contribute to these outcomes, including health literacy, education, geographic location, socioeconomic status (SES), and physician bias.7Malek S.K. Keys B.J. Kumar S. Milford E. Tullius S.G. Racial and ethnic disparities in kidney transplantation.Transpl Int. 2011; 24: 419-424Crossref PubMed Scopus (65) Google Scholar In this issue of AJKD, Wilk et al8Wilk AS Cummings JR Plantinga LC Franch HA Lea JP Patzer RE Racial and ethnic disparities in kidney replacement therapies among adults with kidney failure: an observational study of variation by patient age.Am J Kidney Dis. 2022; 80: 9-19Abstract Full Text Full Text PDF Scopus (2) Google Scholar leverage data from the US Renal Data System (USRDS) to evaluate racial and ethnic differences in KRT utilization with the goal of understanding whether disparities vary based on age. The study cohort included 830,402 adults who started KRT between 2011 and 2018, capturing information after Medicare’s 2011 implementation of a comprehensive ESRD PPS, which improved financial incentives for home dialysis. Outcomes were identified as transplant, in-center hemodialysis (HD), home HD, and PD at day 90 of therapy (used for at least 60 days). Unsurprisingly, the authors found that Hispanic and non-Hispanic Black patients, compared to their non-Hispanic White counterparts, experienced lower rates of transplant and home modalities across all age groups. Notably, the authors found the largest disparities in the age 22-44 group. Among these younger patients, non-Hispanic Black and Hispanic patients were found to be 79% and 53% less likely to receive a transplant than non-Hispanic White patients after adjusting for patient characteristics. In the same age group, non-Hispanic Black and Hispanic patients were 53% and 65% less likely to receive home HD. PD-related disparities were more pronounced in older age groups. After adjustment for pre-KRT insurance status and nephrology care, racial disparities in transplantation and PD narrowed across all age groups. This novel and timely study highlights that (1) established estimates of disparities in kidney care delivery that do not adjust for age at kidney failure incidence may underestimate the impact on younger patients; and (2) these persistent disparities have long-term consequences, affecting longevity, disability, and quality of life. Wilk et al raise critical questions about access to transplantation and home dialysis and the current state of data capture on SES variables. Most importantly, the study serves as a call to action to address disparities impacting younger adult Black and Hispanic patients with kidney disease, given the long-term societal consequences. The authors remind us that access to home dialysis remains strikingly inadequate, with only a quarter of US dialysis facilities offering both PD and home HD training, while nearly half do not offer home dialysis training.8Wilk AS Cummings JR Plantinga LC Franch HA Lea JP Patzer RE Racial and ethnic disparities in kidney replacement therapies among adults with kidney failure: an observational study of variation by patient age.Am J Kidney Dis. 2022; 80: 9-19Abstract Full Text Full Text PDF Scopus (2) Google Scholar,9Prakash S. Coffin R. Schold J. et al.Travel distance and home dialysis rates in the United States.Perit Dial Int. 2014; 34: 24-32Crossref PubMed Scopus (21) Google Scholar This represents a huge barrier in ensuring universal access to home modalities, regardless of geography, and results in missed opportunities to use home dialysis, which offers improved preservation of kidney function, flexibility to continue employment, and short-term survival over in-center HD.2Johansen K.L. Chertow G.M. Gilbertson D.T. et al.US Renal Data System 2021 Annual Data Report: epidemiology of kidney disease in the United States.Am J Kidney Dis. 2022; 79 (Sviii-Sxi; S1-S575)Google Scholar Another major deficit Wilk et al highlight is the lack of self-reported racial and ethnic data for patients with kidney disease. Race and ethnicity as reported by USRDS is primarily obtained from the Medical Evidence Report, completed by health care staff, not patients. Without accurate, consistent, self-identified racial data, it is challenging to design meaningful interventions that stem disparities. To tackle the pronounced disparity in home dialysis and transplant use, particularly among younger Black and Hispanic patients, we can look to existing interventions that have demonstrated improvements in outcomes for kidney patients. National investment in the Special Diabetes Program for Indians (established in 1997 by Congress) resulted in the establishment of diabetes clinical teams, registries, nutrition services, and culturally tailored diabetes education materials, and led to a significant decrease in initiation rates of kidney failure requiring KRT among American Indian and Alaska Native adult patients between 1996 (57.3%) and 2013 (26.5%), representing the steepest decline compared to other racial and ethnic groups.10Bullock A. Burrows N.R. Narva A.S. et al.Vital signs: decrease in incidence of diabetes-related end-stage renal disease among American Indians/Alaska Natives - United States, 1996-2013.MMWR Morb Mortal Wkly Rep. 2017; 66: 26-32Crossref PubMed Scopus (34) Google Scholar Canada, Denmark, and France offer fund-assisted PD, which provides a PD-trained nurse to assist with PD in the home. The caregiver helps overcome physical and cognitive barriers that may otherwise deter a patient from pursuing home dialysis.11Oliver M.J. Salenger P. Making assisted peritoneal dialysis a reality in the United States: a Canadian and American viewpoint.Clin J Am Soc Nephrol. 2020; 15: 566-568Crossref PubMed Scopus (21) Google Scholar New Zealand offers community house HD, wherein patients undergo HD in an unstaffed, nonmedical, home-like setting. The majority of patients using these facilities are younger, minority Māori or Pacific, who report a perceived sense of preservation of identity as well as community support.12Walker R.C. Tipene-Leach D. Graham A. Palmer S.C. Patients' experiences of community house hemodialysis: a qualitative study.Kidney Med. 2019; 1: 338-346Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Finally, telehealth may address geographic barriers to care in rural areas where patients live further away from their facility.13Krishna V.N. Managadi K. Smith M. Wallace E. Telehealth in the delivery of home dialysis care: catching up with technology.Adv Chronic Kidney Dis. 2017; 24: 12-16Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Another important opportunity gleaned from the current study is that adjustment for pre-KRT nephrology care narrowed disparities across all age groups. This finding is consistent with established evidence that predialysis care by nephrology providers results in improved outcomes and offers a concrete approach to mitigating disparities.14Smart N.A. Dieberg G. Ladhani M. Titus T. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease.Cochrane Database Syst Rev. 2014; CD007333PubMed Google Scholar Multidisciplinary advanced CKD clinics have been shown to help address gaps in health literacy, modality education, and home dialysis uptake, as well as emotional and financial burdens.15Chen P.M. Lai T.S. Chen P.Y. et al.Multidisciplinary care program for advanced chronic kidney disease: reduces renal replacement and medical costs.Am J Med. 2015; 128: 68-76Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 16Khan S.S. Xue J.L. Kazmi W.H. et al.Does predialysis nephrology care influence patient survival after initiation of dialysis?.Kidney Int. 2005; 67: 1038-1046Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 17Fishbane S. Agoritsas S. Bellucci A. et al.Augmented nurse care management in CKD stages 4 to 5: a randomized trial.Am J Kidney Dis. 2017; 70: 498-505Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar However, these models of care have not been implemented with the clear goal of addressing disparities. Given the racial reckoning that has happened nationally and within the kidney community over the past 2 years,18Mohottige D Gibson K Staying on track to achieve racial justice in kidney care.Nat Rev Nephrol. 2022; 18: 72-73Crossref PubMed Scopus (4) Google Scholar,19Taylor K. Crews D.C. Toward antiracist reimbursement policy in end-stage kidney disease: from equality to equity.J Am Soc Nephrol. 2021; 32: 2422-2424Crossref PubMed Scopus (4) Google Scholar now is the time to design, implement, and iterate evidence-based, innovative strategies to close long-established disparity gaps. The kidney health community has witnessed a confluence of factors impacting vulnerable patient groups with historically poor clinical outcomes. Coronavirus disease 2019 has disproportionally impacted Black and Hispanic persons, who are at higher risk for CKD, hospitalization, and critical illness.19Taylor K. Crews D.C. Toward antiracist reimbursement policy in end-stage kidney disease: from equality to equity.J Am Soc Nephrol. 2021; 32: 2422-2424Crossref PubMed Scopus (4) Google Scholar A national taskforce reached consensus on a race-free approach to estimating glomerular filtration and adopting race-free biomarkers such as cystatin C, as one potential strategy to mitigate disparate care delivery based on kidney function, including access to transplant.20Delgado C. Baweja M. Crews D.C. et al.A unifying approach for GFR estimation: recommendations of the NKF-ASN task force on reassessing the inclusion of race in diagnosing kidney disease.Am J Kidney Dis. 2022; 79: 268-288.e1Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar In addition, in 2019 the Advancing American Kidney Health initiative was announced with the goal of increasing utilization of home dialysis and transplantation at a national level. This initiative leverages innovative payment models that seek to align provider incentives with patient-centered care and includes the ESRD Treatment Choices (ETC) model, which randomizes dialysis providers and units to receive payment adjustments based on home dialysis and transplantation rates. In July 2021, CMS announced a transformative innovation as part of the ETC final rule, titled “Health Equity Incentive,” which provides financial incentives for dialysis providers who demonstrate “sufficiently significant improvement on the home dialysis rate or transplant rate among their attributed beneficiaries who are dual eligible or receive a Medicare low-income subsidy.”21Centers for Medicare & Medicaid Services (CMS) H. Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, and End-Stage Renal Disease Treatment Choices Model. Accessed January 13, 2022. http://federalregister.gov/d/2021-23907Google Scholar This type of innovative investment in alleviating disparities is heartening and necessary across all patient groups. Investment and engagement are needed across various stakeholder groups—kidney care providers and practices; dialysis organizations; health systems; local, state, and the federal government—to transform kidney care delivery and achieve health equity for all patients. Katherine M. Wang MD, MS, and Mallika L. Mendu MD, MBA. None. The authors declare that they have no relevant financial interests. Received January 18, 2022, in response to an invitation from the journal. Direct editorial input from an Associate Editor and a Deputy Editor. Accepted in revised form February 5, 2022. Racial and Ethnic Disparities in Kidney Replacement Therapies Among Adults With Kidney Failure: An Observational Study of Variation by Patient AgeAmerican Journal of Kidney DiseasesVol. 80Issue 1PreviewNon-Hispanic Black and Hispanic patients present with kidney failure at younger ages than White patients. Younger patients are also more likely to receive transplants and home dialysis than in-center hemodialysis (ICHD), but it is unknown whether racial and ethnic disparities in treatment differ by age. We compared use of kidney replacement therapies between racial and ethnic groups among patients with incident kidney failure overall and by age. Full-Text PDF