Racial and Ethnic Disparities in Use of and Outcomes with Home Dialysis in the United States

Abstract

Home dialysis, which comprises peritoneal dialysis (PD) or home hemodialysis (home HD), offers patients with ESRD greater flexibility and independence. Although ESRD disproportionately affects racial/ethnic minorities, data on disparities in use and outcomes with home dialysis are sparse. We analyzed data of patients who initiated maintenance 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 December 31, 2011 (n =: 162,050, of which 17,791 underwent PD and 2536 underwent home HD for ≥91 days). Every racial/ethnic minority group was significantly less likely to be treated with home dialysis than whites. Among individuals treated with in-center HD or PD, racial/ethnic minorities had a lower risk for death than whites; among individuals undergoing home HD, only blacks had a significantly lower death risk 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 undergoing PD had a lower risk than whites undergoing PD. 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 white counterparts to receive a kidney transplant. In conclusion, there are racial/ethnic disparities in use of and outcomes with home dialysis in the United States. Disparities in kidney transplantation evident for blacks and Hispanics undergoing home dialysis are similar to those with in-center HD. Future studies should identify modifiable causes for these disparities.

Keywords: end-stage renal disease; hemodialysis; peritoneal dialysis.

Figure 1.

Association of race/ethnicity with treatment with PD or home HD. Unadjusted and adjusted odds ratio for blacks, Hispanics, Asians, and others (reference: whites) to be treated for at least one 91-day period with (A) PD or (B) home HD for 162,050 patients who started dialysis between January 1, 2007 and December 31, 2011. Compared to whites, the adjusted odds ratio and 95% confidence interval for (A) PD: black, 0.53 (0.50, 0.56); Hispanic, 0.57 (0.53, 0.61); Asian, 0.82 (0.72, 0.93); and Other, 0.60 (0.52, 0.68); and (B) Home HD: black, 0.40 (0.36, 0.44); Hispanic, 0.25 (0.21, 0.30); Asian, 0.53 (0.41, 0.69); and Other, 0.44 (0.33, 0.57).

Figure 2.

Association of race/ethnicity and initial primary health insurance with treatment with PD or home HD. Adjusted odds for blacks, Hispanics, Asians, and others (reference: whites) to be treated for at least one 91-day period with (A) PD or (B) home HD for 162,050 patients who started dialysis between January 1, 2007 and December 31, 2011, stratified by initial primary health insurance. The group ‘other’ includes patients with Medicare Advantage plans, managed care Medicaid, and employer–based health insurance.

Figure 3.

Association of race/ethnicity with mortality among patients undergoing PD or home HD. Unadjusted and adjusted hazards ratio for blacks, Hispanics, Asians, and others for all-cause mortality among those treated with (A) PD, (B) home HD, and (C) in-center HD. Hazard ratios are presented for models that are (1) unadjusted; (2) adjusted for age, sex, and diabetes; and (3) fully adjusted. Compared to whites, the hazards ratios, adjusted for age, gender, and diabetes mellitus, and 95% confidence interval for all-cause mortality among those treated with (A) PD: black, 0.63 (0.56, 0.71); Hispanic, 0.64 (0.55, 0.75); Asian, 0.49 (0.38, 0.64); and other, 0.75 (0.59, 0.95); (B) home HD: black, 0.57 (0.37, 0.89); Hispanic, 0.85 (0.45, 1.60); Asian, 0.58 (0.19, 1.77); and other, 0.37 (0.09, 1.48); and (C) in-center HD: black, 0.73 (0.72, 0.75); Hispanic, 0.62 (0.60, 0.64); Asian, 0.55 (0.52, 0.59); and other, 0.67 (0.63, 0.71).

Figure 4.

Association of race/ethnicity with transfer to in-center HD among patients undergoing PD or home HD. Unadjusted and adjusted hazards ratio for blacks, Hispanics, Asians, and others for transferring to in-center HD among those treated with (A) PD and (B) home HD. Hazard ratios are presented for models that are (1) unadjusted; (2) adjusted for age, sex, and diabetes; and (3) fully adjusted. Compared to whites, the hazards ratios, adjusted for age, gender, and diabetes mellitus, and 95% confidence interval for transfer to in-center HD among those treated with (A) PD: black, 1.37 (1.26, 1.49); Hispanic, 1.07 (0.96, 1.19); Asian, 0.74 (0.60, 0.91); and other, 0.86 (0.69, 1.06); and (B) home HD: black, 1.41 (1.12, 1.77); Hispanic, 1.45 (0.97, 2.16); Asian, 0.56 (0.25, 1.28); and other, 1.13 (0.60, 2.14).

Figure 5.

Association of race/ethnicity with probability of receiving kidney transplantation among patients undergoing PD or home HD. Unadjusted and adjusted hazards ratios for blacks, Hispanics, Asians, and others for receiving a kidney transplant among those treated with (A) PD, (B) home HD, and (C) in-center HD. Hazard ratios are presented for models that are (1) unadjusted; (2) adjusted for age, sex, and diabetes; and (3) fully adjusted. Compared to whites, the hazards ratios, adjusted for age, gender, and diabetes mellitus, and 95% confidence interval for undergoing kidney transplantation among those treated with (A) PD: black, 0.54 (0.47, 0.62); Hispanic, 0.52 (0.44, 0.62); Asian, 0.88 (0.69, 1.12); and other, 0.77 (0.58, 1.03); (B) home HD: black, 0.57 (0.40, 0.83); Hispanic, 0.84 (0.46, 1.53); Asian, 0.81 (0.36, 1.83); and other, 0.51 (0.16, 1.62); and (C) in-center HD: black, 0.39 (0.36, 0.42); Hispanic, 0.52 (0.49, 0.58); Asian, 0.78 (0.66, 0.91); and other, 0.70 (0.61, 0.82).