Association of Serious Fall Injuries among United States End Stage Kidney Disease Patients with Access to Kidney Transplantation

Abstract

Background and objectives: Serious fall injuries in the setting of ESKD may be associated with poor access to kidney transplant. We explored the burden of serious fall injuries among patients on dialysis and patients on the deceased donor waitlist and the associations of these fall injuries with waitlisting and transplantation.

Design, setting, participants, & measurements: Our analytic cohorts for the outcomes of (1) waitlisting and (2) transplantation included United States adults ages 18-80 years old who (1) initiated dialysis (n=183,047) and (2) were waitlisted for the first time (n=37,752) in 2010-2013. Serious fall injuries were determined by diagnostic codes for falls plus injury (fracture, joint dislocation, or head trauma) in inpatient and emergency department claims; the first serious fall injury after cohort entry was included as a time-varying exposure. Follow-up ended at the specified outcome, death, or the last date of follow-up (September 30, 2014). We used multivariable Cox proportional hazards models to determine the independent associations between serious fall injury and waitlisting or transplantation.

Results: Overall, 2-year cumulative incidence of serious fall injury was 6% among patients on incident dialysis; with adjustment, patients who had serious fall injuries were 61% less likely to be waitlisted than patients who did not (hazard ratio, 0.39; 95% confidence interval, 0.35 to 0.44). Among incident waitlisted patients (4% 2-year cumulative incidence), those with serious fall injuries were 29% less likely than their counterparts to be subsequently transplanted (hazard ratio, 0.71; 95% confidence interval, 0.63 to 0.80).

Conclusions: Serious fall injuries among United States patients on dialysis are associated with substantially lower likelihood of waitlisting for and receipt of a kidney transplant.

Keywords: Accidental Falls; Adult; Bone; Chronic; Craniocerebral Trauma; ESKD; Emergency Service; Follow-Up Studies; Fractures; Hospital; Humans; Incidence; Inpatients; Joint Dislocations; Kidney Failure; Proportional Hazards Models; Tissue Donors; United States; Waiting Lists; geriatric nephrology; kidney transplantation; renal dialysis.

Graphical abstract

Figure 1.

Study exclusions leading to cohorts of 183,047 dialysis patients and 37,752 waitlisted patients. Flow of participants in incident 2010–2013 United States cohorts of (A) patients on dialysis and (B) waitlisted patients.

Figure 2.

The study timeline shows that cohort entry began at 90 days for dialysis patients and at the date of waitlisting for waitlisted patients, with patients followed until outcome or censoring. Cohort entry (dotted line), follow-up, and ascertainment of serious fall injuries for incident 2010–2013 United States cohorts of (A) patients on dialysis and (B) waitlisted patients.

Figure 3.

Over 5 years of follow-up, dialysis patients were more likely to die than to be waitlisted, and this effect was more pronounced among those who experienced a serious fall injury over follow-up. (A) Cumulative incidence of death and waitlisting among patients on dialysis who did not experience a serious fall injury during follow-up. (B) Cumulative incidence of death and waitlisting among patients on dialysis who experienced a serious fall injury at any point during follow-up.

Figure 4.

Over 5 years of follow-up, waitlisted patients without a serious fall injury were more likely to be transplanted than to die, but the opposite was true for those with a serious fall injury. (A) Cumulative incidence of death and transplant among waitlisted patients who did not experience a serious fall injury during follow-up. (B) Cumulative incidence of death and transplant among waitlisted patients who experienced a serious fall injury at any point during follow-up.