Gender and Racial Disparities in Initial Hemodialysis Access and Outcomes in Incident End-Stage Renal Disease Patients

Abstract

Background: Arteriovenous (AV) access confers survival benefits over central venous catheters (CVC) in hemodialysis patients. Although chronic kidney disease disproportionately affects women and racial minorities, disparities in the -utilization of hemodialysis access across Asians, Native Americans, Hispanics, blacks, and whites among males and females after accounting for pre-dialysis health are not well studied.

Methods: We evaluated 885,699 patients with end-stage renal disease who initiated hemodialysis between January 1, 2004 and December 31, 2014 using the US Renal Data System. Multivariable logistic regression models -adjusted for pre-dialysis health were used to test the associations between gender and race on type of vascular access (AV access vs. CVC, and AV fistula vs. AV graft) at hemodialysis initiation as primary outcome, and on 1-year mortality as a secondary outcome.

Results: Mean age was 65 ± 14 years. Females were less likely to use AV access for hemodialysis initiation than were males (OR 0.85; 95% CI 0.84-0.86). Compared to whites, adjusted odds of AV access for hemodialysis initiation were higher in blacks (OR 1.08; 95% CI 1.07-1.70), Asians (OR 1.11; 95% CI 1.07-1.14); and lower in Hispanics (OR 0.89; 95% CI 0.87-0.90). There was no -significant difference in mortality between males and females. Compared to whites, 1-year adjusted mortality was lower in Asians (OR 0.55; 95% CI 0.53-0.56), blacks (OR 0.67; 95% CI 0.66-0.68), Hispanics (OR 0.62; 95% CI 0.61-0.63), and Native Americans (OR 0.62; 95% CI 0.58-0.66).

Conclusion: Females had lower odds of using AV access than do males for hemodialysis initiation. As compared to whites, blacks and Asians were more likely, and Hispanics were less likely to use AV access for first outpatient hemodialysis. Further investigation of biological and process of care factors may help in developing ways to reduce these disparities.

Keywords: Disparities; Gender; Hemodialysis; Mortality; Race; Vascular access.

Fig. 1.

Flow diagram showing the cohort selection process.

Fig. 2.

Distribution of vascular access used for incident hemodialysis in the United States by race and gender. p value < 0.001 for difference in use of 3 access types across 5 races. p value < 0.001 for difference in use of 3 access types between males and females. p value < 0.001 for difference in use of 3 access types across 10 groups by race and gender. AV, arteriovenous.

Fig. 3.

Associations between race and gender and use of AV access for the initiation of hemodialysis among patients with ESRD in United States. Adjusted and unadjusted odds ratios for probability of (a) AV access use versus CVC to initiate hemodialysis, and (b) AV fistula use versus AV graft use to initiate hemodialysis. a Compared to white patients, the ORs, fully adjusted, and 95% CIs for AV access in incident ESRD patients by race: blacks, 1.08 (1.07–1.10); Hispanics, 0.89 (0.87–0.90); Asians, 1.11 (1.07–1.14); and Native Americans, 1.04 (0.98–1.10). Compared to male patients, the ORs, fully adjusted, and 95% CI for females, 0.85 (0.84–0.86). b Compared to white patients, the ORs, fully adjusted, and 95% CIs for AV fistula in incident ESRD patients by race: blacks, 0.52 (0.50–0.54); Hispanics, 0.93 (0.89–0.98); Asians, 0.88 (0.83–0.94); and Native Americans, 1.30 (1.12–1.52). Compared to male patients, the OR, fully adjusted, and 95% CI for female patients, 0.45 (0.44–0.47). AV, arteriovenous; CVC, central venous catheter.

Fig. 4.

Associations between race and gender and 1 year mortality following initiation of hemodialysis among patients with ESRD. Adjusted and unadjusted OR for probability of 1-year mortality. Compared to white patients, the odds ratios, fully adjusted, and 95% CIs in incident ESRD patients by race: blacks, 0.67 (0.66–0.68); Hispanics, 0.62 (0.61–0.63); Asians, 0.55 (0.53–0.56); and Native Americans, 0.62 (0.58–0.66). Compared to male patients, the OR, fully adjusted, and 95% CI for female patients, 1.01 (1.00–1.02).