Elaine Ku1, Wei Yang2, Charles E McCulloch3, Harold I Feldman4, Alan S Go5, James Lash6, Nisha Bansal7, Jiang He8, Ed Horwitz9, Ana C Ricardo6, Tariq Shafi10, James Sondheimer11, Raymond R Townsend12, Sushrut S Waikar13, Chi-Yuan Hsu14. 1. Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA; Division of Pediatric Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, CA. Electronic address: elaine.ku@ucsf.edu. 2. Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. 3. Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA. 4. Division of Nephrology, Department of Medicine, University of Pennsylvania, Philadelphia, PA. 5. Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, San Francisco, CA. 6. Division of Nephrology, Department of Medicine, University of Illinois, Chicago, IL. 7. Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA. 8. Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA. 9. Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland OH. 10. Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD. 11. Department of Medicine, Wayne State University, Detroit MI. 12. Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. 13. Division of Nephrology, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA. 14. Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA.
Abstract
RATIONALE & OBJECTIVES: Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy. STUDY DESIGN: Retrospective cohort study. SETTINGS & PARTICIPANTS: 3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment. EXPOSURE: Race. OUTCOME: Mortality. ANALYTIC APPROACH: Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC. RESULTS: During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28). LIMITATIONS: Residual confounding. CONCLUSIONS: The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.
RATIONALE & OBJECTIVES: Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy. STUDY DESIGN: Retrospective cohort study. SETTINGS & PARTICIPANTS: 3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment. EXPOSURE: Race. OUTCOME: Mortality. ANALYTIC APPROACH: Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC. RESULTS: During 7.1 years of median follow-up, 678 CRICparticipants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28). LIMITATIONS: Residual confounding. CONCLUSIONS: The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.
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