Disparities in Dialysis Modality Selection and Outcomes

Smooth transition from CKD stage 5 to renal replacement therapy (RRT) remains a challenge. This transition period bears a high risk for mortality (1); hence, it requires a multidisciplinary pre-ESRD team approach (2) to address all aspects of care aimed at improving survival and providing adequate patient education about transplantation, in-center hemodialysis (HD), and home-based therapies (3).

Often dubbed an options clinic, this team-based approach needs to be conducted when RRT is anticipated within a year, sufficient time being allowed for access placement and transplant evaluation (4). The decision to choose a modality is not straightforward, and patients often go through states of change from thinking to acting, influenced by psychosocial, socioeconomic, religious, emotional, and systems issues and other factors. In one study, nearly half of patients did not decide on a modality despite receiving adequate education (5).

Poverty, lack of insurance, African American race, and Hispanic ethnicity are independently associated with a lower likelihood of pre-ESRD nephrology care (6, 7). The benefits of pre-ESRD nephrology care, including higher rates for arteriovenous fistula placement (8, 9), access to kidney transplantation (10), choice of peritoneal dialysis (PD) (7), and improved patient survival (11) are reduced in these populations. Furthermore, the benefits of access to care by a nephrologist before RRT to address CKD-specific complications, manage comorbidities, and educate patients about the options for RRT are reduced in these populations (12, 13). These observations plausibly explain the high rates of catheter use to start HD and the low rates of transplantation and PD in these populations.

On the basis of data from the United States Renal Data System, in 2015 the adjusted ESRD incidence rate ratios for African Americans, Hispanics, Asians, American Indians/Alaska Natives, and Native Hawaiians/Pacific Islanders, compared with whites, were 3.0, 1.3, 1.0, 1.2, and 8.4, respectively. The good news is that the excess risk of ESRD among minorities compared with whites over the past 15 years has declined (Figure 1). Most incident ESRD patients (87.3%) began RRT with HD, and 9.6% started with PD. As shown in Table 1, the percentage of African American incident ESRD patients who started with HD was slightly higher (91.1%) than for whites (87.3%) or Hispanics (89.3%). The rates were lower for PD in African Americans (8.1%) than in whites (9.9%) and Hispanics (9.1%) (14). These differences are not statistically different (χ2 0.24; p = 0.9).

Figure 1.

Improvement in the incidence ratios across minority groups over the past 15 years

































Interestingly, African American patients have better survival when using HD compared with whites in all age groups above 30 years. In the 18- to 30-year age group, there remains an increased mortality risk in non-Hispanic blacks versus non-Hispanic whites after adjustment for case mix (adjusted hazard ratio 1.19; 95% confidence interval 1.13–1.25) (15). Higher lean body mass is associated with a lower risk of mortality in HD patients, especially among non-Hispanic whites and African Americans (16). It can be postulated that the higher lean body mass observed in older African Americans at the initiation of dialysis withstands the catabolic state induced by uremia much longer and hence accounts for the better survival compared with other groups. However, no clear biologic mechanisms have been identified to explain these findings. Many investigators have looked at disparities in such factors as duration of dialysis treatments, achieved Kt/V, anemia management targets, lipid abnormalities, phosphorus levels, fibroblast growth factor 23 levels (17), nutritional profile, and different responses to inflammation (18), to explain the differences in survival. Levels of serum calcium, parathyroid hormone, and vitamin D have not been shown to be consistently associated with mortality.

It is also important to note that the size and location of a dialysis facility and the number of patients being treated can influence care and outcomes. In one study, facilities with 16 or more stations conferred a survival benefit. The association between increased mortality and facilities with 15 or fewer stations was stronger for racial minorities and for patients with diabetes or cardiovascular diseases. After adjustments, blacks had a 78% greater 1-year mortality risk in facilities with one to five stations, whereas whites had only a 26% greater risk (19). The authors explained that potential financial constraints faced by the small facilities may limit the opportunities for rigorous clinical care protocols and implementing measures for quality improvement. Consequently, small facilities may lack the experience to care for diabetic and cardiovascular patients and racial/ethnic minorities.

January 2019 (Vol. 11, Number 1)


1. Sim JJ, et al. Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters. Int Urol Nephrol 2018; 50:963–971.

2. Thanamayooran S, Rose C, Hirsch DJ. Effectiveness of a multidisciplinary kidney disease clinic in achieving treatment guideline targets. Nephrol Dial Transplant 2005; 20:2385–2393.

3. Manns BJ, et al. The impact of education on chronic kidney disease patients’ plans to initiate dialysis with self-care dialysis: A randomized trial. Kidney Int 2005; 68:1777–1783.

4. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2012; 2:1–138

5. Hanko J, et al. Optimizing AVF creation prior to dialysis start: The role of predialysis renal replacement therapy choices. Nephrol Dial Transplant 2012; 27:4205–4210.

6. Nee R, et al. Impact of poverty and race on pre-end-stage renal disease care among dialysis patients in the United States. Clin Kidney J 2017; 10:55–61.

7. Gillespie BW, et al. Nephrology care prior to end-stage renal disease and outcomes among new ESRD patients in the USA. Clin Kidney J 2015; 8:772–780

8. Astor BC, et al. Timing of nephrologist referral and arteriovenous access use: The CHOICE Study. Am J Kidney Dis 2001; 38:494–501.

9. Ishani A, et al. Predialysis care and dialysis outcomes in hemodialysis patients with a functioning fistula. Am J Nephrol 2014; 39:238–247.

10. Winkelmayer WC, et al. Predialysis nephrologist care and access to kidney transplantation in the United States. Am J Transplant 2007; 7:872–879.

11. Singhal R, et al. Inadequate predialysis care and mortality after initiation of renal replacement therapy. Kidney Int 2014; 86:399–406.

12. Smart NA, Titus TT. Outcomes of early versus late nephrology referral in chronic kidney disease: A systematic review. Am J Med 2011; 124:1073–1080.

13. Prakash S, et al. Behavioral stage of change and dialysis decision-making. Clin J Am Soc Nephrol 2015; 10:197–204.

14. United States Renal Data System. 2016 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2016. https://www.usrds.org/2017/view/v2_01.aspx.

15. Yan G, et al. The relationship of age, race, and ethnicity with survival in dialysis patients. Clin J Am Soc Nephrol 2013; 8:953–961.

16. Wang J, et al. Lean body mass and survival in hemodialysis patients and the roles of race and ethnicity. J Ren Nutr 2016; 26:26–37.

17. Scialla JJ, et al. Race, mineral homeostasis and mortality in patients with end-stage renal disease on dialysis. Am J Nephrol 2015; 42:25–34.

18. Kalantar-Zadeh K, Norris KC. Is the malnutrition-inflammation complex the secret behind greater survival of African-American dialysis patients? J Am Soc Nephrol 2011; 22:2150–2152.

19. Yan G, et al. Facility size, race and ethnicity, and mortality for in-center hemodialysis. J Am Soc Nephrol 2013; 24:2062–2070.