What does it take for a man to refuse lifesaving dialysis? Despite thorough counseling, our team stood still as our patient continued to refuse hemodialysis for his kidney failure. Admitted because of his severely elevated potassium levels, he understood his imminent risk for sudden cardiac arrest. Yet, as the buildup of toxins in his bloodstream worsened his lethargic and nauseated state, he remained adamant that his family lacked the means to continue with the emergency dialysis he needed to survive.
For our patients of undocumented status, the tragic lack of access to scheduled dialysis is all too common.
An estimated 6500 undocumented immigrants with kidney failure live in the United States (1). Whereas all American citizens who either qualify for Social Security or are dependents of persons who qualify are guaranteed coverage for dialysis by the End-Stage Renal Disease Amendment to the Social Security Act (2, 3), this coverage does not extend to patients of undocumented status. Thus, these patients’ care varies vastly between states. Twelve states provide Medicaid or emergency care coverage for scheduled dialysis (4). Yet, in the majority of states in this country, patients qualify for intermittent emergency dialysis only in the presence of life-threatening laboratory abnormalities or symptoms under the 1986 Emergency Medicaid Treatment and Active Labor Act (EMTALA) (5). After treatment, patients are instructed to return to the emergency department when their symptoms inevitably worsen.
Studies have consistently demonstrated the consequences of emergency-only dialysis, including life-threatening physical symptoms and psychosocial stressors for patients, in addition to harms experienced by clinicians and the public at large. Undocumented patients receiving emergency dialysis have a 14-fold higher odds ratio of death (6) and a lower quality of life in comparison with undocumented patients receiving scheduled dialysis (7). In some cases, symptoms from uremic toxins have been so distressing that patients have reported intentionally consuming high levels of potassium with the goal of satisfying the criteria for emergency dialysis (8).
Despite the injustice placed on patients and their families when we resort to emergency-only dialysis, studies have also highlighted the significant toll placed on our healthcare system, especially safety-net hospitals. Compared with their counterparts receiving scheduled care, patients of undocumented status receiving emergency-only dialysis were found, on average, to require more days of inpatient care (162 days vs. 10 days), more emergency department visits (26.3 vs. 1.4), more blood transfusions (24.9 vs. 2.2) and greater yearly costs ($284,655 vs. $76,906) (9, 10).
A study in Texas noted cost savings of $4316 per patient per month after the transition from emergency-only dialysis to scheduled dialysis (11). The cost savings from reductions in healthcare expenditures were noted to exceed the cost increases from vascular access and scheduled dialysis (11, 12). In addition to increased patient morbidity and poor quality of life, there is the well-documented burden of emergency dialysis on the use of healthcare. This is particularly of concern for hospitals such as Grady Memorial Hospital, Atlanta’s major safety-net hospital, which reported that its 88 dialysis patients accounted for one-tenth of Grady’s total losses despite representing only a small fraction of the greater than 800,000 patient visits it completed that year (13).
In addition to advocating for the universal implementation of scheduled dialysis, a crucial part of the solution lies in improving access to screening and preventive care. This can be approached on the continuum of disease prevention, from primary prevention in addressing common risk factors such as diabetes and high blood pressure, to slowing the progression of chronic kidney disease.
Kidney disease often has no symptoms, but simple urine or blood tests can detect early disease and alert clinicians to manage risk factors aggressively. Notably, risk factors such as diabetes and high blood pressure can be managed in impressively cost-effective ways. Affordable generic medications can be made available at $4 and $10 at major retail corporations, such as Walmart and Target, and thus be made accessible to low-income populations (14, 15). Given that many undocumented immigrants have difficulty navigating the healthcare system in the United States and often rely on federally qualified health centers, population-specific implementation of public health initiatives and outreach can be beneficial for both patients and communities.
Scheduled dialysis is the standard of care for all patients with kidney failure and should be accessible to all people with kidney failure. It has been shown to reduce mortality, healthcare use, and costs when compared with emergency-only dialysis (1, 2, 4–7, 9–11). The universal practice of scheduled dialysis, in place of emergency-only dialysis, avoids the psychosocial distress that plagues both patients and the clinicians who care for them.
As professionals who all take an oath to uphold the highest standard of care and humanism, we cannot let the citizenship status of our patients define the lifesaving care we provide. As individual physicians, we face the front line and witness the impact of harmful policy on our patients’ lives. Our profession has the power to have an impact on policies and, most important, advocate on behalf of the patients and communities we serve. Together we can do better, and we must.
Rodriguez RA. Dialysis for undocumented immigrants in the United States. Adv Chronic Kidney Dis 2015; 22:60–65.
Cervantes L, Mundo W, Powe NR. The status of provision of standard outpatient dialysis for US undocumented immigrants with ESKD. Clin J Am Soc Nephrol 2019; 14:1258–1260.
Cervantes L, Grafals M, Rodriguez RA. The United States needs a national policy on dialysis for undocumented immigrants with kidney failure. Am J Kidney Dis 2018; 71:157–159.
Cervantes L, et al.. Association of emergency-only vs. standard hemodialysis with mortality and health care use among undocumented immigrants with end-stage renal disease. JAMA Int Med 2018; 178:188–195.
Hogan AN, et al.. Emergent dialysis and its impact on quality of life in undocumented patients with end-stage renal disease. Ethn Dis 2017; 27:39–44.
Roberti J, et al.. Work of being an adult patient with chronic kidney disease: A systematic review of qualitative studies. BMJ Open 2018; 8:e023507.
Sheikh-Hamad D, et al.. Care for immigrants with end-stage renal disease in Houston: A comparison of two practices. Tex Med 2007; 103:54–58.
Suarez JJ. Strategies for responding to undocumented immigrants with kidney disease. AMA J Ethics 2019; 21:E86–E92.
Nguyen OK, et al.. Association of scheduled vs emergency-only dialysis with health outcomes and costs in undocumented immigrants with end-stage renal disease. JAMA Intern Med 2019; 179:175–183.
Cervantes L, et al.. The illness experience of undocumented immigrants with end-stage renal disease. JAMA Intern Med 2017; 177:529–535.
Target Pharmacy. $4 and $19 Generic medication list. https://tgtfiles.target.com/pharmacy/WCMP02-032536_RxGenericsList_NM7.pdf.
Walmart. $4 Prescriptions. https://www.walmart.com/cp/$4-prescriptions/1078664.