Early hospital readmission (EHR) is associated with increased morbidity, costs and transition-of-care errors. We sought to quantify rates of and risk factors for EHR after kidney transplantation (KT). We studied 32 961 Medicare primary KT recipients (2000)(2001)(2002)(2003)(2004)(2005) linked to Medicare claims through the United States Renal Data System. EHR was defined as at least one hospitalization within 30 days of initial discharge after KT. The association between EHR and recipient and transplant factors was explored using Poisson regression; hierarchical modeling was used to account for study center-level differences. The overall EHR rate was 31%, and 19 independent patient-level factors associated with EHR were identified: recipient factors included older age, African American race and various comorbidities; transplant factors included ECD, length of stay and lack of induction therapy. The unadjusted rate of EHR by center ranged from 18% to 47%, but conventional center-level factors (percent African American, percent age > 60, percent deceased donor and percent expanded criteria donor) were not associated with EHR. However, intermediate total volume and average length of stay were associated with increased EHR risk. Better identification of patients at risk for early hospital readmission following KT may guide discharge planning and early posttransplant outpatient monitoring. Key words: Hospital readmission, kidney transplantAbbreviations: BMI, body mass index; CHF, congestive heart failure; CI, confidence interval; CMS, centers for medicare and medicaid services; COPD, chronic obstructive pulmonary disease; ECD, extended criteria donor; EHR, early hospital readmission; HCV, hepatitis C virus; HLA, human leukocyte antigen; HTN, hypertension; IQR, inter-quartile range; KT, kidney transplant; MI, myocardial infarction; OPTN, organ procurement and transplant network; RR, relative risk; SD, standard deviation; USRDS, United States Renal Data System.

Context Many studies have reported that blacks survive longer on dialysis than whites. This observation is paradoxical given racial disparities in access to and quality of care, and is inconsistent with observed lower survival among blacks with chronic kidney disease. We hypothesized that age and the competing risk of transplantation modify survival differences by race. Objectives To estimate death on dialysis by race, accounting for age as an effect modifier and kidney transplantation as a competing risk. Design, Setting, and Participants An observational cohort study of 1,330,007 incident end-stage renal disease patients as captured in the United States Renal Data System between January 1, 1995 and September 28, 2009 (median potential follow-up time = 6.7 years, range 1 day-14.8 years). Multivariate age-stratified Cox proportional hazards and competing risk models were constructed to examine death on dialysis. Main Outcome Measures Death on dialysis in blacks versus whites Results Similar to previous studies, blacks had a lower death rate on dialysis compared with whites (232,361 deaths (57.1% mortality) for blacks versus 585,792 deaths (63.5% mortality) for whites, adjusted hazard ratio (aHR) 0.84, 95% CI: 0.83-0.84, p<0.001). However, stratifying by age and treating kidney transplantation as a competing risk, blacks had significantly higher mortality than their white counterparts at ages 18-30 (27.6% mortality versus 14.2%, aHR 1.93, 95% CI: 1.84-2.03), 31-40 (37.5% versus 26.8%, aHR 1.46, 95% CI: 1.41-1.50), and 41-50 (44.8% versus 38.0%, aHR 1.12, 95% CI: 1.10-1.14, p <0.001 for interaction terms between race and each prior age category), as opposed to those 51-60 (51.5% versus 50.9%, aHR 0.93, 95% CI: 0.92-0.94), 61-70 (64.9% versus 67.2%, aHR 0.87, 95% CI: 0.86-0.88), 71-80 (76.1% versus 79.7%, aHR 0.85, 95% CI: 0.84-0.86), and > 80 (82.4% versus 83.6%, aHR 0.87, 95% CI: 0.85-0.88). Conclusions Overall, among dialysis patients in the United States, there was a lower risk of death for black patients compared to their white counterparts. However, the commonly cited dialysis survival advantage for blacks applies only to older adults, and those under the age of 50 have a higher risk of death.

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