IMPORTANCE Undocumented immigrants with end-stage renal disease have variable access to hemodialysis in the United States despite evidence-based standards for frequency of dialysis care. OBJECTIVE To determine whether mortality and health care use differs among undocumented immigrants who receive emergency-only hemodialysis vs standard hemodialysis (3 times weekly at a health care center). DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted of undocumented immigrants with incident end-stage renal disease who initiated emergency-only hemodialysis

No abstract

No abstract

Robert Wood Johnson Foundation and Doris Duke Charitable Foundation.

The cost of dialysis for the estimated 6500 dialysis-dependent undocumented individuals with kidney failure in the United States is high, the quality of dialysis care they receive is poor, and their treatment varies regionally. Some regions use state and matched federal funds to cover regularly scheduled dialysis treatments, while others provide treatment only in emergent life-threatening conditions. Nephrologists caring for patients who receive emergent dialysis are tasked with the difficult moral dilemma of determining "who gets dialysis that day." Without a path to citizenship and by exclusion from the federal marketplace exchanges, undocumented individuals have limited options for their treatment. A novel opportunity to provide scheduled dialysis for this population is through the purchase of insurance off the exchange. Plans purchased off the exchange must still abide by the 2014 provision of the Patient Protection and Affordable Care Act, which prohibits insurance companies from denying coverage based on a preexisting health condition. In 2015 and 2016, >100 patients previously receiving only emergent dialysis at the two largest safety-net hospital systems in Texas obtained off-the-exchange commercial health insurance plans. These undocumented patients now receive scheduled dialysis treatments, which has improved their care and quality of life, as well as decompressed the overburdened hospital systems. The long-term sustainability of this option is not known. Socially responsive and visionary policymakers allowing the move into this bold, new direction deserve special appreciation.

The care of dialysis-dependent undocumented immigrants exemplifies a problem at the crux of 2 US national agendas: immigration and health care reform. Undocumented immigrants represent 3% of the US population and 27% of the uninsured, and an estimated 6,500 individuals are dialysis dependent. With no uniform national policy, an estimated 30% to 50% of these individuals receive treatment only in life-threatening situations (emergent dialysis). Since 2005, about 400 undocumented immigrants have received a kidney transplant (>70% living). Although the Affordable Care Act specifically excluded noncitizens, its policies have indirectly allowed more than 200 individuals to purchase insurance from a health insurance exchange and transition from emergent to thrice-weekly hemodialysis. Under the Trump administration, uncertainties with health care plans, threats of deportation, and rescinding of policies such as sanctuary city status are bound to result in unforeseen challenges for this vulnerable population. Global variation in the care accessible to migrants, refugees, undocumented immigrants, and asylum seekers argues for the need for a framework to transform advocacy into public policy to improve the lives of patients with kidney disease worldwide. Access to nonemergent dialysis is humane and cost-effective; it deserves to be espoused and advocated by leading medical organizations.

Although current therapies for pretransplant desensitization and treatment of antibody-mediated rejection (AMR) have had some success, they do not specifically deplete plasma cells that produce antihuman leukocyte antigen (HLA) antibodies. Bortezomib, a proteasome inhibitor approved for the treatment of multiple myeloma (a plasma cell neoplasm), induces plasma cell apoptosis. In this paper we review the current body of literature regarding the use of this biological agent in the field of transplantation. Although limited experience with bortezomib may seem to show promise in the realm of transplant recipients desensitization and treatment of AMR, there is also experience that may suggest otherwise. Bortezomib's role in desensitization protocols and treatment of AMR will be defined better as more clinical data and trials become available.

Emergent hemodialysis is the practice of dialyzing a patient only when there is a life-threatening need for this treatment. Undocumented immigrants in many cities depend on this practice, as they are not entitled to the regularly scheduled hemodialysis treatments available to US citizens. There are several medical and ethical challenges to emergent hemodialysis. One example is defining the criteria that determine the need for an emergent treatment. Although it is lifesaving, emergent dialysis is inadequate dialysis; it results in unnecessary patient complications, is medically burdensome for the treating physician, and expensive to the providing facility. This article describes how undocumented immigrants are cared for in one county hospital system in a large city.