Temporal Trends in Incident Mortality in Dialysis Patients: Focus on Sex and Racial Disparities

Abstract

Background: Racial minorities and women constitute substantial portions of the incident and prevalent end-stage renal disease (ESRD) population in the United States. Although ESRD is characterized by high mortality, temporal trends, and race and sex differences in mortality have not been studied. Methods: We evaluated 944,650 adult patients who initiated dialysis between January 1, 2005 and December 31, 2014, using the United States Renal Data System, for sex-related and race-related trends in mortality. Logistic regression models adjusted for pre-dialysis health status were used to examine associations among the predictors’ sex, race, and year of incident dialysis, and the outcome all-cause mortality at 1-year post ESRD. Results: The mean age was 65 ± 14 years. The 1-year crude mortality rates in incident ESRD patients decreased by 28% from 2004 to 2015. Risk-adjusted 1-year mortality decreased by 3% for each later year of incident ESRD (p < 0.001). In general, from 2005 to 2014, mortality rates decreased across both sexes, and all races. White patients experienced the lowest reduction in adjusted 1-year mortality rates (16%). While women experienced a survival advantage over men in 2005, by 2014 it was reversed to survival advantage for men. Combining all years, the adjusted risk of dying at 1-year after initiating dialysis was lower in women than men (OR 0.98; 95% CI 0.97–0.99), and as compared to whites, was lower in blacks (OR 0.73; 95% CI ­0.72–0.74), Hispanics (OR 0.64; 95% CI 0.63–0.65), Asians (OR 0.55; 95% CI 0.53–0.56), and Native Americans (OR 0.67; 95% CI 0.63–0.71). Conclusion: The 1-year mortality rates among patients with ESRD have decreased steadily during a recent 10-year period across both men and women, and in all 5 races. Women have only a 2% lower risk of dying at 1-year after dialysis initiation than men. White patients had higher mortality as compared to other races. Our results suggest the need for sex, and race-specific treatment strategies in ESRD care.

Association between Ultrafiltration Rate and Clinical Outcome Is Modified by Muscle Mass in Hemodialysis Patients

“…Although the mortality rate among hemodialysis (HD) patients is on a steady decline, it is still higher than that of the general population [1,2]. Various risk factors for worse survival rates have been reported [3][4][5][6][7][8][9].…”

Survival of the Fittest: Addressing the Disparities in the Burden of Chronic Kidney Disease

“…Vart et al indicated in a meta-regression analysis study that race is possibly related to the degree of association between low SES and CKD (P value = 0.001) [19]. Additionally, they demonstrated that the relative risk (RR) of CKD in low-SES people was 58% higher in African Americans (RR, [24]. Noori et al demonstrated that there was a strong association between higher levels of C-reactive protein (CRP) and interleukin-6 (IL-6) and an increase in the adjusted mortality risks of 799 African American and white dialysis patients followed over six years [25].…”

“…However, the preponderance of ESRD is higher for minorities than their non-Hispanic white counterparts ( Table 2). The study by Shah et al concluded that even though the likelihood of death is higher in African Americans with CKD than in non-Hispanic individuals with CKD, once ESRD is established, there is a reversal in the trend [24]. The racial/ethnic differences in inflammation highlighted by Noori et al may be the reason for the unexpected difference in survival between African American and white patients on dialysis [25].…”

“…After adjusting for age, gender, and diabetes, the increased risk for blacks versus whites was moderately affected. Shah et al demonstrated that after the initiation of dialysis, the adjusted risk of dying at one year was lower in blacks (OR, 0.73; 95% CI, 0.72-0.74), Hispanics (OR, 0.64; 95% CI, 0.63-0.65), Asians (OR, 0.55; 95% CI, 0.53-0.56), and Native Americans (OR, 0.67; 95% CI, 0.63-0.71) as compared to whites [ 24 ]. Noori et al demonstrated that there was a strong association between higher levels of C-reactive protein (CRP) and interleukin-6 (IL-6) and an increase in the adjusted mortality risks of 799 African American and white dialysis patients followed over six years [ 25 ].…”

Briefly Noted

“…USRDS data for 944,650 dialysis patients for 2005 – 2014 found that the 1 year adjusted mortality rates were lower for blacks (OR 0.73), Hispanics (OR 0.64), Asians (OR 0.55) and Native Americans (OR 0.67) compared with whites (CR 1.0); over the study period mortality rates fell for both men (28.3% to 20.2%) and women (28.4% to 20.7%). Closer analysis found that the survival advantage for women (observed in 2005) changed to an advantage for men (observed in 2014), quite different from the gender difference favoring women in the general population …”