Variation in initial kidney replacement therapy for end‐stage renal disease due to lupus nephritis in the United States

Abstract

Objective Little is known about patterns of use of initial kidney replacement therapies among patients with LN end-stage renal disease (LN ESRD). We aimed to identify sociodemographic and clinical factors associated with variation in initial kidney replacement therapies among LN ESRD patients. Methods Patients with incident LN ESRD (1995–2006) were identified in the US Renal Data System. Age, sex, race, ethnicity, medical insurance, employment status, residential region, clinical factors and comorbidities were considered as potential predictors of ESRD treatment choice -- peritoneal dialysis (PD), hemodialysis (HD) or pre-emptive kidney transplantation -- in age-adjusted and multivariable-adjusted logistic regression analyses. Results Of 11,317 individuals with incident LN ESRD, 82.0% initiated HD; 12.2% PD, and 2.8% underwent pre-emptive kidney transplantation. Receiving initial PD was significantly associated with earlier calendar year, female sex, higher albumin and hemoglobin, and lower serum creatinine levels. African Americans (vs. Whites), Medicaid beneficiaries and those with no health insurance (vs. private insurance), and those unemployed (vs. employed) had significantly reduced PD initiation. Comorbidities including congestive heart failure, peripheral vascular disease and inability to ambulate were also associated with decreased PD. Many sociodemographic and clinical factors favoring PD were associated with pre-emptive kidney transplant (vs. dialysis) as well. Conclusion Few patients with LN ESRD receive initial PD or pre-emptive kidney transplantation. Race, ethnicity, employment and medical insurance type are strongly associated with initial kidney replacement therapy choice. Future studies need to investigate the appropriateness of sociodemographic and clinical variation and the comparative effectiveness of kidney replacement therapies for LN ESRD.

Systemic lupus erythematous and clinical outcomes in peritoneal dialysis

“…17,18 Nevertheless, only a small percentage of SLE patients start their RRT in PD. 19 Our study confirms a similar survival rate between SLE and non-SLE patients. Highlighted within the data is that causes of death differ between these groups.…”

Racial and Ethnic Differences in Mortality and Cardiovascular Events Among Patients With End‐Stage Renal Disease Due to Lupus Nephritis

“…Adjustment for multiple comorbidities and renal replacement therapy modality was possible and multiple stratified and sensitivity analyses were performed to fully investigate the reported associations. Given the differential access to kidney transplantation observed in LN ESRD and differences rates of loss to follow-up in the present study, we performed competing risk analyses, accounting for the competing risks of loss to follow-up and kidney transplantation 37 . In summary, we observed important variation in CV outcomes and mortality by race and ethnicity among LN ESRD patients.…”

Comparison of Mortality of ESRD Patients with Lupus by Initial Dialysis Modality

“…Peritoneal dialysis (PD) is an underutilized RRT for ESRD patients with SLE in the United States (1,2). Recent studies show that PD utilization as the initial RRT at the beginning of ESRD has declined from 16.4% to 9.9%; however, hemodialysis (HD) utilization has increased from 75.9% to 83.9% in the last decade (1,2).…”

“…Recent studies show that PD utilization as the initial RRT at the beginning of ESRD has declined from 16.4% to 9.9%; however, hemodialysis (HD) utilization has increased from 75.9% to 83.9% in the last decade (1,2). Although limited geographic access to PD facilities and more readily available hemodialysis facilities are in great part responsible for this trend in the United States (3), it is a concern among some providers that outcomes are worse with PD.…”