Laboratory Abnormalities at the Onset of Treatment of End-Stage Renal Disease

Abstract

Background: Laboratory abnormalities at the start of treatment of end-stage renal disease (ESRD) have been reported as worse in racial/ethnic minorities than in white patients, suggesting racial disparities in care. It is not known whether these differences are attributable to racial/ ethnic differences in socioeconomic status (SES). Methods: We tested associations between race/ ethnicity, SES, and type of medical insurance and serum creatinine level, estimated glomerular filtration rate, serum albumin level, and hematocrit at the start of treatment of ESRD and use of epoietin before ESRD treatment in a large national population-based sample. Data on 515 561 patients beginning ESRD treatment between January 1, 1996, and June 30, 2004, were obtained for this cross-sectional survey from the United States Renal Data System. Results: Race/ethnicity had a much stronger association than SES with each laboratory measure. Adjusted mean serum creatinine levels were lowest in white patients (7.5 mg/dL [663.0 µmol/L]; 95% confidence interval [CI], 7.45-7.49) and highest in black patients (8.9 mg/dL [786.7 µmol/L]; 95% CI, 8.92-8.97) (PϽ.001 across racial/ethnic groups). Adjusted mean hematocrit for white patients (29.5%; 95% CI, 29.4%-29.6%) was significantly higher and for black patients (28.3%; 95% CI, 28.2%-28.4%) significantly lower than that of all other racial/ethnic groups (PϽ.001 across racial/ethnic groups). Less marked differences were present for estimated glomerular filtration rate and serum albumin level. In contrast, predialysis use of epoietin was associated with race/ ethnicity (black vs white: odds ratio, 0.80; 95% CI, 0.78-0.81; Hispanic vs white: odds ratio, 0.87; 95% CI, 0.85-0.89) and showed a graded decrease with decreasing SES (odds ratio for the lowest vs highest socioeconomic quartile 0.68; 95% CI, 0.67-0.70). Patients without medical insurance had more abnormal laboratory values than those with insurance, but these associations were weaker than those of race/ethnicity. Conclusions: Minorities, particularly black patients, had more severe laboratory abnormalities at the start of ESRD treatment than white patients. These differences were not readily attributable to SES differences. Absence of medical insurance, SES, and race/ethnicity were associated with the likelihood of predialysis use of epoietin.

Ethnicity, Socioeconomic Status, and Attainment of Clinical Practice Guideline Standards in Dialysis Patients in the United Kingdom

“…Socially deprived patients in the US have lower hemoglobin (Hb) (3) and lower rates of erythropoietin (EPO) use at the start of RRT (4). Once on dialysis in the US, Blacks tend to achieve lower Hb levels (5), lower dialysis dose (5), and higher parathyroid hormone (PTH) levels (6) than Whites, whereas patients of South Asian descent achieve Hb levels comparable to those of Whites and a higher dialysis dose (7).…”

Validation of erythropoietin use data on Medicare's End-Stage Renal Disease Medical Evidence Report

“…Multiple USRDS reports using Form 2728 data have concluded that ongoing levels of suboptimal degrees of anemia in incident patients with ESRD are in part because of underuse of ESA [17] review articles, which relied on Form 2728 data, have also found that less than one-third of patients with incident dialysis received predialysis ESA and that those with lower hemoglobin values were even less likely to have received predialysis ESA [6][7][8][9][10][15][16]19]. Only one group of investigators expressed concern about predialysis ESA data misclassification on Form 2728, but doubted it was significant because an inverse correlation was found between ESA use and low hemoglobin (r = -0.65, p = 0.004) [6,8].…”

“…CMS dialysis networks across the United States also use data from this source to assess quality of predialysis and dialysis care and to target quality improvement initiatives. Furthermore, researchers have used information from Form 2728 in a large number of clinical, epidemiological, and health services research studies [6][7][8][9][10].…”

“…ESAs are recommended and used to correct severe anemia, which occurs frequently as a complication of severe CKD, and may ameliorate many of the negative sequelae of anemia, which include lower quality of life and increased hospitalization, cardiovascular complications, and mortality [12][13][14][15][16][17][18][19][20]. Recent USRDS reports and clinical studies have suggested that ESA underuse in patients with pre-ESRD may be contributing to the unacceptable severity of anemia in these patients at initiation of dialysis [1][2][6][7][8][9][10]15,19]. To better understand the quality of the data underpinning these observations, we investigated the accuracy and completeness of predialysis ESA use data on Form 2728 by comparing them with Department of Veterans Affairs (VA) pharmacy prescription records and Medicare claims records in a cohort of veterans reliant on VA and/or Medicare-covered services.…”

Evaluating Risk of ESRD in the Urban Poor

“…8,9 Moreover, uninsured persons and Medicaid enrollees are suboptimally prepared for ESRD, as evidenced by worse biochemical abnormalities at ESRD onset, lower prevalence of permanent vascular access at dialysis initiation, and marked delays in accessing a kidney transplant compared with counterparts with Medicare or private health insurance. [10][11][12][13] A major contributor to socioeconomic disparities in ESRD incidence and CKD care is the lack of a surveillance system for tracking the care of the poor or …”