Rural and Micropolitan Residence and Mortality in Patients on Dialysis

Abstract

SummaryBackground and objectives Micropolitan and rural patients face challenges when initiating dialysis, including healthcare access. Previous studies have shown little association of nonurban residence with dialysis outcomes but have not examined the association of dialysis modality with residence location.Design, setting, participants, & measurements This retrospective cohort study used data from the U.S. Renal Data System. Adults who initiated maintenance dialysis between January 1, 2006, and December 31, 2007, were classified as rural, micropolitan, or urban. Early and long-term mortality and kidney transplantation were examined with Cox regression stratified by dialysis modality.Results Of 204,463 patients, 80% were urban; 10.2%, micropolitan; and 9.8%, rural. Micropolitan and rural patients were older, were less racially diverse, had more comorbid conditions, and were more likely to start peritoneal dialysis (PD). Median follow-up was 2.0 years. Early mortality or long-term hemodialysis (HD) mortality did not significantly differ by geographic residence. After adjustment, micropolitan and rural PD patients had higher risk for long-term mortality (hazard ratio [HR] Conclusions Micropolitan and rural residence is associated with higher mortality in PD patients and similar or higher likelihood of kidney transplantation among HD and PD patients. Studies examining the underlying mechanisms of these associations are warranted.

Dialysis and Mortality

“…Figure 1 shows the distributions of dialysis units and population centers in these states, and the potential geographic barriers are obvious in large frontier states like Alaska along with the disincentive to choose incenter hemodialysis. This study by Maripuri et al was able to show higher long-term mortality risk for those peritoneal dialysis patients residing farther from a dialysis unit, a finding that has been reported in other countries (2,5).…”

“…For patients who are failing peritoneal dialysis, home hemodialysis could also be a viable option. Kidney transplantation is the best solution for appropriate rural candidates, and it was reassuring that this study by Maripuri et al confirmed that rural patients had a similar or higher likelihood of kidney transplantation as urban patients (2,13). In addition to the nephrology team, management of these rural patients require a multidisciplinary team approach involving local primary care physicians and local medical facilities, which are likely to be unfamiliar with the management of peritoneal dialysis patients and the transplant referral process.…”

Clinical Outcomes of Remote Peritoneal Dialysis Patients: A Retrospective Cohort Study from a Single Center in China

“…Maripuri et al [3] demonstrated that patient survival rates at 1 and 3 years were 90 and 67% in urban PD patients, and 85 and 60% in micropolitan or rural areas PD patients, approximately. Gray et al [16] reported that technique survival rates of rural Australian PD patients were 79.0, 63.0 and 53.0% approximately at 1, 2 and 3 years, respectively.…”

Telenephrology: Providing Healthcare to Remotely Located Patients with Chronic Kidney Disease

“…Moreover patients who live in rural regions with less consistent access to physicians and, specifically, nephrologists, are more likely to consider peritoneal dialysis over hemodialysis, especially, if they are referred early and have time to be educated about peritoneal dialysis [21]. Thus, telenephrology may not only enhance the number of subjects choosing peritoneal dialysis, but also be able to deliver quality care to the rural peritoneal dialysis population [22]. Studies are underway by other investigators to evaluate the role of home videoconferencing for peritoneal dialysis patients [23].…”