Original Investigation
Pathogenesis and Treatment of Kidney Disease
Survival Disparity of African American Versus Non–African American Patients With ESRD Due to SLE

https://doi.org/10.1053/j.ajkd.2015.04.011Get rights and content

Background

A recent study showed an increased risk of death in African Americans compared with whites with end-stage renal disease (ESRD) due to lupus nephritis (LN). We assessed the impact of age stratification, socioeconomic factors, and kidney transplantation on the disparity in patient survival among African American versus non–African American patients with LN-caused ESRD, compared with other causes.

Setting & Participants

Using the US Renal Data System database, we identified 12,352 patients with LN-caused ESRD among 1,132,202 patients who initiated maintenance dialysis therapy from January 1, 1995, through December 31, 2006, and were followed up until December 31, 2010.

Predictors

Baseline demographics and comorbid conditions, Hispanic ethnicity, socioeconomic factors (employment status, Medicare/Medicaid insurance, and area-level median household income based on zip code as obtained from the 2000 US census), and kidney transplantation as a time-dependent variable.

Outcome

All-cause mortality.

Measurements

Multivariable Cox and competing-risk regressions.

Results

Mean duration of follow-up in the LN-caused ESRD and other-cause ESRD cohorts were 6.24 ± 4.20 (SD) and 4.06 ± 3.61 years, respectively. 6,106 patients with LN-caused ESRD (49.43%) and 853,762 patients with other-cause ESRD (76.24%) died during the study period (P < 0.001). Patients with LN-caused ESRD were significantly younger (mean age, 39.92 years) and more likely women (81.65%) and African American (48.13%) than those with other-cause ESRD. In the fully adjusted multivariable Cox regression model, African American (vs non–African American) patients with LN-caused ESRD had significantly increased risk of death at age 18 to 30 years (adjusted HR, 1.43; 95% CI, 1.24-1.65) and at age 31 to 40 years (adjusted HR, 1.17; 95% CI, 1.02-1.34). Among patients with other-cause ESRD, African Americans were at significantly increased risk at age 18 to 30 years (adjusted HR, 1.17; 95% CI, 1.11-1.22).

Limitations

We used zip code−based median household income as a surrogate for patient income. Residual socioeconomic confounders may exist.

Conclusions

African Americans are at significantly increased risk of death compared with non–African Americans with LN-caused ESRD at age 18 to 40 years, a racial disparity risk that is 10 years longer than that in the general ESRD population. Accounting for area-level median household income and transplantation significantly attenuated the disparity in mortality of African American versus non–African American patients with LN-caused ESRD.

Section snippets

Methods

This study used the US Renal Data System (USRDS) database, which incorporates baseline and follow-up demographic and clinical data for all patients accessing the Medicare ESRD program in the United States. We conducted a retrospective cohort study consisting of patients who initiated maintenance dialysis therapy from January 1, 1995, through December 31, 2006, and were followed up until December 31, 2010. Our cohort consisted only of patients who were included in the USRDS annual data reports

Results

We identified 12,352 patients with LN-caused ESRD in a retrospective cohort of 1,132,202 patients who initiated maintenance dialysis therapy from January 1, 1995, through December 31, 2006, followed up until December 31, 2010. Table 1 shows demographic and unadjusted characteristics of the LN-caused versus other-cause ESRD cohort. Compared to the general ESRD population, patients with LN-caused ESRD were more likely to be younger at dialysis therapy initiation, African American, women, and on

Discussion

It is widely reported that among patients with ESRD on maintenance dialysis therapy, African Americans have lower mortality than non–African Americans, especially in comparison with white patients.11 Our findings indicate that among patients with ESRD due to LN, African Americans have higher mortality compared with non–African Americans (adjusted HR, 1.18). This survival disadvantage among African American patients with LN-caused ESRD was significantly attenuated by area-level median household

Acknowledgements

The views expressed in this aticle are those of the authors and do not reflect the official policy of the Department of the Army, the Department of the Navy, the Department of Defense, or the United States government.

Support: None.

Financial Disclosure: The authors declare that they have no relevant financial interests.

Contributions: Research idea and study design: RN, KCA, JMO, DJL; data acquisition: LA, KCA; data analysis/interpretation: RN, KCA, CMY, LA, MAW; statistical analysis: RN, KCA;

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