Racial/Ethnic Differences in Dialysis Discontinuation and Survival after Hospitalization for Serious Conditions among Patients on Maintenance Dialysis

Abdulkareem Agunbiade; Abhijit Dasgupta; Michael M. Ward

doi:10.1681/ASN.2019020122

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Significance Statement

Racial and ethnic minorities, particularly blacks, survive longer on maintenance dialysis than whites. Minorities are also less likely to discontinue dialysis, which affects relative survival. Both differences have been attributed by some clinicians to better health among minorities on dialysis. To test if health differences explain racial and ethnic differences in dialysis discontinuation, the authors compared the frequency of dialysis discontinuation among racial and ethnic groups after hospitalization for one of four serious medical conditions. Despite hospitalization for the same condition, racial and ethnic minorities were less likely than whites to discontinue dialysis. Using a simulation that accounted for differences in dialysis discontinuation substantially reduced the survival advantage of racial and ethnic minorities. The study suggests that racial and ethnic differences in survival were largely determined by differential discontinuation of dialysis.

Abstract

Background Racial and ethnic minorities on dialysis survive longer than whites, and are less likely to discontinue dialysis. Both differences have been attributed by some clinicians to better health among minorities on dialysis.

Methods To test if racial and ethnic differences in dialysis discontinuation reflected better health, we conducted a retrospective cohort study of survival and dialysis discontinuation among patients on maintenance dialysis in the US Renal Data System after hospitalization for either stroke (n=60,734), lung cancer (n=4100), dementia (n=40,084), or failure to thrive (n=42,950) between 2003 and 2014. We examined the frequency of discontinuation of dialysis and used simulations to estimate survival in minorities relative to whites if minorities had the same pattern of dialysis discontinuation as whites.

Results Blacks, Hispanics, and Asians had substantially lower frequencies of dialysis discontinuation than whites in each hospitalization cohort. Observed risks of mortality were also lower for blacks, Hispanics, and Asians. In simulations that assigned discontinuation patterns similar to those found among whites across racial and ethnic groups, differences in survival were markedly attenuated and hazard ratios approached 1.0. Survival and dialysis discontinuation frequencies among American Indians and Alaska Natives were close to those of whites.

Conclusions Racial and ethnic differences in dialysis discontinuation were present among patients hospitalized with similar health events. Among these patients, survival differences between racial and ethnic minorities and whites were largely attributable to differences in the frequency of discontinuation of dialysis.

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