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Reverse race and ethnic disparities in survival increase with severity of chronic kidney disease: What does this mean?

Clinical Journal of the American Society of Nephrology (Impact Factor: 5.25). 10/2006; 1(5):905-6. DOI: 10.2215/CJN.02660706
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    ABSTRACT: African Americans experience a higher mortality rate and an excess burden of ESRD compared with Caucasians in the general population, but among those treated with dialysis, African Americans typically survive longer than Caucasians. We examined whether differences in inflammation may explain this paradox. We prospectively followed a national cohort of incident dialysis patients in 81 clinics for a median of 3 years (range 4 months to 9.5 years). Among 554 Caucasians and 262 African Americans, we did not detect a significant difference in median CRP between African Americans and Caucasians (3.4 versus 3.9 mg/L). Mortality was significantly lower for African Americans versus Caucasians (34% versus 56% at 5 years); the relative hazard was 0.7 (95% CI, 0.5 to 0.9) after adjusting for age, gender, dialysis modality, smoking, body mass index, diabetes, BP, cholesterol, cardiovascular disease, congestive heart failure, comorbid disease, hemoglobin, albumin, CRP, and IL-6. However, the risk varied by CRP tertile: the relative hazards for African Americans compared with Caucasians were 1.0 (95% CI, 0.7 to 1.4), 0.7 (95% CI, 0.4 to 1.3), and 0.5 (95% CI, 0.3 to 0.8) in the lowest, middle, and highest tertiles, respectively. We obtained similar results when we accounted for transplantation as a competing event, and we examined mortality across tertiles of IL-6. In summary, racial differences in survival among dialysis patients are not present at low levels of inflammation but are large at higher levels. Differences in inflammation may explain, in part, the racial paradox of ESRD survival.
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    ABSTRACT: Chronic kidney disease (CKD) is prevalent in minority populations and racial/ethnic differences in survival are incompletely understood. Secondary analysis of Kidney Early Evaluation Program participants from 2000 through 2008 with CKD, not on dialysis, and without previous kidney transplant was performed. Self-reported race/ethnicity was categorized into five groups: non-Hispanic white, African American, Asian, American Indian/Alaska Native, and Hispanic. CKD was defined as a urinary albumin to creatinine ratio of ≥30 mg/g among participants with an estimated GFR (eGFR) ≥60 ml/min per 1.73 m(2) or an eGFR of <60 ml/min per 1.73 m(2). The outcome was all-cause mortality. Covariates used were age, sex, obesity, diabetes, hypertension, albuminuria, baseline eGFR, heart attack, stroke, smoking, family history, education, health insurance, geographic region, and year screened. 19,205 participants had prevalent CKD; 55% (n = 10,560) were White, 27% (n = 5237) were African American, 9% (n = 1638) were Hispanic, 5% (n = 951) were Asian, and 4% (n = 813) were American Indian/Alaska Native. There were 1043 deaths (5.4%). African Americans had a similar risk of death compared with Whites (adjusted Hazard Ratio (AHR) 1.07, 95% CI 0.90 to 1.27). Hispanics (AHR 0.66, 95% CI 0.50 to 0.94) and Asians (AHR 0.63, 95% CI 0.41 to 0.97) had a lower mortality risk compared with Whites. In contrast, American Indians/Alaska Natives had a higher risk of death compared with Whites (AHR 1.41, 95% CI 1.08 to 1.84). Significant differences in mortality among some minority groups were found among persons with CKD detected by community-based screening.
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