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: 4.61). 10/2006; 1(5):905-6. DOI: 10.2215/CJN.02660706
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ABSTRACT: Knowing whether risk factors for mortality differ in dialysis patients who survive longer and the strengths of these risk factors for mortality change over time would assist physicians in making better prognostic judgments. Prospective cohort study. 1,041 incident dialysis patients treated in 81 clinics (mean follow-up, 3.1 years). A parsimonious set of risk factors (older age, white race, unemployed status, comorbidity, ever smoking, decreased systolic blood pressure, and decreased serum albumin level) chosen from several available demographic, clinical, and laboratory variables. Long-term (4+ years) survival and mortality over yearly intervals of follow-up, examined in logistic regression and Cox proportional hazards analyses. All baseline risk factors were associated with a decreased chance of surviving 4+ years, even after adjustment for confounders. Increased age was a strong and independent risk factor for mortality over all yearly intervals; comorbidity, smoking, and decreased blood pressure were early risk factors; low albumin level and unemployed status were intermediate risk factors; and white race was a late risk factor. When risk factors were updated with time, low albumin level and severe comorbidity became significant risk factors over most intervals. Lack of some follow-up data and inability to rule out residual confounding or make causal inference based on results. Long-term survivors on dialysis therapy may have different risk factors for mortality than patients in earlier phases of end-stage renal disease (eg, race versus blood pressure); other risk factors may be constant over time (eg, age, comorbidity, and albumin level). Such information may help guide physicians in making prognostic judgments for individual patients with particular dialysis vintages.
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ABSTRACT: Chronic kidney disease (CKD) is a national public health problem beset by inequities in incidence, prevalence, and complications across gender, race/ethnicity, and socioeconomic status. As health care providers, we can directly address some factors crucial for closing the disparities gap. Other factors are seemingly beyond our reach, entrenched within the fabric of our society, such as social injustice and human indifference. Paradoxically, the existence of health inequities provides unique, unrecognized opportunities for understanding biologic, environmental, sociocultural, and health care system factors that can lead to improved clinical outcomes. Several recent reports documented that structured medical care systems can reduce many CKD-related disparities and improve patient outcomes. Can the moral imperative to eliminate CKD inequities inspire the nephrology community not only to advocate for but also to demand high-quality, structured health care delivery systems for all Americans in the context of social reform that improves the ecology, health, and well-being of our communities? If so, then perhaps we can eliminate the unacceptable premature morbidity and mortality associated with CKD and the tragedy of health inequities. By so doing, we could become global leaders not only in medical technology, as we currently are, but also in health promotion and disease prevention, truly leaving no patient behind.