Kidney Replacement Therapy Sequences: Racial/Ethnic Disparities in End-Stage Kidney Disease Patients’ 10-Year Treatment Histories

Rationale & Objective: There are substantial racial/ethnic disparities in access to kidney replacement therapies (KRT). Although existing work often focuses on discrete treatment outcomes, a holistic depiction of racial/ethnic groups’ differential experiences requires a longitudinal approach. Study Design: A sequence analysis in national registry data. Setting & Participants: Adults aged 18-64 years with incident kidney failure in 2009 in the United States Renal Data System database. Exposure: Race/ethnicity (non-Hispanic Asian American [Asian-NH], non-Hispanic African American or Black [Black-NH], Hispanic, and non-Hispanic White [White-NH]) and age group (18-44 years and 45-64 years). Outcome: Ten-year KRT modality sequences (in-center dialysis, home dialysis, deceased donor kidney transplant [DDKT], living donor kidney transplant, stopped dialysis, and mortality). Analytical Approach: Using sequence analysis, longitudinal KRT modalities were characterized using descriptive statistics and visualized with state distribution plots, stratified by race/ethnicity and age. Results: The study included 50,776 adults with kidney failure (24% 18-44 years old and 76% 45-64 years old; 3.6% Asian-NH, 35.8% Black-NH, 17.7% Hispanic, and 42.9% White-NH). Among those aged 18-44, Hispanic and Asian-NH patients more frequently survived 10 years compared with Black-NH and White-NH patients. Among non-White patients, receipt of DDKT increased in years 4-6. Asian-NH patients had the highest DDKT receipt frequency. Asian-NH and White-NH patients more frequently experienced treatment sequences with 3 or more KRT modalities, and these sequences more commonly included transplant. Among patients initially receiving home dialysis, Asian-NH and White-NH patients more commonly transitioned to transplant compared with Black-NH and Hispanic patients. Compared with patients aged 18-44 years, racial/ethnic differences in KRT treatment sequences were attenuated among those aged 45-64 years. Limitations: Descriptive analyses cannot identify causal mechanisms. Excluding patients missing KRT modality may limit generalizability. Conclusions: Patterns in the KRT modality sequences offer a more nuanced view of racial/ethnic disparities in access to treatments for incident kidney failure. Plain-Language Summary: Although much prior research has investigated racial/ethnic differences in kidney failure treatments, they typically focus on one outcome at a time instead of looking at a patient's full treatment course. This project uses data from the United States Renal Data System to show patterns in patient history in kidney replacement therapies. Patterns in patient history for kidney replacement therapies are shown based on racial and ethnic identity, age, and sex over a 10-year period. Findings show that differences are much larger for younger patients than older, have patterns unique to home dialysis, and visualize the extent of differences in access to transplantation.