TY - JOUR
T1 - Race and Mortality in CKD and Dialysis
T2 - Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study
AU - CRIC Study Investigators
AU - Ku, Elaine
AU - Yang, Wei
AU - McCulloch, Charles E.
AU - Feldman, Harold I.
AU - Go, Alan S.
AU - Lash, James
AU - Bansal, Nisha
AU - He, Jiang
AU - Horwitz, Ed
AU - Ricardo, Ana C.
AU - Shafi, Tariq
AU - Sondheimer, James
AU - Townsend, Raymond R.
AU - Waikar, Sushrut S.
AU - Hsu, Chi yuan
AU - Appel, Lawrence J.
AU - Kusek, John W.
AU - Rao, Panduranga S.
AU - Rahman, Mahboob
N1 - Funding Information:
This work was supported by the National Kidney Foundation Satellite Dialysis Clinical Investigator Grant and R01 DK115629 to Dr Ku and Dr McCulloch, K23 HL131023 to Dr Ku, and K24 DK92291 to Dr Hsu. Funding for the CRIC Study was obtained under a cooperative agreement from National Institute of Diabetes and Digestive and Kidney Diseases ( U01DK060990 , U01DK060984 , U01DK061022 , U01DK061021 , U01DK061028 , U01DK060980 , U01DK060963 , and U01DK060902 ). In addition, this work was supported in part by the Perelman School of Medicine at the University of Pennsylvania Clinical and Translational Science Award (CTSA) National Institutes of Health (NIH)/ National Center for Advancing Translational Sciences (NCATS) UL1TR000003 , Johns Hopkins University UL1 TR-000424 , University of Maryland General Clinical Research Center M01 RR-16500 , Clinical and Translational Science Collaborative of Cleveland , UL1TR000439 from the NCATS component of the NIH and NIH Roadmap for Medical Research, Michigan Institute for Clinical and Health Research (MICHR) UL1TR000433 , University of Illinois at Chicago CTSA UL1RR029879 , Tulane COBRE for Clinical and Translational Research in Cardiometabolic Diseases P20 GM109036 , and Kaiser Permanente NIH/ National Center for Research Resources UCSF-CTSI UL1 RR-024131 . The funders of this study did not have any role in study design; collection, analysis, and interpretation of data; writing the report; or the decision to submit the report for publication.
Funding Information:
Lawrence J. Appel, MD, MPH, John W. Kusek, PhD, Panduranga S. Rao, MD, Mahboob Rahman, MD. Elaine Ku, MD, MAS, Wei Yang, PhD, Charles E. McCulloch, PhD, Harold I. Feldman, MD, Alan S. Go, MD, James Lash, MD, Nisha Bansal, MD, Jiang He, MD, Ed Horwitz, MD, Ana C. Ricardo, MD, Tariq Shafi, MD, James Sondheimer, MD, Raymond R. Townsend, MD, Sushrut S. Waikar, MD, and Chi-yuan Hsu, MD, MSc. Research idea and study design: EK, WY, CEM, HF, AG, C-yH; data acquisition: HF, AG, JL, NB, JH, EH, AR, TS, JS, RT, SW, C-yH; data analysis/interpretation: all authors; statistical analysis: WY, CEM, EK; supervision or mentorship: HF, AG, JL, NB, JH, EH, AR, TS, JS, RT, SW, C-yH. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. This work was supported by the National Kidney Foundation Satellite Dialysis Clinical Investigator Grant and R01 DK115629 to Dr Ku and Dr McCulloch, K23 HL131023 to Dr Ku, and K24 DK92291 to Dr Hsu. Funding for the CRIC Study was obtained under a cooperative agreement from National Institute of Diabetes and Digestive and Kidney Diseases (U01DK060990, U01DK060984, U01DK061022, U01DK061021, U01DK061028, U01DK060980, U01DK060963, and U01DK060902). In addition, this work was supported in part by the Perelman School of Medicine at the University of Pennsylvania Clinical and Translational Science Award (CTSA) National Institutes of Health (NIH)/National Center for Advancing Translational Sciences (NCATS) UL1TR000003, Johns Hopkins University UL1 TR-000424, University of Maryland General Clinical Research Center M01 RR-16500, Clinical and Translational Science Collaborative of Cleveland, UL1TR000439 from the NCATS component of the NIH and NIH Roadmap for Medical Research, Michigan Institute for Clinical and Health Research (MICHR) UL1TR000433, University of Illinois at Chicago CTSA UL1RR029879, Tulane COBRE for Clinical and Translational Research in Cardiometabolic Diseases P20 GM109036, and Kaiser Permanente NIH/National Center for Research Resources UCSF-CTSI UL1 RR-024131. The funders of this study did not have any role in study design; collection, analysis, and interpretation of data; writing the report; or the decision to submit the report for publication. The authors declare that they have no relevant financial interests. The interpretation and reporting of the data presented here are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government. Received April 14, 2019. Evaluated by 2 external peer reviewers and a statistician, with editorial input from an Acting Editor-in-Chief (Editorial Board Member Yoshio N. Hall, MD, MS). Accepted in revised form August 2, 2019. The involvement of an Acting Editor-in-Chief to handle the peer-review and decision-making processes was to comply with AJKD's procedures for potential conflicts of interest for editors, described in the Information for Authors & Journal Policies.
Publisher Copyright:
© 2019 National Kidney Foundation, Inc.
PY - 2020/3
Y1 - 2020/3
N2 - Rationale & Objectives: Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy. Study Design: Retrospective cohort study. Settings & Participants: 3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment. Exposure: Race. Outcome: Mortality. Analytic Approach: Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC. Results: During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28). Limitations: Residual confounding. Conclusions: The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.
AB - Rationale & Objectives: Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy. Study Design: Retrospective cohort study. Settings & Participants: 3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment. Exposure: Race. Outcome: Mortality. Analytic Approach: Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC. Results: During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28). Limitations: Residual confounding. Conclusions: The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.
KW - Chronic Renal Insufficiency Cohort (CRIC)
KW - Mortality
KW - cardiovascular disease
KW - chronic kidney disease (CKD)
KW - comorbid conditions
KW - dialysis
KW - end-stage renal disease (ESRD)
KW - non–dialysis-dependent CKD (NDD-CKD)
KW - race
KW - racial disparities
KW - survival analysis
KW - survival paradox
KW - transition to dialysis
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U2 - 10.1053/j.ajkd.2019.08.011
DO - 10.1053/j.ajkd.2019.08.011
M3 - Article
C2 - 31732235
AN - SCOPUS:85075346978
SN - 0272-6386
VL - 75
SP - 394
EP - 403
JO - American Journal of Kidney Diseases
JF - American Journal of Kidney Diseases
IS - 3
ER -