Black, Hispanic dialysis patients admitted more often for infections

Black and Hispanic patients on dialysis for end-stage renal disease had markedly higher rates of infection-related hospitalizations and were less likely to have visited a specialist for pre-treatment care, a new study finds.

Infection-related hospitalizations were about 20% higher for blacks of all ages, and about 30% higher for older Hispanics, compared with white patients, said study co-author Dr. Keith Norris of the David Geffen School of Medicine at UCLA.

“Even when hospitalizations were lower overall, we still saw these high rates of infection-related hospitalizations for Hispanics and blacks,” Norris said.

Additional research is needed to find interventions that reduce such hospitalizations and lower costs associated with care, the authors stated.

Patients with end-stage renal disease (ESRD) have kidneys that no longer function. To stay alive they require either a transplant or hemodialysis treatments several times a week to remove waste and extra fluid from the blood.

It is well known that those living with the condition have high rates of hospitalization. The new study, published in the Clinical Journal of the American Society of Nephrology, examines specific risk factors associated with hospital admissions.

Using records from the U.S. Renal Data System, researchers from the University of Virginia, UCLA, the University of Southern California, the University of Utah and the Veterans Affairs Department in Salt Lake City analyzed records of 563,281 patients who began long-term or maintenance hemodialysis between 1995 and 2009. They looked specifically at Hispanics, blacks and whites, and also at three age ranges: ages 18 to 40; 41 to 70; and ages 71 and older.

There were unexpected differences by race, age and cause of hospitalization. For example, Hispanics had lower rates of both all-cause hospital days and hospital admissions overall, but those age 60 and older were more likely to be admitted for infections. Similarly, blacks had a lower rate of all-cause admissions, but when it came specifically to catheter-related infections, their risk was higher.

The study also found that black and Hispanic patients were less likely to have met with a nephrologist for nutritional education and to establish a treatment plan before undergoing dialysis. These patients were more likely to show up for treatment at later stages of the disease, Norris said, and therefore may not have time to undergo the preferred means of receiving dialysis.

Among the three dialysis options, the recommended method is insertion of an AV fistula (AVF), made by joining an artery and vein in the patient's arm. It requires advance planning, according to the National Institutes of Health, because the fistula can take several months to properly form after surgery. A second, less optimal method involves an AV graft, made by using a soft tube to join an artery and vein in the arm. When that's not possible, a catheter is placed into a large vein for temporary access, usually in the patient's neck, a method that is associated with higher rates of infections.

“Too many patients don't get a fistula as early as they should,” Norris said. For younger people, this may be because of a lack of health insurance, or inability to pay for the AVF procedure. For older patients, who have access to Medicare, delays in seeking care may be related to cultural differences, or discomfort with the medical system, Norris suggested. But, he added, more research is needed to fully understand what's happening.

“There are some specific issues that we need to try to address to improve care and reduce costs,” Norris said, “If we know there are high rates of infections among certain populations, then we have to try to figure out why.”

Rates of hospitalization for infection in the hemodialysis population increased 43% between 1993 and 2011, with catheter use having the largest associated risk, according to a 2013 annual data report from the U.S. Renal Data System. Medicare spent $34.3 billion in 2011 on end-stage renal disease, according to that report.

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