PHILADELPHIA – Race, socioeconomic status, and insurance status all impact survival for children with end-stage renal disease, with poor, uninsured black children at greater risk of death than all others.
Dr. Sandra G. Amaral of Children’s Hospital of Philadelphia and her colleagues used information from the United States Renal Data System to identify racial and socioeconomic disparities associated with mortality risk in pediatric end-stage renal disease (ESRD).
"We know that, among children with [ESRD], death risk is much lower for those who receive a kidney transplant, compared with those who stay on dialysis, but we don’t know much about which children die before reaching transplant," Dr. Amaral said. "We wanted to determine whether there are racial or ethnic differences in the risk of dying when children remain on dialysis."
They identified 8,146 patients younger than 21 years who had been diagnosed with ESRD from Jan. 2000 through Sept. 2008 and followed through September 2009, looking at patients who were on dialysis but had not been transplanted and whose race/ethnicity was white, Hispanic, or black. Of the 8,146 children, 896 died before reaching transplant, she said at the meeting, sponsored by the American Society of Nephrology.
"We wanted to determine whether there are racial or ethnic differences in the risk of dying when children remain on dialysis."
Of the patients who died, 357 were white, 161 were Hispanic, and 378 were black, Dr. Amaral said. By health insurance status, 179 were privately insured, 527 were publicly insured, 87 children were uninsured, and 103 were classified as "other," she said.
The number of children who died, independent of race/ethnicity, was related to neighborhood poverty. Specifically, 304 of the children who died had lived in the poorest neighborhoods – those where at least 20% of residents were at or below the federal poverty line – compared with 80 children from the wealthiest neighborhoods in which 0 to 4.9% of the residents had incomes at or below poverty level, she said.
"We saw significant differences by race, health insurance, and poverty among patients who were alive vs. those who died, and proportionally, among all of the black patients, more died than in any other subgroup," Dr. Amaral said, adding that "more patients among those who died had public insurance and were from poorer neighborhoods."
Survival curves showed that Hispanic children had the highest rate of survival, followed by white children. "Black children had the lowest rate of survival," Dr. Amaral stated. In an analysis adjusted for age, gender, and diagnosis, "the poorest children, regardless of race, had higher mortality."
However, the risk of death among those of different ethnic backgrounds varied by type of health insurance and not by poverty. "Uninsured black children, for example, had a 78% increased risk, compared with uninsured white children," she said, while black children with private insurance had only a 19% increased risk, compared with privately insured white children.
The current findings are limited by the fact that the data set included only patients who had been diagnosed with ESRD, Dr. Amaral said.
"We don’t know what happened to them before that," she said. "There may be issues in patient access to care. It’s possible that the reason patients are not even getting wait-listed at diagnosis is that they’re too sick," she said.
Dr. Amaral disclosed having no financial conflicts of interest related to her presentation.