Northwest Kidney Centers

Risks of kidney failure versus death in diabetes have not been previously quantified across a full range of kidney function. The study aim was to assess competing risks of kidney failure and death in a real-world cohort with diabetes. Cumulative incidence functions for kidney failure and death, stratified by baseline estimated glomerular filtration rate (eGFR), were estimated for the diabetes population from electronic health record data at Providence and the University of California Los Angeles health systems. Cox proportional hazards models assessed predictors of kidney failure and death. For kidney failure, cause-specific hazards were modeled with competing risk of death. Among 618,739 persons with diabetes followed for a median (interquartile range) of 3.79 (1.80-6.00) years during 2013-2022, 4% (n=24,097) developed kidney failure and 10% (n=63,128) died. Five-year cumulative incidence of kidney failure increased from 2% (95% confidence interval [CI] 1.4%-1.5%) for eGFR ≥90 mL/min/1.73m2 to 62% (95% CI 61.0%-63.5%) for eGFR 15-29 mL/min/1.73m2. Cumulative incidence of all-cause death was higher than kidney failure with eGFR ≥45 mL/min/1.73m2, whereas kidney failure became more common at eGFR <30 mL/min/1.73m2. Hazards of kidney failure were higher in males (reference: females), 40-59 and 60-79-year groups (reference: 18-39 years), non-White race or Hispanic or Latino/a ethnicity groups (reference: non-Hispanic White), and by noncommercial (reference: commercial) health insurance or hospitalization (yes/no) within 1 year prior to follow-up. Hazards of death were similar except that age ≥80 years imparted the highest risk, and only the American Indian or Alaska Native and Other race groups had higher risk. Death was more likely than kidney failure at eGFR ≥45 mL/min/1.73m2, but this trend reversed at eGFR <30 mL/min/1.73m2. These contemporary risk estimates are important for public health and clinical strategies for monitoring and interventions to improve kidney health in diabetes.

1Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington 2Northwest Kidney Centers, Seattle, Washington Correspondence: Dr. Matthew B. Rivara, email: [email protected] See related article, "Trends in Automated Peritoneal Dialysis Prescriptions in a Large Dialysis Organization in the United States," on pages 723–731.

Reliable transportation is an important determinant of access to health care and health outcomes that carries particular significance for people with ESKD. In the United States, there are almost half a million patients receiving treatment with in-center dialysis, translating into more than 70 million roundtrips to dialysis centers annually. Difficulty with transportation can interfere with patients' quality of life and contribute to missed or shortened dialysis treatments, increasing their risk for hospitalization. Medicare, the principal payer for dialysis in this country, has not traditionally provided coverage for nonemergency medical transportation, placing the burden of traveling to and from the dialysis center on patients and families and a range of other private and public entities that were not designed and are poorly equipped for this purpose. Here, we review the relationship between access to reliable transportation and health outcomes such as missed and shortened dialysis treatments, hospitalizations, and quality of life. We also describe current approaches to the delivery of transportation for patients receiving in-center hemodialysis, highlighting potential opportunities for improvement.