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.