Disparities in kidney care access for pregnant patients

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A recent study highlights significant disparities in kidney transplant and nephrology care access for pregnant patients with end-stage kidney disease, revealing reduced survival rates and limited access to crucial care compared to non-pregnancy-related causes.

Disparities in kidney care access for pregnant patients | Image Credit: © SewcreamStudio - © SewcreamStudio - stock.adobe.com.

Disparities in kidney care access for pregnant patients | Image Credit: © SewcreamStudio - © SewcreamStudio - stock.adobe.com.

Patients with pregnancy-related end-stage kidney disease (ESKD) face reduced transplant and nephrology care access, according to a recent study published in JAMA Network Open.

Takeaways

  1. The study reveals that patients with pregnancy-related end-stage kidney disease (ESKD) face challenges in accessing kidney transplant and nephrology care, suggesting potential gaps in healthcare services for this specific population.
  2. Pregnant patients experiencing acute kidney injury (AKI) encounter significantly increased risks, including a 13-fold higher maternal mortality risk and a 9-fold higher risk of cardiovascular events. This underscores the critical need for understanding and addressing the outcomes for this vulnerable group.
  3. Significant racial disparities exist in maternal health, with Black patients facing a higher incidence of AKI compared to White patients. Recognizing and addressing these disparities is crucial for improving overall maternal health outcomes.
  4. Survival rates vary among patients with different primary causes of end-stage kidney disease (ESKD). Patients with pregnancy-related ESKD have higher survival rates compared to those with diabetes or hypertension as the primary cause but lower survival rates compared to those with glomerulonephritis or cystic kidney disease.
  5. Patients with pregnancy-related ESKD experience reduced rates of access to pre-ESKD care, including nephrology care and arteriovenous graft or fistula placement. Additionally, there is a notable decrease in access to kidney transplant for this group.

The United States has significantly increased maternal morbidity and mortality rates compared to other nations. Pregnant patients with acute kidney injury (AKI) experience significantly increased risk of adverse outcomes, including a 13-fold increased risk of maternal mortality and 9-fold increased risk of cardiovascular events.

Significant disparities in maternal health have been observed based on race, with 32.6 cases of AKI per 10,000 hospitalizations in Black patients compared to 10.9 for White patients. AKI may lead to ESKD requiring dialysis or kidney transplant, making it important to understand outcomes in differences in care for patients with pregnancy-related ESKD.

To evaluate ESKD outcomes, investigators conducted a study using data from the US Renal Data System, which records all patients with ESKD in the United States. Participants included female patients aged 14 to 50 years with dialysis or preemptive kidney transplant from January 1, 2000, to November 20, 2020, with a primary cause of kidney failure reported.

Categories for nonpregnancy-related causes of kidney failure include diabetes, hypertension, glomerulonephritis, cystic kidney disease, and other or unknown causes. Baseline characteristics compared between patients with pregnancy-related ESKD and general pregnant patients included diabetes, chronic hypertension, smoking status, race and ethnicity, age, and body mass index.

Follow-up occurred until death or November 20, 2020, with death confirmed using linkage to the Social Security Master Death File. Study authors described access to kidney transplant as, “joining the deceased donor waiting list or receiving a kidney transplant from a living donor.” 

Differences in access to kidney transplant and time to transplant after joining the waitlist were evaluated to compare the hazard of death between cohorts. Differences in pre-ESKD care were used to determine patients’ access to nephrology care, arteriovenous graft or fistula, and if they had been informed about kidney transplant before ESKD onset.

There were 341 patients with a pregnancy-related primary cause of ESKD included in the analysis, with Black individuals overrepresented in this group compared to the general birthing population. Of patients with pregnancy-related ESKD, 5.3% had diabetes vs 1.1% of the general birthing population.Chronic hypertension rates in these groups were 68.8% and 0.7%, respectively.

A pregnancy-related primary cause of ESKD was reported in 0.19% of patients with ESKD, diabetes in 38.1%, hypertension in 19.8%, glomerulonephritis in 21.9%, cystic kidney disease in 4.6%, and other or unknown cause in 15.3%. Patients with pregnancy-related ESKD were more likely to be younger, only have Medicaid insurance, be Hispanic, and be in school or employed.

Rates of survival were significantly decreased in patients with diabetes or hypertension as the primary cause of ESKD vs pregnancy-related causes and glomerulonephritis or cystic kidney disease. An adjusted inverse hazard ratio of 0.49 for death was reported when comparing pregnancy-related ESKD with diabetes or hypertension vs 0.96 when compared with glomerulonephritis or cystic kidney disease.

Decreased access to kidney transplant was observed among patients with pregnancy-related ESKD compared to patients with glomerulonephritis or cystic kidney disease, with an adjusted inverse subhazard ratio (aSHR) of 0.51. In comparison, an aSHR of 0.82 was observed when compared to diabetes, hypertension, or other causes.

Patients with pregnancy-related ESKD also had reduced rates of access to nephrology care before ESKD onset compared to patients with other causes of ESKD, at 33.6% vs 58.1% to 77.6%.Similar results were observed for having a graft or fistula placed before ESKD onset, at 4.4% vs 11.3% to 18%.

These results indicated reduced access to care among patients with pregnancy-related ESKD. Investigators recommended future research within a larger population of patients with pregnancy-related AKI.

Reference

Kucirka LM, Angarita AM, Manuck TA, et al. Characteristics and outcomes of patients with pregnancy-related end-stage kidney disease. JAMA Netw Open. 2023;6(12):e2346314. doi:10.1001/jamanetworkopen.2023.46314

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