Contextual Issues in Comparing Outcomes and Care Processes for ESRD Patients around the World

To compare mortality risk among cadaveric renal transplant recipients vs transplant candidates on dialysis in the cyclosporine era. Patient mortality risk was analyzed by treatment modality for a completed statewide patient population. All Michigan residents younger than age 65 years who started endstage renal disease (ESRD) therapy between January 1, 1984, and December 31, 1989, were included. Patients were followed up from ESRD onset (n = 5020), to wait-listing for renal transplant (n = 1569), to receiving a cadaveric first transplant (n = 799), and to December 31, 1989. Mortality rates. Using a time-dependent variable based on the waiting time from date of wait-listing to transplantation and adjusting for age, sex, race, and primary cause of ESRD, the relative risk (RR) of dying was increased early after transplantation and then decreased to a beneficial long-term effect, given survival to 365 days after transplantation (RR, 0.36; P .05). Overall, the estimated times from transplantation to equal mortality risk was 117 +/- 28 days and to equal cumulative mortality was 325 +/- 91 days. The overall mortality risk following renal transplantation was initially increased, but there was a long-term survival benefit compared with similar patients on dialysis. These analyses allow improved description of comparative mortality risks for dialysis and transplant patients and allow advising patients regarding comparative survival outcomes.

To assess the impact of sociodemographic factors and comorbid conditions on access to renal transplantation for adult US dialysis patients with end-stage renal disease (ESRD). Cohort analytic study. Data on comorbid conditions at onset of ESRD were abstracted from patients' medical records and matched to sociodemographic and ESRD data from the United States Renal Data System database. United States Medicare dialysis population. Random, national sample of ESRD patients starting dialysis in 1986 and 1987 (n = 4118). Time to first renal transplant (living or cadaver donor) since onset of ESRD regressed with two nested Cox proportional hazards models, first against sociodemographic factors alone, and then against sociodemographic factors and comorbid conditions. Cardiovascular diseases are most predictive of who received a transplant; patients with coronary heart disease, congestive heart failure, or left ventricular hypertrophy showed lower transplantation rates relative to patients without the disease (relative rate [RR] = 0.65 to 0.80, P < .05 each). Obese patients and patients with peripheral vascular disease also showed lower transplantation rates (RR = 0.65 to 0.75, P < .05 each). Previously reported sociodemographic effects of lower transplantation rates for older patients, women, nonwhite patients, and lower income patients were confirmed (P < .01). Sociodemographic effects remained essentially unchanged when adjusted for comorbid conditions. These findings indicate that sociodemographics have strong independent effects on access to transplantation that cannot be explained away as "surrogate" effects related to comorbid factors. Furthermore, the results suggest that lower mortality rates for transplant recipients relative to dialysis patients are due, in part, to a healthier case mix among patients receiving transplants.