Racial differences in end stage renal disease incidence, access to kidney transplantation, and hemodialysis survival

End Stage Renal Disease (ESRD) is the irreversible loss of renal function, making the patient permanently dependent upon renal replacement therapy (dialysis or transplantation). Racial differences in disease incidence and outcomes in the US have been consistently reported but the reasons remain poorly understood.;This dissertation focused on investigating the potential role of neighborhood and treatment environment factors in racial differences in ESRD incidence, access to kidney transplantation, and hemodialysis (HD) survival. The specific aims were the following: (1) To explore the role of neighborhood poverty in racial disparity in incidence of allcause ESRD; (2) To investigate whether ESRD treatment facility factors playa role in observed racial differences in kidney transplantation; (3) To investigate whether ESRD treatment facility factors play a role in observed racial differences in HD survival.;Data were obtained from an ESRD surveillance system for 3 southeastern states. Requested information included sociodemographic, comorbidity, and laboratory data from incident ESRD patients; patient follow-up data; and facility-specific organizational and performance data. Population counts for ESRD incidence rates calculation and neighborhood poverty measures were obtained from US Census Bureau.;The correlated nature of the data (individuals nested within neighborhoods; patients nested within treatment facilities) was accounted for in multilevel analysis.;Racial disparity in ESRD incidence was the most pronounced in the most impoverished neighborhoods, but was observed at every level of neighborhood deprivation.;Racial differences in transplantation were found to vary across treatment facilities and were more pronounced in the facilities with the overall lower adequacy of dialysis care than, in better care facilities, leading to a number of potential explanations and hypotheses.;The observed mortality during the first year of HD initiation was higher for white compared to black patients and this disparity was accentuated among obese. While ESRD treatment facility factors contributed to racial disparity in transplantation, there was no effect of these factors on racial disparity in mortality. Better observed survival among black HD patients could be a manifestation of bias resulting, in the presence of unmeasured risk factors, from differential selection of subjects who survive to and develop ESRD.