Undocumented Immigrants with ESRD Experience a Significant Delay for Arteriovenous Access Creation Compared to Documented Patients
Christopher R Ramos1, Emma Rooney1, Jaime Benarroch-Gampel1, Helen O'Leary1, Caroline Wasserman1, Victoria Teodorescu1, Katie Metts2, Sarah Johnson1, Ravi R Rajani1
1Emory University, Atlanta, GA;2Philadelphia College of Osteopathic Medicine, Suwanee, GA
BACKGROUND: Dialysis care in the United States for undocumented immigrants remains challenging, with limited available literature assessing outcomes when compared with a standard Medicare population. Dialysis for this patient population is limited to emergency-only dialysis after the patient is deemed critically-ill, requiring hospitalization. The objective of this study is to evaluate the timeliness of medical care provided for undocumented immigrants with ESRD compared to their insured counterparts.
METHODS: A retrospective chart analysis was performed of patients undergoing first time arteriovenous (AV) access creation at a single center from 2012-2018. Patients without adequate follow-up were excluded and the data set was divided based on documentation of immigration status. Patient demographics and operative details were collected. AV access was considered mature when deemed so by the vascular surgeon or when successfully used for hemodialysis. The primary outcome was initial evaluation by vascular surgery in relation to the initiation of hemodialysis.
RESULTS: 290 patients underwent first time AV access creation (62 undocumented vs 228 United States citizens or permanent residents). Undocumented patients were younger (46.6 years vs 54.4 years, P<.0001) and more likely to be Hispanic (91.9% vs 6.2%, P<.0001). There was no difference between groups in the etiology of kidney disease. Undocumented patients were more likely to be on hemodialysis when they were initially evaluated for access creation by vascular surgery (74.2% vs. 42%, P<.0001) as well as to start dialysis with a tunneled catheter (90.3% vs 63.8%, P=.003). In relation to hemodialysis initiation, undocumented patients had a delay in evaluation by vascular surgery for AV access creation (165 days vs -130 days, P<.0001). After being evaluated for hemodialysis access creation, there was no difference in time from vascular surgery evaluation to surgery (51 days vs 56 days, P=.67) or from surgery to access maturation (118 days vs 106 days, P=.58).
CONCLUSION: Due to limited access to healthcare, undocumented immigrants with kidney disease had a delay in evaluation by vascular surgeons for AV access creation with a higher use of tunneled catheter for dialysis initiation. This requires special attention by vascular surgeons and nephrologists to improved outcomes in this vulnerable population.
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