Nephrology Care Gaps Drive Vascular Access Disparities for Hispanic Dialysis Patients
Key Clinical Summary
- Hispanic patients initiating hemodialysis were 23% less likely than White patients to have a mature, usable vascular access at dialysis start.
- Lack of predialysis nephrology care accounted for approximately one-third of this vascular access disparity.
- Findings highlight system-level gaps in timely nephrology referral as a key driver of inequitable kidney failure outcomes.
Hispanic individuals with kidney failure are significantly less likely than White individuals to initiate hemodialysis with a mature arteriovenous fistula or graft, despite being younger and having fewer comorbidities. A large cohort study using data from the US Renal Data System (USRDS) quantifies how disparities in predialysis nephrology care contribute to these differences, underscoring a major quality-of-care gap with policy implications.
Study Findings
The retrospective cohort study analyzed 427 340 adult Medicare beneficiaries who initiated hemodialysis between 2010 and 2019, using the 2021 USRDS database. The primary analysis focused on patients with at least 6 months of continuous Medicare coverage before dialysis initiation.
Among the cohort, 10.8% of patients self-identified as Hispanic, 63.1% as non-Hispanic White, and 21.7% as Black. Overall, only 17.6% of patients initiated dialysis with a mature vascular access, including arteriovenous fistula (14.5%) or graft (3.1%), while 82.2% started with a central venous catheter (CVC).
After adjustment, Hispanic patients had significantly lower odds of receiving any predialysis nephrology care compared with White patients (adjusted odds ratio [aOR], 0.70; 95% CI, 0.68-0.72). They also had 23% lower odds of initiating dialysis with a mature vascular access (aOR, 0.77; 95% CI, 0.75-0.80).
Causal mediation analysis showed that lack of predialysis nephrology care explained 32.59% of the disparity in incident vascular access use and 62.00% of the underuse of maturing access. Sensitivity analyses incorporating longer duration of nephrology care and predialysis kidney disease education further strengthened the observed associations.
Secondary analyses found that Hispanic patients who initiated dialysis with a CVC were more likely than White patients to convert to a functional fistula or graft within one year, suggesting higher access maturation potential despite worse initial access.
Clinical Implications
Incident vascular access is a key quality metric in kidney failure care, given its association with lower infection risk, improved survival, and reduced health care costs compared with catheter use. The findings suggest that disparities observed at dialysis initiation are not primarily driven by patient suitability but by upstream system failures in predialysis care delivery.
Hispanic patients in this cohort were younger and had lower comorbidity burden—characteristics typically associated with higher success rates for fistula or graft placement. Yet they were less likely to receive timely nephrology care, which is essential for vascular access planning, education, and referral for surgical placement.
For payers and managed care organizations, these data point to missed opportunities for improving outcomes and reducing costs through earlier identification of advanced chronic kidney disease and improved access to nephrology services. Addressing predialysis care gaps may also support broader policy goals, including equitable access to optimal kidney replacement therapy initiation.
The authors note that “system-based disparities in predialysis access to nephrology care contribute to approximately one-third of incident vascular access disparities among Hispanic individuals,” emphasizing the need for targeted policy interventions. They highlight that improving early nephrology referral could allow health systems to “leverage the clinical and health care cost benefits of improving predialysis care on optimal kidney replacement therapy initiation.”
Conclusion
This large USRDS cohort study demonstrates that inequities in predialysis nephrology care are a major driver of vascular access disparities for Hispanic patients starting hemodialysis. System-level strategies focused on timely referral and access to nephrology care are essential to achieve more equitable kidney failure outcomes.
Reference
Pramod S, Scheiffele G, Huang W. Predialysis nephrology care disparities and incident vascular access among Hispanic individuals. JAMA Netw Open. 2025;8(9):e2530972. doi:10.1001/jamanetworkopen.2025.30972
