How Race and Ethnicity Affect the Relationship Between Quality of Life and Mortality in a Hemodialysis Population: “Quality of Life Is More Important Than Life Itself”

Abstract

in reference to the modern-day hemodialysis population, they are certainly fitting. In 2016, approximately 125,000 new cases of endstage renal disease (ESRD) joined an estimated 726,000 people already carrying this diagnosis. The vast majority (87%) of incident dialysis patients initiated in-center maintenance hemodialysis, joining approximately 450,000 people already receiving dialysis in a hemodialysis facility. It is well-established that mortality rates on hemodialysis are exceptionally high. Despite a decline in 5-year mortality rates for patients receiving hemodialysis during the past 2 decades, an estimated 55% of hemodialysis patients die within the first 5 years of initiating therapy. Based on recent 5-year survival rate comparisons, adults initiating hemodialysis have lower life expectancy than most people who develop solid-organ cancers, including colorectal, breast, and prostate cancer. This underscores the need to identify potentially modifiable risk factors and new treatments to improve hemodialysis outcomes. Health-related quality of life (HRQoL) has emerged as one such factor. HRQoL is an important patient-reported outcome in its own right, with the burden imposed by maintenance dialysis well demonstrated by the fact that patients with ESRD report significantly lower HRQoL compared with the general population. Additionally, low HRQoL is itself recognized as a risk factor for worse outcomes, including higher hospitalization and mortality rates among dialysis patients. However, prior studies have been limited by the lack of robust longitudinal assessments of HRQoL and cohorts without adequate diverse racial/ ethnic makeup. This is critical because for reasons that remain not entirely delineated, Hispanics and African Americans have a survival advantage on maintenance hemodialysis compared with non-Hispanic whites. Attempts to elucidate whether differences in HRQoL between Hispanics, African Americans, whites, and other races/ ethnicities affect mortality risk are lacking. In this issue of Kidney Medicine, Kalantar et al address these gaps in the literature. The authors investigated the