Challenges surrounding hemodialysis initiation faced by undocumented immigrants.

OBJECTIVE: Hemodialysis (HD) care in the United States for undocumented immigrants remains a challenging issue. The objective of this study is to evaluate the timeliness of nephrology and vascular surgery care provided to undocumented immigrants with end-stage renal disease compared with their documented counterparts. Additionally, we evaluate catheter-related complications in undocumented patients on HD.

METHODS: A retrospective chart analysis was performed of patients undergoing first-time arteriovenous access (AVA) creation at a single center from 2012 to 2018 to compare outcomes between documented and undocumented patients. Additionally, within the undocumented group, we compared outcomes between patients dependent on a central venous catheter (CVC group) to patients with a CVC and transition to an AVA (CAV group). The primary outcomes were time to initial evaluation by nephrology, vascular surgery, and AVA creation, as well as complications associated with long-term CVC use within the undocumented patients.

RESULTS: A total of 290 patients underwent first-time AVA creation (62 undocumented; 228 documented). Undocumented patients were younger at the time of surgery and, more commonly, Hispanic. Undocumented patients were more likely to receive their first nephrology evaluation upon HD initiation (59.7% vs 25.4%; P < .001). Regarding vascular access surgery initial evaluation for AVA creation, undocumented patients were more likely to be evaluated after initiating HD (74.2% vs 38.6%; P < .001). After being evaluated for AVA creation, there was no difference in time from vascular surgery evaluation to surgery (25 days vs 20 days; P = .95) or from surgery to AVA maturation (77 days vs 57 days; P = .31). As a result, undocumented patients were more likely to start dialysis with a CVC (90.3% vs 66.7%; P = .0004). Undocumented patients in the CVC group were more likely to experience catheter-related complications compared with their undocumented counterparts in the CAV group (CVC 72.5% vs CAV 45.9%; P = .032). The CAV patients were found to have an earlier occurrence of their first catheter-related complications, driving an earlier evaluation for AVA creation and subsequent CVC removal.

CONCLUSIONS: Due to limited access to health care, undocumented immigrants with end-stage renal disease had a significant delay in evaluation by nephrologists and vascular access surgeons for AVA creation with a higher use of CVC for dialysis initiation. CVC-related complications are highly frequent and avoidable in undocumented patients with an earlier referral for creation of appropriate AVA.