Addressing Disparities in ESKD Care

We read with great interest the recent JASN study by Shukla et al., highlighting race-related and ethnicity-related disparities in predialysis nephrology care, kidney disease education, and home dialysis utilization.1 Their findings strongly resonate with our own experience at Brugmann University Hospital, a major public teaching hospital in Brussels, Belgium, which serves one of Europe's most diverse and socially vulnerable patient populations. Our observational study of 514 incident dialysis patients (2010–2024) similarly identified significant disparities in nephrology care access and treatment pathways, particularly among immigrants. Like Shukla et al., we found that marginalized populations often enter dialysis in an urgent setting, with limited prior nephrology follow-up. In our cohort, Western European patients had a median predialysis follow-up of 8 months, whereas North African, sub-Saharan African, and Eastern European patients had less than 1 month. These findings align with the disparities in predialysis nephrology care and kidney disease education reported by Shukla et al., further reinforcing the need for early intervention. However, our findings also provide a complementary perspective. Despite severe socioeconomic challenges, sub-Saharan African patients in our center had a relatively high rate of peritoneal dialysis (PD) initiation (31%), compared with significantly lower rates in Hispanic and Black patients in the US study. This discrepancy may stem from structural and organizational factors rather than intrinsic racial disparities. Our collaboration with the Federal Agency for the Reception of Asylum Seekers has facilitated PD implementation, even among patients facing language barriers and inadequate home facilities. This suggests that, with appropriate support systems, PD underutilization among marginalized groups may be mitigated. Another critical disparity noted by both studies is delayed access to kidney transplantation. In our study, North African, sub-Saharan African, and Eastern European patients experienced median waiting times of 3.5, 3.6, and 5.3 years, respectively, compared with 1.7 years for Western European patients. Yet, sub-Saharan African patients had the highest transplantation rate over 10 years (27.8% versus 15% for native Belgians), likely due to younger age and lower comorbidity burden. This emphasizes that systemic barriers, particularly administrative delays, contribute substantially to transplantation inequities, rather than ethnicity alone. We congratulate Shukla et al. for their critical work in highlighting disparities in nephrology care. Our findings further underline the necessity of addressing modifiable structural and socioeconomic barriers to optimize kidney care outcomes across diverse populations.