Authors' Reply: Addressing Disparities in ESKD Care: Insights from a Multicultural European Cohort

We appreciate Jacob et al.'s comments1 on our JASN article “Race- and Ethnicity-Related Disparities in Predialysis Nephrology Care, Kidney Disease Education, and Home Dialysis Utilization.2 Jacob et al. highlight similar disparity concerns in predialysis care among marginalized populations in Belgium as those faced by American Black and Hispanic populations but report significantly higher (31%) peritoneal dialysis (PD) utilization. We agree with their broad message but would like to emphasize key considerations when discussing marginalized populations' care across health care systems. First, while impressive, it is important to note that Jacob et al. describe two distinct processes: access to care and its characteristics. Health care disparities among marginalized populations, including socially vulnerable patients in Western Europe, are influenced by various patient-, provider-, and system-related barriers. Our findings—demonstrating that the lack of access to essential care, particularly predialysis nephrology care and KRT-directed education, contributes to 30% of PD underuse among Hispanic individuals (14% among Black individuals)—underscore the significance of system-related barriers in driving home dialysis disparities in the United States, with the rest attributable to other potentially patient- and provider-related barriers.2 As such, addressing these system-based barriers, as Jacob et al. achieved through collaboration with the federal agency for asylum seekers, cannot entirely correct disparate outcomes. Disparities among marginalized populations are also intertwined with complex linguistic and cultural practices.3 Significant interactions across the directed acyclic graph in our analysis allude to these considerations, suggesting that nephrology care and patient education practices have a differential effect on PD utilization among marginalized populations across the broader health care system. Jacob et al. tackling this second component, i.e., qualitatively adapting institutional clinical practices to address language barriers and provide appropriate support, seems critical to their improved outcomes. Second, it is interesting to note that Jacob et al. report substantially higher PD utilization (31%) among their vulnerable cohort than the overall rates for their national population reported in the Belgian registry, which, at 9%–11%, are similar to the United States.4 This striking contrast likely exemplifies the differences between the uniform outcomes of a well-designed institutional practice versus the variable efficacy of the heterogeneous practices promoting informed KRT use across the broader health care system. Nearly all studies to date show that using patient-centered comprehensive KRT-directed prekidney failure education substantially increases home dialysis utilization, although their effect, as measured by the reported home dialysis rates across these studies, varies widely.5 To sum up, the current need is not just to address the system-based access to care barriers our article highlights but to complement them with implementation studies, which scale up the adoption of successful multilevel institutional models, as described by Jacob et al., to disseminate their benefits more uniformly across the larger health care system. Nonetheless, as the authors point out, there remains a need to ensure that these models guarantee the benefits of the full spectrum of KRTs, including kidney transplantation, for all races and ethnicities.