Racial and Ethnic Disparities in Access to Home‐Based Renal Replacement Therapies Among Incident End‐Stage Renal Disease Patients in the United States

BACKGROUND: Racial and ethnic disparities in access to home-based renal replacement therapies (RRT) remain a major concern in the management of end-stage renal disease (ESRD) in the United States. Despite national efforts to expand home hemodialysis (HHD) and peritoneal dialysis (PD), inequities at treatment initiation persist. Therefore, the goal was to evaluate racial and ethnic disparities in the initial modality of RRT among incident adult ESRD patients in the United Stated from 2014 to 2020. METHODS: This retrospective, pooled cross-sectional study used United States Renal Data System (USRDS) data on adults initiating dialysis between 2014 and 2020. Descriptive analyses compared biological, environmental, and behavioral determinants across modalities. Poisson regression models with robust variance estimated adjusted incidence rate ratios (IRRs) for initiating HHD or PD versus in-center hemodialysis (ICHD), controlling for demographic, clinical, socioeconomic, and behavioral factors within an integrated health risk management framework. RESULTS: Among 3.49 million incident ESRD cases, 82.8% initiated ICHD, 15.5% PD, and 1.7% HHD. Significant disparities were observed by race/ethnicity. Compared with White patients, Black patients had markedly lower adjusted incidence rates of initiating HHD (IRR 0.69; 95% CI 0.67-0.72) and PD (IRR 0.55; 95% CI 0.55-0.56). Hispanic or Latino patients similarly demonstrated reduced initiation of HHD (IRR 0.42; 95% CI 0.40-0.45) and PD (IRR 0.64; 95% CI 0.64-0.65). Asian patients had a modestly higher adjusted rate of PD initiation (IRR 1.08; 95% CI 1.06-1.09) but lower rates of HHD. Other racial groups also showed consistently reduced use of home modalities. CONCLUSIONS: Substantial racial and ethnic disparities persist in the initiation of home dialysis in the U.S. While structural and system-level factors likely contribute, patient-level clinical considerations, cultural norms, social support availability, and provider practice patterns also play important roles.