The Survival of Roma Minority Patients on Chronic Hemodialysis Therapy - A Romanian Multicenter Survey

RESEARCH ARTICLE The Survival of Roma Minority Patients on Chronic Hemodialysis Therapy - A Romanian Multicenter Survey Florica Gadalean1☯, Daniel Lighezan2☯, Dana Stoian3*, Oana Schiller4, Romulus Timar5, Bogdan Timar6, Flaviu Bob1, Mihaela Dora Donciu7, Mircea Munteanu5, Adelina Mihaescu1, Adrian Covic7, Adalbert Schiller1 a11111 OPEN ACCESS Citation: Gadalean F, Lighezan D, Stoian D, Schiller O, Timar R, Timar B, et al. (2016) The Survival of Roma Minority Patients on Chronic Hemodialysis Therapy - A Romanian Multicenter Survey. PLoS ONE 11(5): e0155271. doi:10.1371/journal. pone.0155271 Editor: Vivekanand Jha, Postgraduate Medical Institute, INDIA 1 Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania, 2 Department of Internal Medicine, ‘Victor Babes’ University of Medicine and Pharmacy, Municipal Clinical Emergency Hospital, Timisoara, Romania, 3 Department of Obstetrics and Gynecology, ‘Victor Babes’ University of Medicine and Pharmacy, Municipal Hospital, Timisoara, Romania, 4 B Braun Avitum Dialysis Center Timisoara, Timisoara, Romania, 5 Department of Diabetes and Metabolic Diseases, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania, 6 Department of Medical Informatics and Biostatistics, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania, 7 Department of Nephrology and Internal Medicine, University of Medicine “Gr. T. Popa” Iasi, Hospital “C. I. Parhon” Iasi, Iasi, Romania ☯ These authors contributed equally to this work. * Abstract Objective The Roma minority represents the largest ethnic group in Central and South-East European countries. Data regarding the mortality in Roma hemodialysis subjects are limited. We evaluated the 3 year mortality of ESRD Roma patients treated with hemodialysis (HD). Received: January 20, 2016 Accepted: April 26, 2016 Published: May 19, 2016 Copyright: © 2016 Gadalean et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: This research project was funded by an internal grant from the University of Medicine and Pharmacy ‘‘Victor Babes’’ Timisoara, PIII-C2-PCFI2015/2016, www.umft.ro. AS received the funding. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have no conflict of interest. Adalbert Schiller is medical consultant for Study Design and Setting Our prospective cohort study included 600 ESRD patients on HD therapy recruited from 7 HD centers, from the main geographical regions of Romania. The median age of the patients was 56 (19) years, 332 (55.3%) being males, 51 (8.5%) having Roma ethnicity. Results Roma ESRD patients initiate dialysis at a younger age, 47.8 years vs. 52.3 years (P = 0.017), present higher serum albumin (P = 0.013) and higher serum phosphate levels (P = 0.021). In the Roma group, the overall 3 year mortality was higher when compared to Caucasians (33.3% vs. 24.8%). The multivariate survival analysis revealed that being of Roma ethnicity is an independent risk factor for mortality (HR = 1.74; 95% CI = 1.04–2.91; P = 0.035). Conclusions Roma patients with ESRD initiate HD therapy at a younger age as compared to Caucasians. They have a higher 3 year mortality rate and are dying at a younger age. Roma ethnicity represents an independent risk factor for mortality in our cohort. PLOS ONE | DOI:10.1371/journal.pone.0155271 May 19, 2016 1 / 12 The Survival of Roma Minority Patients Undergoing Chronic Hemodialysis BBraun Avitum Ltd, Romania. The BBraun Avitum Ltd Romania provided support in the form of salaries for author Oana Schiller, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Introduction Recent epidemiology data have shown that the Roma minority represents the largest ethnic group in Central and South-East European countries (up to7-9% of the population) [1]. Several studies showed a higher prevalence of chronic diseases (hypertension, diabetes, chronic respiratory disease, obesity, metabolic syndrome) in the Roma minority in comparison to the general population [2, 3, 4]. These findings, along with genetic, social, cultural and economic contributors, may explain the 20% prevalence of chronic kidney disease (CKD) in this ethnic group [4], with a relative risk of progressing to end stage renal disease (ESRD) 1.34 times higher comparing to the general population [5]. However, there is no data about the outcomes of the Roma minority with ESRD undergoing HD therapy. According to our knowledge this is the first multicenter study to address this issue. Subjects and Methods In this prospective observational study we included all 600 ESRD patients under chronic HD therapy on 1st of November 2010 (332 men and 268 women) in 7 Romanian centers. The cohort was followed-up until 31st of December 2013, or until death. No patient was lost to follow-up. At inclusion, patient’s data were obtained from their medical records. Dialysis vintage was defined as the time between the first day of dialysis treatment and the study entry date. A routine, complete hematologic and biochemical panel of analysis was performed according to the protocols of the Romanian Ministry of Health (assessment of anemia, inflammatory status, CKD-MBD, liver disease markers and hepatitis virus infection). Patients were treated with high flux, high surface, polysulfone (Xevonta) filters (not reused) and ready-to-use dialysis fluid (B. Braun acidic bicarbonate HD concentrate). Anemia and CKD-MBD were treated according to the KDIGO guidelines [6, 7]. Ethnicity was established based on patient’s self-identification and the appraisal of the nephrologist. Outcome analysis Survival time was calculated from the study entry date (1st November 2010) to the date of death or the administrative end of the study (31st of December 2013). We assessed the association between ethnicity and all-cause mortality using Cox-proportional hazard models in which patients remained at risk until death or the end of the study. In the adjusted analysis of survival differences, the following covariates were included: ethnicity (Roma vs. Caucasian), patient’s age, HD duration, body mass index (BMI), hemoglobin, vitamin D levels, history of coronary artery disease, peripheral vascular disease, stroke, hepatitis virus infection and type 2 diabetes mellitus (DM). Statistical analysis Data were collected and analyzed using the SPSS v.17 software suite (SPSS Inc. Chicago, IL, USA) and are presented as mean ± standard deviations for continuou (...truncated)