'Bold Action' Urged on Outpatient Dialysis for Undocumented US Patients

By Anne Harding

May 28, 2020

NEW YORK (Reuters Health) - During the COVID-19 era, all 50 U.S. states should cover standard outpatient dialysis for undocumented immigrant patients with kidney failure, many of whom now rely on emergency-only dialysis, according to new recommendations.

"Emergency-only hemodialysis utilizes a number of resources and would increase exposure for both providers and the patient undergoing emergency-only hemodialysis, as well as anyone else in the emergency department," Dr. Katherine Rizzolo of Maine Medical Center in Portland, Oregon, told Reuters Health by phone.

From 5,500 to 8,857 undocumented immigrants with kidney failure live in the U.S., according to 2019 estimates, Dr. Rizzolo and her team note in the American Journal of Kidney Diseases. Those who have no coverage for standard dialysis wait until they become critically ill and require emergency care, which occurs an average of six times a month, they add.

Patients getting emergency-only dialysis have a worse quality of life and their five-year mortality is 14 times higher than for patients on standard dialysis, the authors note. Emergency-only dialysis costs $285,000-$400,000 a year per person, they add, versus $76,177-$90,971 for standard dialysis.

Twelve states with substantial undocumented immigrant populations including Arizona, North Carolina and Virginia have expanded their Emergency Medicaid programs to cover outpatient dialysis, Dr. Rizzolo and her colleagues note.

While having dialysis three times a week can expose a patient to COVID-19, the authors add, "outpatient dialysis units are taking extensive precautions to protect patients and prevent intra-unit spread, making it a safer environment to receive dialysis than the unpredictable hospital setting."

Another concern is that fears about the Public Charge rule, which states that anyone at risk of requiring government assistance in the future can be denied admission to the U.S., may make undocumented patients with kidney failure wait even longer to get care, Dr. Rizzolo said.

"The Public Charge rule should be completely disbanded during this time," she said.

Dr. Rajeev Raghavan, a nephrologist at Baylor College of Medicine in Houston, Texas, told Reuters Health by email, "Chronically ill undocumented patients and their families face immense challenges with regards to obtaining adequate healthcare. The Covid-19 pandemic has taught us that the health of the entire community is critical to reduce the spread of disease."

He added, "If all states adopted policies to provide dialysis to undocumented patients, this would be fiscally responsible, humane, and would minimize unnecessary exposures to the virus."

Texas has the second-largest population of undocumented immigrants in the U.S., Dr. Raghavan noted, but does not cover outpatient dialysis with state funds. "It is a concern due to the high cost of emergency care, compared to outpatient dialysis, and because the patients remain very sick with emergency-only care resulting in frequent hospital admissions," he said.

"Kidney transplantation, particularly living-donor, should be the treatment of choice for this population. It will facilitate return to work and is more cost effective than even scheduled dialysis for the healthier patients," said Dr. Raghavan, who was not involved in the study.

"This topic is at the intersection of major national agendas, healthcare reform and immigration. These patients are among the most vulnerable," he said. "By tackling this problem, we can provide more cost-effective and humane care, while simultaneously slowing the risk of progression of Covid-19."

SOURCE: https://bit.ly/36HvlQd American Journal of Kidney Diseases, online May 12, 2020.