Table 1.

Potential Contributory Factors for the African American Survival Differential Between Younger Versus Older Dialysis Patients

Potential Mechanism	Description	Suggested Solution
Lower transplant rate in African Americans	African Americans could be steered away from transplants because of the general perception of lower mortality on dialysis therapy. This could inflate artificially the survival advantage (similar to Japanese dialysis patient survival).	Use survival models that adjust for competing censorship.
Inclusion of Hispanics in the reference group	Pooling “white” or “nonblack” patients into a single reference leads to the inclusion of Hispanic whites (and in some cases Asians), who traditionally have better survival, analogous to blacks.	Exclude minorities from the reference groups.
Higher background mortality of young African Americans	In persons 15–44 years of age, minorities have higher death rates from homicide, motor vehicle accident, suicide, and drug overdose.	Adjust for background mortality disparities of the non-ESRD population.
Differences in insurance mix	Younger African Americans have less insurance, whereas in older patients, there is more parity in insurance coverage.	Adjust for insurance mix in multivariate models.
Differences in trust of institutions	Younger African Americans may have an even greater distrust of institutions, including medical establishments, leading to delayed/reduced visits and/or lesser adherence even if access to care is available.	Adjust for adherence surrogates in multivariate models.
Age permissibility of genetic factors	Age may exert a permissive or effect-modifying role on the genetic factors that impact on survival.	Conduct gene expression studies.

Abbreviation: ESRD, end-stage renal disease.