Pre-ESKD Nephrology Care and Employment at the Start of Dialysis

Abstract Background Employment is associated with improved sense of well-being and quality of life in patients with kidney disease. Earlier nephrology referral and longer duration of pre-ESKD nephrology care are associated with improved health outcomes in patients with advanced kidney disease who initiate dialysis. It is unknown if pre-ESKD nephrology care helps patients stay employed leading up to dialysis initiation. Methods We used the US ESKD registry to identify adults aged 18-54 who initiated dialysis between 2007 and 2014. Analyses were restricted to patients who reported being employed 6-months prior to ESKD. We used multivariable regression models with estimated average marginal effects to examine the independent association between ≥6 months of pre-ESKD nephrology care and employment at dialysis initiation. To reduce bias, we conducted an instrumental variable (IV) analysis based upon geographic variation in pre-ESKD care. Results Out of 75,700 patients included in study cohort, 49% reported receiving pre-ESKD nephrology care for ≥6 months and 62% were employed at dialysis initiation. Although geographic variation in pre-ESKD nephrology care was strongly associated with the likelihood that working-aged patients in our analytic cohort received pre-ESKD care, the receipt of pre-ESKD nephrology care was not significantly associated with employment at dialysis initiation; estimated probability: 5%; 95% CI -6% to 14%. Conclusion Pre-ESKD nephrology care 6-months prior to initiation of dialysis is not associated with the likelihood of remaining employed at the initiation of dialysis. While nephrology care has a potential to help patients to remain employed, these benefits do not materialize in current practice.