Healthcare outcomes in undocumented immigrants undergoing two emergency dialysis approaches

Background: Current estimates suggest 6,500 undocumented end-stage renal disease (ESRD) patients in the United States are ineligible for scheduled hemodialysis and require emergent dialysis. In order to remain in compliance with Emergency Medicaid, an academic health center altered its emergency dialysis criteria from those emphasizing interdialytic interval to a set emphasizing numerical thresholds. We report the impact of this administrative change on the biochemical parameters, utilization, and adverse outcomes in an undocumented patient cohort. Methods: This retrospective case series examines 19 undocumented ESRD patients during a 6-month transition divided into three 2-month periods (P1, P2, P3). In P1, patients received emergent dialysis based on interdialytic interval and clinical judgment. In P2 (early transition) and P3 (equilibrium), patients were dialyzed according to strict numerical criteria coupled with clinical judgment. Results: Emergent criteria-based dialysis (P2 and P3) was associated with increased potassium, blood urea nitrogen (BUN), and acidosis as compared to P1 (p < 0.05). Overnight hospitalizations were more common in P2 and P3 (p < 0.05). More frequent adverse events were noted in P2 as compared to P1 and P3, with an odds ratio (OR) for the composite endpoint (intubation, bacteremia, myocardial infarction, intensive care unit admission) of 48 (5.9 – 391.2) and 16.5 (2.5 – 108.6), respectively. Per-patient reimbursement-to-cost ratios increased during criteria-based dialysis periods (P1: 1.49, P2: 2.3, P3: 2.49). Discussion: Strict adherence to criteria-based dialysis models increases biochemical abnormalities while improving Medicaid reimbursement for undocumented immigrants. Alternatives to emergent dialysis are required which minimize cost, while maintaining dignity, safety, and quality of life.