While improvements have been seen recently, the number of patients with end-stage renal disease who remain in the workplace after starting dialysis remains low, according to a recently published study.

Kevin F. Erickson, MD, and colleagues at Baylor College of Medicine and at Rice University studied employment status among patients (aged 18 to 54 years) who initiated dialysis in the United States between 1996 and 2013. Researchers compared unadjusted trends in employment at the start of dialysis and 6 months prior to end-stage renal disease (ESRD) and estimated changes in employment with time after they adjusted for patient characteristics and local unemployment rates in the general population. Data were based on employment information acquired from the CMS Medical Evidence Report (form CMS-2728) that the dialysis care team completes for each patient starting on dialysis.

Researchers found employment was low among patients starting dialysis throughout the study period at 23% to 24%, and 38% of patients who were employed 6 months prior to being diagnosed with kidney failure stopped working by the time they initiated dialysis. In the general population, 81% to 85% of adults with similar age were employed.

After adjusting for patient characteristics and local unemployment rates in the general population, however, investigators found the probability of employment among patients starting dialysis increased with time. Compared with patients starting dialysis between 1996 and 2001, patients starting dialysis between 2008 and 2013 had a 4.7% increase in the absolute probability of employment. Although researchers found Black and Hispanic patients had higher odds of being unemployed than other patients starting dialysis, this difference decreased during the study period.

“ESRD is the only health condition that qualifies patients for federal Medicare coverage regardless of their age, and a major objective of the law that granted Medicare coverage to patients with ESRD was to help them to remain productive members of society,” Erickson wrote about the study. “While the U.S. ESRD program has provided many patients with access to life-saving dialysis and transplant therapy, it has been less successful in helping patients to continue working.”

In an editorial accompanying the study, Ayman Hallab, MD, and Jay B. Wish, MD, from the department of medicine, division of nephrology, at Indiana University School of Medicine, wrote that patients with progressive chronic kidney disease transitioning to kidney failure “face multiple disincentives to employment, including medical, logistical and financial.”

Unemployment among working-age ESRD patients is not unique to the United States; other countries, such as Finland and India, show employment rates of 33% and 29%, respectively, after initiating dialysis.

“The main questions for the nephrology community to consider are how the likelihood of patients being employed at the time of initiation of dialysis can be increased, how can employed patients be assured to stay in the workforce after initiation of dialysis and how unemployed patients can be helped to join the workforce,” Hallab and Wish wrote. “Understanding the factors influencing employment rates and the disincentives to employment is the first step.”

Those factors, they wrote, can include:

  • pre-dialysis employment;
  • higher level of education;
  • access to vocational training;
  • choice of dialysis modality;
  • early access to nephrology care prior to the need for dialysis;
  • treatment for anemia with erythropoiesis stimulating agents before ESRD onset; and
  • availability of evening shifts at dialysis clinics.

Previous studies have shown that U.S. patients who started peritoneal dialysis had higher employment rates compared to patients who started hemodialysis.

“Studies from Finland and India also showed significantly higher employment rates among patients receiving home therapies as compared to those receiving in-center hemodialysis,” Hallab and Wish wrote. Other studies have shown that late-evening hemodialysis shifts offered by dialysis clinics, and those which offer training in peritoneal dialysis or home hemodialysis had higher percentage of employed patients, they noted.

“For employment-preserving strategies to succeed, there must be a fundamental change in the way health care is delivered to vulnerable populations in the U.S. with improved disease management and funding for the social services required to overcome the employment disincentives,” Hallab and Wish wrote. “Improving access to medical care, including early evaluation by a nephrologist, availability of home dialysis modalities, proper patient preparation including integrated pre-dialysis education models and encouraging vocational rehabilitation are possible interventions to assist patients in rejoining or remaining in the workforce and to help fulfilling the promise of 1972.” – by Mark E. Neumann


Erickson KF, et, al. CJASN. 2018;doi:10.2215/CJN.06470617.

Hallab A, et al. CJASN. 2018;doi:10.2215/CJN.13491217.

Disclosures: The authors report no relevant financial disclosures.