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Employment among patients with kidney disease remains low even after dialysis or a transplant, with physical and social factors contributing to employment rates.

Although advances in the treatment of end-stage kidney disease have improved outcomes and survival for people with the disease, employment rates for these patients remain low even after the start of effective treatment, according to findings published in BMC Nephrology.

End-stage chronic kidney disease and other chronic diseases can make it difficult for people with these illnesses to stay employed, and many patients are forced into early retirement or are unemployed long-term, researchers explained. This can leave them unable to earn a living even as treatment grants them a longer life.

“In recent decades, treatment options for end-stage kidney disease have improved, including home hemodialysis, improved peritoneal dialysis options, and enhanced survival following kidney transplantation,” Merete Osler, MD, PhD, and colleagues wrote. “Despite this progress, inability to work remains a major problem.”

Study Parameters

The researchers performed a registry-based cohort study of adults who underwent first-time dialysis or kidney transplant for end-stage kidney disease from 2005 to 2019. Dr. Osler and colleagues identified patients using a national nephrological registry and linked social security documents. They matched each patient with kidney disease to as many as three reference patients. Patients’ index time was defined as the date they started dialysis or underwent kidney transplantation. To account for the fact that most patients take leave from work ahead of surgery, researchers recorded the surgical recipients’ employment status as it stood at 4 weeks before transplantation.

All patients were aged 18 to 65 years.

The main outcome was employment among patients with kidney disease at 3 years before the index date, 1 year before the index date, time of intervention (index date), 1 year post-index, and 3 years post-index. The secondary outcome was the difference in employment rates between references and patients during three intervals: 2005 to 2009, 2010 to 2014, and 2015 to 2019.

Patient Characteristics

The study population included 4,469 patients who started dialysis during the study period matched with 13,262 reference cases, as well as 2,294 patients who received a first kidney transplant matched with 6,790 reference cases.

Patients who started dialysis were a median of 55 years and 65% were men. For those who had a first kidney transplant, the median age was 49 years, and 64% were men. Most transplant recipients were previously on dialysis (79%), and one-fifth of these patients (21%) underwent pre-emptive transplantation. About two-thirds of patients who had dialysis before undergoing transplant (64%) had previously undergone hemodialysis as opposed to peritoneal dialysis. 

Employment In People With Kidney Disease Vs Reference Cases

Among patients who initiated dialysis, the employment rate was 11% compared with 61% for the reference group, the researchers reported. For those who had a kidney transplant, the employment rate was 20%, versus 67% for the reference group. 

At all points during the study, patients who started dialysis or had a first kidney transplant showed significantly lower employment rates than their matched references, Dr. Osler and colleagues found (P<0.001). This included a significantly lower employment rate 3 years before dialysis or transplantation versus the respective reference case (P< 0.001), they wrote.

Barriers To Employment

“An important finding in our dataset is a large decline in employment during the years before the initiation of renal replacement therapy,” Dr. Osler and colleagues wrote. “This information shows that initiatives in maintaining employment should take place in the early stages of chronic kidney disease and not wait until patients need replacement therapy.”

Many patients in the study population had significant comorbidity burdens, and these comorbidities were related to employment status. Further, factors contributing to unemployment in these patients were both physical and social, Dr. Osler and colleagues noted. Such factors ranged from diabetes to affective disorders.

Improving social conditions for these patients before the onset of disease has the potential to help people stay employed when kidney disease does occur, they continued.

“Social conditions including the educational level are very important but often overlooked and require focus many years before the onset of end-stage kidney disease,” the researchers wrote. “For patients undergoing kidney transplantation, pre-transplant employment is very important for continuous affiliation to the labor market, which points to the importance of pre-emptive transplantation, more living donor transplantations, and the avoidance of a long time on waiting lists.”