title: Care of undocumented-uninsured immigrants in a large urban dialysis unit.
abstract: BACKGROUND
  Medical, ethical and financial dilemmas may arise in treating undocumented-uninsured patients with end-stage renal disease (ESRD). Hereby we describe the 10-year experience of treating undocumented-uninsured ESRD patients in a large public dialysis-unit.
  
  
  METHODS
  We evaluated the medical files of all the chronic dialysis patients treated at the Tel-Aviv Medical Center between the years 2000-2010. Data for all immigrant patients without documentation and medical insurance were obtained. Clinical data were compared with an age-matched cohort of 77 insured dialysis patients.
  
  
  RESULTS
  Fifteen undocumented-uninsured patients were treated with chronic scheduled dialysis therapy for a mean length of 2.3 years and a total of 4953 hemodialysis sessions, despite lack of reimbursement. All undocumented-uninsured patients presented initially with symptoms attributed to uremia and with stage 5 chronic kidney disease (CKD). In comparison, in the age-matched cohort, only 6 patients (8%) were initially evaluated by a nephrologist at stage 5 CKD. Levels of hemoglobin (8.5 ± 1.7 versus 10.8 ± 1.6 g/dL; p < 0.0001) and albumin (33.8 ± 4.8 versus 37.7 ± 3.9 g/L; p < 0.001) were lower in the undocumented-uninsured dialysis patients compared with the age-matched insured patients at initiation of hemodialysis therapy. These significant changes were persistent throughout the treatment period. Hemodialysis was performed in all the undocumented-uninsured patients via tunneled cuffed catheters (TCC) without higher rates of TCC-associated infections. The rate of skipped hemodialysis sessions was similar in the undocumented-uninsured and age-matched insured cohorts.
  
  
  CONCLUSIONS
  Undocumented-uninsured dialysis patients presented initially in the advanced stages of CKD with lower levels of hemoglobin and worse nutritional status in comparison with age-matched insured patients. The type of vascular access for hemodialysis was less than optimal with regards to current guidelines. There is a need for the national and international nephrology communities to establish a policy concerning the treatment of undocumented-uninsured patients with CKD.
authors.affiliation: Nephrology Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, 64239, Israel. gilc@tasmc.health.gov.il
authors.forename: Gil
authors.initials: G
authors.lastname: Chernin
authors.forename: Amir
authors.initials: A
authors.lastname: Gal-Oz
authors.forename: Idit F
authors.initials: IF
authors.lastname: Schwartz
authors.forename: Moshe
authors.initials: M
authors.lastname: Shashar
authors.forename: Doron
authors.initials: D
authors.lastname: Schwartz
authors.forename: Talia
authors.initials: T
authors.lastname: Weinstein
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D054242:Emigrants and Immigrants / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007557:Israel / Q000453:epidemiology; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008875:Middle Aged; D009398:Nephrology / Q000706:statistics & numerical data; D015995:Prevalence; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000453:epidemiology* / Q000534:rehabilitation*; D012959:Socioeconomic Factors; D014505:Urban Population / Q000706:statistics & numerical data*