A DIETITIANS’ PERSPECTIVE: UNDOCUMENTED PATIENTS WITH CHRONIC KIDNEY DISEASE

Damaris Cruz, MS, RDN, LDN
CRN of Florida Chapter Co-Chair

As of 2018, an estimated 11.4 million undocumented immigrants were living in the United States.¹Historically, the undocumented immigrant population has been negatively impacted by social health disparities, such as food insecurity, lack of housing, and inadequate access to health care. They also encounter greater stigma and marginalization, challenges with acculturation, and persistent fear of deportation.²Therefore, it is no surprise that undocumented immigrants face further complications that exacerbate chronic kidney disease and often progress to end-stage renal disease (ESRD) or renal failure.

The undocumented immigrant population became increasingly vulnerable amidst the COVID-19 pandemic, where marginalized groups were disproportionally affected.^3,4 During the pandemic, undocumented immigrants were not awarded the economic relief package, which heightened financial resource strain. Undocumented immigrants had minimal funds for medications, nutritious foods, and other health-related needs. In addition, the Affordable Care Act excludes undocumented immigrants, leaving millions without health insurance. Due to a lack of access to primary care services, chronic conditions in this population are often undiagnosed or poorly controlled.⁴Uncontrolled diabetes and hypertension are the leading causes of chronic kidney disease.⁵

In the United States, approximately 5,500 to 8,857 undocumented immigrants are estimated to live with ESRD.³ Many undocumented immigrants rely on emergency-only dialysis, which means they can only receive dialysis when their condition becomes critical. This differs substantially from the standard of care for dialysis patients, which is traditionally three times per week in an incenter dialysis setting or daily home hemodialysis or peritoneal dialysis.⁶ In a retrospective cohort study published by the Journal of the American Medical Association (JAMA), undocumented immigrants with ESRD treated with emergency-only hemodialysis had higher mortality rates and experienced longer hospital stays.⁷ The emergency-only hemodialysis group’s 5-year mortality rate was 14-fold higher than those receiving standard hemodialysis treatments (P-.03).⁷ Emergency dialysis also results in increased costs in comparison to standard treatments. A cohort study conducted by Nguyen et al⁸, discovered a cost reduction of $5,768 in healthcare costs per month with scheduled dialysis compared to emergency-only dialysis.⁸ There are currently 12 states where undocumented immigrants are eligible to receive outpatient dialysis treatments through the state’s Emergency Medicaid coverage. Where this provision is not available, undocumented patients may be able to receive outpatient dialysis treatments through private insurance paid by charitable organizations or safety net hospital-funded outpatient dialysis centers.⁶

Registered dietitians can play an integral role in helping undocumented immigrants navigate their dialysis journey. It is important for RDNs to be culturally inclusive and sensitive when providing nutrition education. Dietitians should ask questions to learn about their patient’s cultural backgrounds and traditions, cooking methods, and food choices to provide the most appropriate nutritional recommendations. Considering these cultural differences allows the patient to feel respected and dignified, in addition to creating a bond and building rapport with the patient. When considering patients’ cultural norms, it is essential for RDNs to explore ways to make their recipes “renal-friendly” and focus on portion sizes versus eliminating entire food groups. This way the patient is far more likely to adhere to the renal diet, as it aligns with their cultural preferences. The National Kidney Foundation and Todays Dietitian are great resources for making culturally appropriate substitutions.

An additional important aspect to consider is effective communication. In a systematic analysis, 36% of the studies reviewed reported communication ability as a significant barrier to healthcare experienced by undocumented immigrants.⁹Dietitians may need to use bilingual staff or language interpreting services to effectively communicate with patients. Health literacy should also be considered, ensuring that nutrition educational materials are appropriate for the patient. Visual aids can also be a simple and efficient way to enhance health literacy and comprehension. No patient is the same, thus dietitians need to individualize evidence-based nutritional recommendations, by paying special attention to the patient's cultural cuisines and traditions, health literacy, and communication preferences.

Other common barriers undocumented patients experience in the dialysis setting are food insecurity and inadequate access to other healthcare services and unaffordability of medications. It is essential for the interdisciplinary team (dietitian, social worker, nurse, clinical manager, and medical director) to work together to find resources for this population. RDNs and social workers can collaborate to connect patients with eligible local food pantries, community kitchens, farmers’ markets, etc. Dietitians can encourage patients to choose fresh, locally grown, and seasonal food items, which tends to be more affordable since they are readily available. In certain states, there are state-funded food assistance programs for undocumented immigrants. In addition, it is important for dietitians to educate their patients on how to create budget-friendly meals, that are also suitable for the renal diet. For primary care visits and medications, clinics can locate designated nonprofit, federally qualified community health centers that provide care regardless of immigration status. Specific drug assistance programs are also available for certain phosphate binders and calcimimetic agents.

Overall, registered dietitian nutritionists are integral to the interdisciplinary team in helping patients thrive in a dialysis setting. RDNs can provide culturally competent nutrition education and collaborate with other key members to educate patients on the local resources available in the community. Dietitians can have a key role in reducing the stigma and social health disparities experienced by this underserved population. Healthcare providers can be valuable and trusted resources for undocumented immigrants, enabling them to take charge of their health and feel safe and cared for in healthcare settings.

References:

Estimates of the unauthorized immigrant population residing in the United States. Estimates of the Unauthorized Immigrant Population Residing in the United States | Homeland Security. Accessed June 8, 2023. https://www.dhs.gov/immigration-statistics/population-estimates/unauthorized-resident.
Chang CD. Social Determinants of Health and Health Disparities Among Immigrants and their Children. Curr Probl Pediatr Adolesc Health Care. 2019;49(1):23-30. doi:10.1016/j.cppeds.2018.11.009
Rizzolo K, Novick TK, Cervantes L. Dialysis Care for Undocumented Immigrants With Kidney Failure in the COVID-19 Era: Public Health Implications and Policy Recommendations. Am J Kidney Dis. 2020;76(2):255-257. doi:10.1053/j.ajkd.2020.05.001
Novick TK, Rizzolo K, Cervantes L. COVID-19 and Kidney Disease Disparities in the United States. Adv Chronic Kidney Dis. 2020;27(5):427-433. doi:10.1053/j.ackd.2020.06.005
Facts about chronic kidney disease. National Kidney Foundation. May 3, 2023. Accessed June 8, 2023. https://www.kidney.org/atoz/content/about-chronic-kidney-disease.
Rizzolo K, Novick TK, Cervantes L. Dialysis Care for Undocumented Immigrants with Kidney Failure in the COVID-19 Era: Public Health Implications and Policy Recommendations. Am J Kidney Dis. 2020;76(2):255-257. doi:10.1053/j.ajkd.2020.05.001
Cervantes L, Tuot D, Raghavan R, et al. Association of Emergency-Only vs Standard Hemodialysis with Mortality and Health Care Use Among Undocumented Immigrants with End-stage Renal Disease. JAMA Intern Med. 2018;178(2):188-195. doi:10.1001/jamainternmed.2017.7039
Nguyen OK, Vazquez MA, Charles L, et al. Association of Scheduled vs Emergency-Only Dialysis with Health Outcomes and Costs in Undocumented Immigrants with End-stage Renal Disease. JAMA Intern Med. 2019;179(2):175-183. doi:10.1001/jamainternmed.2018.5866
Hacker K, Anies M, Folb BL, Zallman L. Barriers to health care for undocumented immigrants: a literature review. Risk Manag Healthc Policy. 2015;8:175-183. Published 2015 Oct 30. doi:10.2147/RMHP.S70173