Racial disparities in kidney disease outcomes

Balancing Efficiency and Equity in Population-Wide CKD Screening

Importance

In the era of sodium-glucose cotransporter 2 (SGLT2) inhibitors, population-wide screening for chronic kidney disease (CKD) may provide good value, yet implications across racial and ethnic groups are unknown.

Objective

To evaluate the health outcomes, costs, and cost-effectiveness of population-wide CKD screening for 4 racial and ethnic groups.

Design, Setting, and Participants

In this cost-effectiveness analysis, a decision-analytic Markov model was separately calibrated to simulate CKD progression among simulated cohorts of US Hispanic adults, non-Hispanic Black adults, non-Hispanic White adults, and adults who belong to additional racial and ethnic groups (ie, Asian and multiracial individuals and those self-reporting other race and ethnicity). Effectiveness of SGLT2 inhibitors was derived from the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease trial. Mortality, quality-of-life weights, and cost estimates were obtained from published cohort studies, randomized clinical trials, and Centers for Medicare & Medicaid Services data. Analyses were conducted from January 1, 2023, to November 6, 2024.

Exposures

One-time or periodic (every 10 or 5 years) screening for albuminuria, initiated between age 35 and 75 years, with and without addition of SGLT2 inhibitors to angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy for CKD.

Main Outcomes and Measures

Lifetime cumulative incidence of kidney failure requiring kidney replacement therapy (KRT); discounted life-years (LYs), quality-adjusted LYs (QALYs), lifetime health care costs (in 2024 US dollars), and incremental cost-effectiveness ratios.

Results

Under the status quo, non-Hispanic Black adults aged 35 years had the highest lifetime incidence of kidney failure requiring KRT (6.2% [95% UI, 2.8%-10.6%]) compared with Hispanic adults (3.6% [95% UI, 1.1%-6.7%]), non-Hispanic White adults (2.3% [95% UI, 0.4%-5.2%]), and adults from additional racial and ethnic groups (3.3% [95% UI, 1.2%-6.5%]). Screening every 5 years from ages 55 to 75 years combined with SGLT2 inhibitors reduced incidence of KRT and increased LYs across all racial and ethnic groups, with the largest average changes observed for non-Hispanic Black adults (0.8-percentage point decrease and 0.19-year increase). Every 5-year screening from age 55 to 75 years cost $99 100/QALY gained for the overall population and less than $150 000/QALY gained across racial and ethnic groups, with the lowest cost observed for non-Hispanic Black adults ($73 400/QALY gained). Screening starting at age 35 years was only cost-effective for non-Hispanic Black adults ($115 000/QALY gained).

Conclusions and Relevance

In this cost-effectiveness analysis, population-wide screening for CKD from ages 55 to 75 years was projected to improve population health, was cost-effective, and reduced disparities across 4 racial and ethnic groups. Starting population-wide screening at younger ages was projected to further benefit non-Hispanic Black adults.

Differences in Covid-19 deaths amongst cancer patients and possible mediators for this relationship

Previous research demonstrated Non-Hispanic Black populations experience higher COVID-19 mortality rates than Non-Hispanic White individuals. Additionally, cancer status is a known risk factor for COVID-19 death. While prior studies investigated comorbidities as exploratory variables in differences in COVID-19 hospitalization, none have explored their role in COVID-19-related deaths. This study aimed to evaluate whether Charlson Comorbidity Index (CCI) and subsequently, individual diseases are potential explanatory variables for this relationship. The analysis focused on Non-Hispanic Black and Non-Hispanic White cancer patients aged 20 or older, diagnosed between 2011 and 2019, who tested positive for COVID-19 from the start of pandemic through June 30, 2021 from Louisiana Tumor Registry. Two separate mediation analyses were conducted. First checked whether overall comorbidity, measured by CCI, could explain the difference in COVID-19 mortality. If so, further checked which individual comorbidities contributed to this difference. The hazard rate for Non-Hispanic Black cancer patients dying from COVID-19 was 6.46 times than that of Non-Hispanic White patients. The CCI accounted for 12.7% of the differences observed in COVID-19 mortality, with renal disease as the top contributor, explaining 4.9%. These findings could help develop interventions to reduce COVID-19 mortality and address the disproportionate impact, especially by managing chronic conditions like renal disease.

Differences in inflammation among black and white individuals: A systematic review and meta-analysis

IMPORTANCE

Despite persisting health disparities between Black and White individuals, racial differences in inflammation have yet to be comprehensively examined.

OBJECTIVE

To determine if significant differences in circulating levels of inflammatory markers between Black and White populations exist.

DATA SOURCES

Studies were identified through systematic searches of four electronic databases in January 2022. Additional studies were identified via reference lists and e-mail contact.

STUDY SELECTION

Eligible studies included full-text empirical articles that consisted of Black and White individuals and reported statistics for inflammatory markers for each racial group. Of the 1368 potentially eligible studies, 84 (6.6 %) representing more than one million participants met study selection criteria.

DATA EXTRACTION AND SYNTHESIS

Risk of bias was assessed via meta regressions that considered relevant covariates. Data heterogeneity was tested using both the Cochrane Q-statistic and the standard I2 index. Random effects models were used to calculate estimates of effect size from standardized mean differences.

MAIN OUTCOMES AND MEASURES

Outcome measures included 12 inflammatory markers, including C-reactive protein (CRP), Fibrinogen, Interleukin-6 (IL-6), Tumor necrosis factor-alpha (TNF-α), and soluble intercellular adhesion molecule 1 (sICAM-1).

RESULTS

Several markers had robust sample sizes for analysis, including CRP (White N = 934,594; Black N = 55,234), Fibrinogen (White N = 80,880; Black N = 18,001), and IL-6 (White N = 20,269; Black N = 14,675). Initial results indicated significant effects on CRP (k = 56, pooled Hedges' g = 0.24), IL-6 (k = 33, g = 0.15), and Fibrinogen (k = 19, g = 0.49), with Black individuals showing higher levels. Results also indicated significant effects on sICAM-1 (k = 6, g = -0.46), and Interleukin-10 (k = 4, g = -0.18), with White individuals showing higher levels. Sensitivity analyses confirmed robust effects for CRP, IL-6, Fibrinogen, and sICAM-1 while also revealing significant effects on TNF-α (k = 18, g = -0.17) and Interleukin-8 (k = 5, g = -0.19), with White individuals showing higher levels of both.

CONCLUSIONS AND RELEVANCE

Current meta-analytic results provide evidence for marked racial differences in common circulating inflammatory markers and illustrate the complexity of the inflammatory profile differences between Black and White individuals. Review Pre-Registration: PROSPERO Identifier - CRD42022312352.

Excess risk of chronic health conditions in Black adolescent and young adult cancer survivors

BACKGROUND

The US population of adolescent and young adult (age 15-39 years at diagnosis) cancer survivors is growing. Previous studies have identified racial and ethnic disparities in survival and health outcomes in racially minoritized survivors, including Black survivors, compared with White survivors. However, comparisons should be made between those of the same race or ethnicity with and without a history of AYA cancer to fully understand the association of a cancer diagnosis with socioeconomic status (SES) and health outcomes within a minoritized population.

METHODS

Non-Hispanic Black AYA cancer survivors and non-Hispanic Black age- and sex-matched controls were identified from self-reported data from the National Health Interview Survey (2009-2018). SES factors and chronic health conditions prevalence were compared between survivors and controls using chi-square tests. Survey-weighted logistic regression models were used to determine odds of chronic conditions by SES factors within and between survivors and controls. Interactions between each variable and cancer group were assessed.

RESULTS

A total of 445 survivors and 4450 controls were included. Survivors were less likely than controls to be married, have family income >45K/year, have completed a bachelor's degree or higher, and have private insurance. Survivors had higher odds than controls of having at least one (odds ratio (OR): 7.02, p<0.001) and ≥3 (OR: 4.44, p<0.001) chronic conditions. Survivors had higher odds of each chronic condition assessed including cardiovascular disease, diabetes, and hypertension. Survivors had higher odds of having chronic health conditions compared with controls across all SES variables.

CONCLUSIONS

A cancer diagnosis during adolescence and young adulthood is associated with poor SES outcomes and increased odds of comorbidities within the Black population, thus further exacerbating existing disparities.

IMPLICATIONS FOR CANCER SURVIVORS

Black AYA cancer survivors have a very high risk of developing chronic health conditions after cancer treatment and interventions are needed to improve long-term health outcomes for this population.

A comprehensive exploration of chronic kidney disease and dialysis in Canada's Indigenous population: from epidemiology to genetic influences

PURPOSE

This study aims to review the escalating prevalence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among Canada's Indigenous population, focusing on risk factors, hospitalization and mortality rates, and disparities in kidney transplantation. The study explores how these factors contribute to the health outcomes of this population and examines the influence of genetic variations on CKD progression.

METHODS

The review synthesizes data on prevalence rates, hospitalization and mortality statistics, and transplantation disparities among Indigenous individuals. It also delves into the complexities of healthcare access, including geographical, socioeconomic, and psychological barriers. Additionally, the manuscript investigates the impact of racial factors on blood characteristics relevant to dialysis treatment and the genetic predispositions influencing disease progression in Indigenous populations.

RESULTS

Indigenous individuals exhibit a higher prevalence of CKD and ESRD risk factors such as diabetes and obesity, particularly in regions like Saskatchewan. These patients face a 77% higher risk of death compared to their non-Indigenous counterparts and are less likely to receive kidney transplants. Genetic analyses reveal significant associations between CKD and specific genomic variations. Through analyses, we found that healthy Indigenous individuals may have higher levels of circulating inflammatory markers, which could become further elevated for those with CKD. In particular, they may have higher levels of C-reactive protein (CRP) fibrinogen, as well as genomic variations that affect IL-6 production and the function of von Willebrand Factor (vWF) which has critical potential influence on the compatibility with dialysis membranes contributing to complications in dialysis.

CONCLUSION

Indigenous people in Canada are disproportionately burdened by CKD and ESRD due to socioeconomic factors and potential genetic predispositions. While significant efforts have been made to assess the socioeconomic conditions of the Indigenous population, the genetic factors and their potential critical influence on compatibility with dialysis membranes, contributing to treatment complications, remain understudied. Further investigation into these genetic predispositions is essential.

Academy of Nutrition and Dietetics Commentary on the Phosphorus Recommendation in the KDOQI Clinical Practice Guidelines for Nutrition in CKD: 2020 Update

The Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease: 2020 Update recommends adjusting dietary phosphorus to maintain a serum phosphate goal for hemodialysis patients in the normal range (0.81 to 1.45 mmol/L [2.5 to 4.5 mg/dL]). This is lower than the serum phosphate goal used by many dialysis centers (0.97 to 1.78 mmol/L [3.0 and 5.5 mg/dL]). Although context and clinical judgment must always be considered when providing individualized care to patients, a guideline implementation study conducted from December 2020 to December 2022 found that, based on their documentation, registered dietitian nutritionists from two national dialysis chains are almost universally using dialysis center goals instead of the lower phosphate goal recommended by the guideline. This commentary discusses the possible barriers to implementing the Kidney Disease Outcomes Quality Initiative 2020 nutrition guideline's phosphorus recommendation and proposes a systems level approach to promote and support adoption of the recommendation. Calls to action for potential changes in clinician practices, organizational/institutional culture, and government regulations are put forth.

Enhancing Quality of Life in African American Patients with Chronic Kidney Disease: An Evidence-Based Intervention

This study aimed to assess the effectiveness of achronic kidney disease (CKD) peer coach's educational intervention on the quality of life of African-American individuals with CKD. This study employed an experimental research design to assess a peer coaching educational intervention for African-American individuals with CKD. The theoretical underpinning was grounded in social learning theory, emphasizing observational learning, imitation, and modeling. 165 patients were randomly assigned to either the intervention group (n = 81) or the control group (n = 84). Pre- and post-intervention analyses showed no significant differences in most health measures between the two groups. However, the intervention group demonstrated significant improvement in the energy/fatigue subscale, witha16-point difference supporting the intervention group (p = .003). Additionally, the intervention group showed increased scores in the pain subscale (p = .015), while the control group did not. The CKD educational intervention highlighted cultural considerations and provided cost-effective strategies for social workers. It emphasizes the importance of targeted educational interventions and calls for further research and interventions to address the comprehensive needs of CKD patients and improve their quality of life.

Relative predictive value of sociodemographic factors for chronic diseases among All of Us participants: a descriptive analysis

BACKGROUND

Although sociodemographic characteristics are associated with health disparities, the relative predictive value of different social and demographic factors remains largely unknown. This study aimed to describe the sociodemographic characteristics of All of Us participants and evaluate the predictive value of each factor for chronic diseases associated with high morbidity and mortality.

METHODS

We performed a cross-sectional analysis using de-identified survey data from the All of Us Research Program, which has collected social, demographic, and health information from adults living in the United States since May 2018. Sociodemographic data included self-reported age, sex, gender, sexual orientation, race/ethnicity, income, education, health insurance, primary care provider (PCP) status, and health literacy scores. We analyzed the self-reported prevalence of hypertension, coronary artery disease, any cancer, skin cancer, lung disease, diabetes, obesity, and chronic kidney disease. Finally, we assessed the relative importance of each sociodemographic factor for predicting each chronic disease using the adequacy index for each predictor from logistic regression.

RESULTS

Among the 372,050 participants in this analysis, the median age was 53 years, 59.8% reported female sex, and the most common racial/ethnic categories were White (54.0%), Black (19.9%), and Hispanic/Latino (16.7%). Participants who identified as Asian, Middle Eastern/North African, and White were the most likely to report annual incomes greater than $200,000, advanced degrees, and employer or union insurance, while participants who identified as Black, Hispanic, and Native Hawaiian/Pacific Islander were the most likely to report annual incomes less than $10,000, less than a high school education, and Medicaid insurance. We found that age was most predictive of hypertension, coronary artery disease, any cancer, skin cancer, diabetes, obesity, and chronic kidney disease. Insurance type was most predictive of lung disease. Notably, no two health conditions had the same order of importance for sociodemographic factors.

CONCLUSIONS

Age was the best predictor for the assessed chronic diseases, but the relative predictive value of income, education, health insurance, PCP status, race/ethnicity, and sexual orientation was highly variable across health conditions. Identifying the sociodemographic groups with the largest disparities in a specific disease can guide future interventions to promote health equity.

Disparities in healthcare access experienced by Hispanic chronic kidney disease patients: a cross-sectional analysis

BACKGROUND

Chronic kidney disease (CKD) is a public health concern, and the disease disproportionately affects Hispanics. Improved healthcare access for Hispanic CKD patients can reduce the disease burden. This study assesses the healthcare access disparities experienced by Hispanic CKD patients compared to Whites.

METHODS

We analyzed three National Health and Nutrition Examination Survey (NHANES) datasets for 2013-2014, 2015-2016, and 2017-2018. The primary predictor variable was race, and the outcome variable was three domains of healthcare access: insurance status, having any routine place for healthcare, and having any health visits in the past year. Chi-square tests and unadjusted and adjusted multivariate logistic regressions were conducted. The models were adjusted for age, education, income, and CKD stages and were weighted to account for the sampling strategy.

RESULTS

The sample size was 1864 CKD patients from three two-year cycles of NHANES datasets (2013-2014, 2015-2016, and 2017-2018). The final adjusted model found that Hispanic CKD patients were more likely to be uninsured (OR: 2.52, CI 1.66-3.83) and have no routine place for healthcare (OR: 1.68, CI 1.03-2.75) than White CKD patients, but did not have differences in healthcare visits in the past year.

CONCLUSIONS

Hispanic CKD patients have limited healthcare access compared to White populations showing existing care access disparities experienced by them. Improved programs and policies are required to enhance kidney health among Hispanics and promote equity in CKD.

Ethnic disparities of vascular complications in pre-diabetes, undiagnosed diabetes, and newly diagnosed diabetes

In the U.S., ethnic minorities with pre-diabetes, undiagnosed type 2 diabetes (T2D), and newly diagnosed T2D had a higher prevalence of microvascular complications than non-Hispanic Whites and exhibited distinct risk factors, whereas Whites had a higher rate of cardiovascular disease.

Association between Racial Residential Segregation and COVID-19 Mortality

This study investigates the impact of racial residential segregation on COVID-19 mortality during the first year of the US epidemic. Data comes from the Center for Disease Control and Prevention (CDC), and the Robert Wood Johnson Foundation's and the University of Wisconsin's joint county health rankings project. The observation includes a record of 8,670,781 individuals in 1488 counties. We regressed COVID-19 deaths, using hierarchical logistic regression models, on individual and county-level predictors. We found that as racial residential segregation increased, mortality rates increased. Controlling for segregation, Blacks and Asians had a greater risk of mortality, while Hispanics and other racial groups had a lower risk of mortality, compared to Whites. The impact of racial residential segregation on COVID-19 mortality did not vary by racial group.

Prescription of guideline-directed medical therapies in patients with diabetes and chronic kidney disease from the CURE-CKD Registry, 2019-2020

AIM

Guideline-directed medical therapy (GDMT) is designed to improve clinical outcomes. The study aim was to assess GDMT prescribing rates and prescribing-persistence predictors in patients with diabetes and chronic kidney disease (CKD) from the Center for Kidney Disease Research, Education, and Hope Registry.

MATERIALS AND METHODS

Data were obtained from adults ≥18 years old with diabetes and CKD between 1 January 2019 and 31 December 2020 (N = 39 158). Baseline and persistent (≥90 days) prescriptions for GDMT, including angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), sodium-glucose cotransporter-2 (SGLT2) inhibitor and glucagon-like peptide 1 (GLP-1) receptor agonist were assessed.

RESULTS

The population age (mean ± SD) was 70 ± 14 years, and 49.6% (n = 19 415) were women. Baseline estimated glomerular filtration rate (2021 CKD-Epidemiology Collaboration creatinine equation) was 57.5 ± 23.0 ml/min/1.73 m2 and urine albumin/creatinine 57.5 mg/g (31.7-158.2; median, interquartile range). Baseline and ≥90-day persistent prescribing rates, respectively, were 70.7% and 40.4% for ACE inhibitor/ARB, 6.0% and 5.0% for SGLT2 inhibitors, and 6.8% and 6.3% for GLP-1 receptor agonist (all p < .001). Patients lacking primary commercial health insurance coverage were less likely to be prescribed an ACE inhibitor/ARB [odds ratio (OR) = 0.89; 95% confidence interval (CI) 0.84-0.95; p < .001], SGLT2 inhibitor (OR 0.72; 95% CI 0.64-0.81; p < .001) or GLP-1 receptor agonist (OR 0.89; 95% CI 0.80-0.98; p = .02). GDMT prescribing rates were lower at Providence than UCLA Health.

CONCLUSIONS

Prescribing for GDMT was suboptimal and waned quickly in patients with diabetes and CKD. Type of primary health insurance coverage and health system were associated with GDMT prescribing.

Peer support interventions in patients with kidney failure: A systematic review

BACKGROUND

Peer support has been associated with improved health-related outcomes (e.g., psychological well-being and treatment adherence) among patients with serious, chronic conditions, including kidney disease. Yet, there is little existing research evaluating the effects of peer support programs on health outcomes among patients with kidney failure being treated with kidney replacement therapy.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we conducted a systematic review using five databases to assess the effects of peer support programs on health-related outcomes (e.g., physical symptoms, depression) among patients with kidney failure undergoing kidney replacement therapy.

RESULTS

Peer support in kidney failure was assessed across 12 studies (eight randomized controlled trials, one quasi-experimental controlled trial, and three single-arm trials) with 2893 patients. Three studies highlighted the links between peer support and improved patient engagement with care, while one found peer support did not significantly impact engagement. Three studies showed associations between peer support and improvements in psychological well-being. Four studies underscored the effects of peer support on self-efficacy and one on treatment adherence.

CONCLUSIONS

Despite preliminary evidence of the positive associations between peer support and health-related outcomes among patients with kidney failure, peer support programs for this patient population remain poorly understood and underutilized. Further rigorous prospective and randomized studies are needed to evaluate how peer support can be optimized and incorporated into clinical care for this vulnerable patient population.

Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care

In this article, we demonstrate first how the term "aggressive care," used loosely by clinicians to denote care that can negatively impact quality of life in serious illness, is often used to inappropriately label the preferences of African American patients, and discounts, discredits, and dismisses the deeply held beliefs of African American Christians. This form of biased communication results in a higher proportion of African Americans than whites receiving care that is non-goal-concordant and contributes to the prevailing lack of trust the African American community has in our healthcare system. Second, we invite clinicians and health care centers to make the perspectives of socially marginalized groups (in this case, African American Christians) the central axis around which we find solutions to this problem. Based on this, we provide insight and understanding to clinicians caring for seriously ill African American Christian patients by sharing their beliefs, origins, and substantive importance to the African American Christian community. Third, we provide recommendations to clinicians and healthcare systems that will result in African Americans, regardless of religious affiliation, receiving equitable levels of goal-concordant care if implemented. KEY MESSAGE: Labeling care at end-of-life as "aggressive" discounts the deeply held beliefs of African American Christians. By focusing on the perspectives of this group clinicians will understand the importance of respecting their religious values. The focus on providing equitable goal-concordant care is the goal.

Representation of Racial and Ethnic Minorities in Nephrology Clinical Trials: A Systematic Review and Meta-Analysis

SIGNIFICANCE STATEMENT

Racial and ethnic disparities in clinical trial enrollment are well described. However, whether these disparities are present in nephrology randomized clinical trials has not been previously reported. We performed a systematic review and meta-analysis of 380 randomized clinical trials involving different aspects of kidney disease published between 2000 and 2021. Our results indicate that worldwide reporting of race and ethnicity is poor and that White individuals account for most of the randomized participants with decreased enrollment of Black participants in more recent trials. However, trials conducted in the United States have representation of Black and Hispanic participants consistent with the population prevalence of disease and under-representation of Asian participants.

BACKGROUND

Under-representation of racial and ethnic minorities in clinical trials could worsen disparities, but reporting and enrollment practices in nephrology randomized clinical trials have not been described.

METHODS

PubMed was searched to capture randomized clinical trials for five kidney disease-related conditions published between 2000 and 2021 in ten high-impact journals. We excluded trials with <50 participants and pilot trials. Outcomes of interest were the proportion of trials reporting race and ethnicity and the proportions of enrolled participants in each race and ethnicity category.

RESULTS

Among 380 trials worldwide, race was reported in just over half and ethnicity in 12%. Most enrolled participants were White, and Black individuals accounted for ≤10% of participants except in dialysis trials where they accounted for 26% of participants. However, Black participants were enrolled at high proportions relative to disease and population prevalence in US CKD, dialysis, and transplant trials representing 19% of participants in AKI, 26% in CKD, 44% in GN, 40% in dialysis, and 26% in transplant trials. Enrollment of Asian participants was low worldwide except in GN trials with marked under-representation in US CKD, dialysis, and transplant trials. Hispanic individuals represented only 13% of participants in US dialysis trials compared with 29% of US dialysis population.

CONCLUSION

More complete reporting of race and ethnicity in nephrology trials is needed. Black and Hispanic patients are well-represented in kidney disease trials in the United States. Asian patients are poorly represented in kidney trials both globally and in the United States.

Reimagining Nephrology Fellowship Education to Meet the Future Needs of Nephrology: A Report of the American Society of Nephrology Task Force on the Future of Nephrology

The American Society of Nephrology (ASN) Task Force on the Future of Nephrology was established in April 2022 in response to requests from the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education regarding training requirements in nephrology. Given recent changes in kidney care, ASN also charged the task force with reconsidering all aspects of the specialty's future to ensure that nephrologists are prepared to provide high-quality care for people with kidney diseases. The task force engaged multiple stakeholders to develop 10 recommendations focused on strategies needed to promote: ( 1 ) just, equitable, and high-quality care for people living with kidney diseases; ( 2 ) the value of nephrology as a specialty to nephrologists, the future nephrology workforce, the health care system, the public, and government; and ( 3 ) innovation and personalization of nephrology education across the scope of medical training. This report reviews the process, rationale, and details (the "why" and the "what") of these recommendations. In the future, ASN will summarize the "how" of implementing the final report and its 10 recommendations.

Decomposing interaction and mediating effects of race/ethnicity and circulating blood levels of cystatin C on cognitive status in the United States health and retirement study

Background and objectives

Elevated circulating cystatin C is associated with cognitive impairment in non-Hispanic Whites, but its role in racial disparities in dementia is understudied. In a nationally representative sample of older non-Hispanic White, non-Hispanic Black, and Hispanic adults in the United States, we use mediation-interaction analysis to understand how racial disparities in the cystatin C physiological pathway may contribute to racial disparities in prevalent dementia.

Methods

In a pooled cross-sectional sample of the Health and Retirement Study (n = 9,923), we employed Poisson regression to estimate prevalence ratios and to test the relationship between elevated cystatin C (>1.24 vs. ≤1.24 mg/L) and impaired cognition, adjusted for demographics, behavioral risk factors, other biomarkers, and chronic conditions. Self-reported racialized social categories were a proxy measure for exposure to racism. We calculated additive interaction measures and conducted four-way mediation-interaction decomposition analysis to test the moderating effect of race/ethnicity and mediating effect of cystatin C on the racial disparity.

Results

Overall, elevated cystatin C was associated with dementia (prevalence ratio [PR] = 1.2; 95% CI: 1.0, 1.5). Among non-Hispanic Black relative to non-Hispanic White participants, the relative excess risk due to interaction was 0.7 (95% CI: -0.1, 2.4), the attributable proportion was 0.1 (95% CI: -0.2, 0.4), and the synergy index was 1.1 (95% CI: 0.8, 1.8) in a fully adjusted model. Elevated cystatin C was estimated to account for 2% (95% CI: -0, 4%) for the racial disparity in prevalent dementia, and the interaction accounted for 8% (95% CI: -5, 22%). Analyses for Hispanic relative to non-white participants suggested moderation by race/ethnicity, but not mediation.

Discussion

Elevated cystatin C was associated with dementia prevalence. Our mediation-interaction decomposition analysis suggested that the effect of elevated cystatin C on the racial disparity might be moderated by race/ethnicity, which indicates that the racialization process affects not only the distribution of circulating cystatin C across minoritized racial groups, but also the strength of association between the biomarker and dementia prevalence. These results provide evidence that cystatin C is associated with adverse brain health and this effect is larger than expected for individuals racialized as minorities had they been racialized and treated as non-Hispanic White.

Flattening the Playing Field for Treatment of Diabetic Kidney Disease

Diabetic kidney disease (DKD) remains a major health care issue and is beset with significant racial and ethnic disparities in regard to its incidence, progression, and complication rate. An individual's health is influenced strongly by an array of societal-level factors commonly called the social determinants of health. Among these, DKD is influenced highly by structured resources and opportunities, as well as an individual's socioeconomic status, health insurance status, access to care, education, health literacy, nutrition, green space exposure, level of trust in the medical community, and more. Health equity is considered a state in which everyone has a fair and just opportunity to attain his or her highest level of health. Conversely, health inequities are a consequence of a structured discriminatory system of inequitable allocation of social determinants of health. When this discriminatory system is race-based it is referred to as structural racism, which eventually leads to racial and ethnic health disparities. The further downstream sequela of structural racism, consciously or unconsciously, impacts health systems, providers, and patients, and can lead to disparities in DKD development, progression, and complications. In this article, we explore potential interventions at the societal, health system, and provider levels that can help flatten the playing field and reduce racial and ethnic disparities in DKD.

Burden of Hypertensive Crisis in Patients With End-Stage Kidney Disease on Maintenance Dialysis: Insights From United States Renal Data System Database

BACKGROUND

There is paucity of information on the incidence, clinical characteristics, admission trends, and outcomes of hypertensive crisis (HTN-C) in patients with end-stage kidney disease (ESKD) who are on maintenance dialysis.

METHODS

We conducted a retrospective observational study of HTN-C admissions in patients with end-stage kidney disease using the United States Renal Data System. We identified patients with end-stage kidney disease aged ≥18 years on dialysis and were hospitalized for HTN-C from January 2006 to August 2015.

RESULTS

A total of 54 483 patients with end-stage kidney disease were hospitalized for HTN-C during the study period. After study exclusions, 37 214 patients were included in the analysis. A majority of patients were Black, there were more women than men and the South region of the country accounted for a great majority of patients. During the study period, hospitalization rates increased from 1060 per 100 000 beneficiary years to 1821 (P_trend<0.0001). Overall, in-hospital mortality, 30-day, and 1-year mortality were 0.6%, 2.3%, and 21.8%, respectively, and 30-day readmission rate was 31.1%. During the study period, most study outcomes showed a significant decreasing trend (in-hospital mortality 0.6%-0.5%, 30-day mortality 2.4%-1.9%, 1-year mortality 23.9%-19.7%, P_trend<0.0001 for all).

CONCLUSIONS

Hospitalizations for HTN-C have increased consistently during the decade studied. Although temporal trends showed improving mortality and readmission rates, the absolute rates were still high with 1 in 3 patients readmitted within 30 days and 1 in 5 patients dying within 1 year of index hospitalization.

A prospective cohort study of racial/ethnic variation in the association between change in cystatin C and dietary quality in older Americans

Using a sample of US adults aged 65 years and older, we examined the role of dietary quality in cystatin C change over 4 years and whether this association varied by race/ethnicity. The Health and Retirement Study provided observations with biomarkers collected in 2012 and 2016, participant attributes measured in 2012, and dietary intake assessed in 2013. The sample was restricted to respondents who were non-Hispanic/Latino White (n 789), non-Hispanic/Latino Black (n 108) or Hispanic/Latino (n 61). Serum cystatin C was constructed to be equivalent to the 1999-2002 National Health and Nutrition Examination Survey (NHANES) scale. Dietary intake was assessed by a semi-quantitative FFQ with diet quality measured using an energy-adjusted form of the Alternative Healthy Eating Index-2010 (AHEI-2010). Statistical analyses were conducted using autoregressive linear modelling adjusting for covariates and complex sampling design. Cystatin C slightly increased from 1·2 mg/l to 1·3 mg/l over the observational period. Greater energy-adjusted AHEI-2010 scores were associated with slower increase in cystatin C from 2012 to 2016. Among respondents reporting moderately low to low dietary quality, Hispanic/Latinos had significantly slower increases in cystatin C than their non-Hispanic/Latino White counterparts. Our results speak to the importance of considering racial/ethnic determinants of dietary intake and subsequent changes in health in ageing populations. Further work is needed to address measurement issues including further validation of dietary intake questionnaires in diverse samples of older adults.

Seeking justice, equity, diversity and inclusion in pediatric nephrology

Inequity, racism, and health care disparities negatively impact the well-being of children with kidney disease. This review defines social determinants of health and describes how they impact pediatric nephrology care; outlines the specific impact of systemic biases and racism on chronic kidney disease care and transplant outcomes; characterizes and critiques the diversity of the current pediatric nephrology workforce; and aims to provide strategies to acknowledge and dismantle bias, address barriers to care, improve diversity in recruitment, and strengthen the pediatric nephrology community. By recognizing historical and current realities and limitations, we can move forward with strategies to address racism and bias in our field and clinical practices, thereby cultivating inclusive training and practice environments.

Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease

Importance

For patients with end-stage kidney disease treated with hemodialysis, the optimal timing of hemodialysis prior to elective surgical procedures is unknown.

Objective

To assess whether a longer interval between hemodialysis and subsequent surgery is associated with higher postoperative mortality in patients with end-stage kidney disease treated with hemodialysis.

Design, Setting, and Participants

Retrospective cohort study of 1 147 846 procedures among 346 828 Medicare beneficiaries with end-stage kidney disease treated with hemodialysis who underwent surgical procedures between January 1, 2011, and September 30, 2018. Follow-up ended on December 31, 2018.

Exposures

One-, two-, or three-day intervals between the most recent hemodialysis treatment and the surgical procedure. Hemodialysis on the day of the surgical procedure vs no hemodialysis on the day of the surgical procedure.

Main Outcomes and Measures

The primary outcome was 90-day postoperative mortality. The relationship between the dialysis-to-procedure interval and the primary outcome was modeled using a Cox proportional hazards model.

Results

Of the 1 147 846 surgical procedures among 346 828 patients (median age, 65 years [IQR, 56-73 years]; 495 126 procedures [43.1%] in female patients), 750 163 (65.4%) were performed when the last hemodialysis session occurred 1 day prior to surgery, 285 939 (24.9%) when the last hemodialysis session occurred 2 days prior to surgery, and 111 744 (9.7%) when the last hemodialysis session occurred 3 days prior to surgery. Hemodialysis was also performed on the day of surgery for 193 277 procedures (16.8%). Ninety-day postoperative mortality occurred after 34 944 procedures (3.0%). Longer intervals between the last hemodialysis session and surgery were significantly associated with higher risk of 90-day mortality in a dose-dependent manner (2 days vs 1 day: absolute risk, 4.7% vs 4.2%, absolute risk difference, 0.6% [95% CI, 0.4% to 0.8%], adjusted hazard ratio [HR], 1.14 [95% CI, 1.10 to 1.18]; 3 days vs 1 day: absolute risk, 5.2% vs 4.2%, absolute risk difference, 1.0% [95% CI, 0.8% to 1.2%], adjusted HR, 1.25 [95% CI, 1.19 to 1.31]; and 3 days vs 2 days: absolute risk, 5.2% vs 4.7%, absolute risk difference, 0.4% [95% CI, 0.2% to 0.6%], adjusted HR, 1.09 [95% CI, 1.04 to 1.13]). Undergoing hemodialysis on the same day as surgery was associated with a significantly lower hazard of mortality vs no same-day hemodialysis (absolute risk, 4.0% for same-day hemodialysis vs 4.5% for no same-day hemodialysis; absolute risk difference, -0.5% [95% CI, -0.7% to -0.3%]; adjusted HR, 0.88 [95% CI, 0.84-0.91]). In the analyses that evaluated the interaction between the hemodialysis-to-procedure interval and same-day hemodialysis, undergoing hemodialysis on the day of the procedure significantly attenuated the risk associated with a longer hemodialysis-to-procedure interval (P<.001 for interaction).

Conclusions and Relevance

Among Medicare beneficiaries with end-stage kidney disease, longer intervals between hemodialysis and surgery were significantly associated with higher risk of postoperative mortality, mainly among those who did not receive hemodialysis on the day of surgery. However, the magnitude of the absolute risk differences was small, and the findings are susceptible to residual confounding.

A Framework for Antiracist Curriculum Changes in Nephrology Education

Addressing persistent racial health disparities in cases of kidney disease will first require significant investment in examining how structural racism has influenced our clinical practice and medical education. Improving how we understand and articulate race is critical for achieving this goal. This work begins with ensuring that race's mention within nephrology literature and curricular materials for medical trainees is thoroughly rooted in evidence-based rationale-not to serve as a proxy for polygenic contributions, social determinants of health, or systemic health care barriers. While many institutions are increasingly recognizing the importance of instituting such changes on behalf of the systematically marginalized patient populations who are most affected by these disparities, there is a paucity of guidance on how to critically appraise and revise decades of pathophysiological and epidemiological findings through an antiracist lens. In this article, we propose an inquiry-based framework with case-study examples to help readers recognize improper use of race within nephrology, assess personal and institutional readiness to introduce changes to said content, and generate materials that center evidence-based findings and reject harmful misinterpretations of race.

Contributions of Structural Racism to the Food Environment: A Photovoice Study of Black Residents With Hypertension in Baltimore, MD

BACKGROUND

Disproportionate exposure to poor food environments and food insecurity among Black Americans may partially explain critical chronic disease disparities by race and ethnicity. A complex set of structural factors and interactions between Black residents and their food environments, including store types, quantity, proximity, and quality of goods and consumer interactions within stores, may affect nutritional behaviors and contribute to higher cardiovascular and kidney disease risk.

METHODS

We used the Photovoice methodology to explore the food environment in Baltimore, MD, through the perspectives of Black residents with hypertension between August and November 2019. Twenty-four participants were enrolled in the study (mean age: 65.1 years; 67% female). After a brief photography training, participants captured photos of their food environment, which they discussed in small focus groups over the course of 5 weeks. Discussions were audiotaped and analyzed for emergent themes using a line-by-line inductive approach. Themes were, then, organized into a collective narrative.

RESULTS

Findings describe physical and social features of the food environment as well as participants' perceptions of its origins and holistic and generational health effects. The study illustrates the interrelationships among the broader socio-political environment, the quality and quantity of stores in the food landscape, and the ways in which they engage with the food environment as residents and consumers who have been marginalized due to their race and/or social class. The following meta-themes emerged from the data: (1) social injustice; (2) structural racism and classism; (3) interpersonal racism; (4) generational effects; (5) mistrust; (6) social programs; and (7) community asset-based approaches, including advocacy and civic engagement.

CONCLUSIONS

Understanding residents' perceptions of the foundations and effects of the food environment on their health may help stakeholders to cocreate multilevel interventions alongside residents to improve access to healthy food and health outcomes among disparities affected populations.

Black and White Adults With CKD Hospitalized With Acute Kidney Injury: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

RATIONALE & OBJECTIVE

Few studies have investigated racial disparities in acute kidney injury (AKI), in contrast to the extensive literature on racial differences in the risk of kidney failure. We sought to study potential differences in risk in the setting of chronic kidney disease (CKD).

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

We studied 2,720 self-identified Black or White participants with CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study from July 1, 2013, to December 31, 2017.

EXPOSURE

Self-reported race (Black vs White).

OUTCOME

Hospitalized AKI (≥50% increase from nadir to peak serum creatinine).

ANALYTICAL APPROACH

Cox regression models adjusting for demographics (age and sex), prehospitalization clinical risk factors (diabetes, blood pressure, cardiovascular disease, estimated glomerular filtration rate, proteinuria, receipt of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers), and socioeconomic status (insurance status and education level). In a subset of participants with genotype data, we adjusted for apolipoprotein L1 gene (APOL1) high-risk status and sickle cell trait.

RESULTS

Black participants (n = 1,266) were younger but had a higher burden of prehospitalization clinical risk factors. The incidence rate of first AKI hospitalization among Black participants was 6.3 (95% CI, 5.5-7.2) per 100 person-years versus 5.3 (95% CI, 4.6-6.1) per 100 person-years among White participants. In an unadjusted Cox regression model, Black participants were at a modestly increased risk of incident AKI (HR, 1.22 [95% CI, 1.01-1.48]) compared with White participants. However, this risk was attenuated and no longer significant after adjusting for prehospitalization clinical risk factors (adjusted HR, 1.02 [95% CI, 0.83-1.25]). There were only 11 AKI hospitalizations among individuals with high-risk APOL1 risk status and 14 AKI hospitalizations among individuals with sickle cell trait.

LIMITATIONS

Participants were limited to research volunteers and potentially not fully representative of all CKD patients.

CONCLUSIONS

In this multicenter prospective cohort of CKD patients, racial disparities in AKI incidence were modest and were explained by differences in prehospitalization clinical risk factors.

The Association between Mercury and Lead Exposure and Liver and Kidney Function in Pregnant Surinamese Women Enrolled in the Caribbean Consortium for Research in Environmental and Occupational Health (CCREOH) Environmental Epidemiologic Cohort Study

Exposure to mercury (Hg) and lead (Pb) may have an effect on pregnant women. We assessed the effect of exposure to mercury and lead on liver and kidney functions in a subcohort of pregnant women who participated in the Caribbean Consortium for Research in Environmental and Occupational Health (CCREOH)—Meki Tamara, study. From 400 women aged 16−46 living in rural, urban, and interior regions of Suriname, we measured blood mercury and blood lead levels. Creatinine, urea, and cystatin C were measured to assess kidney function, and aspartate amino transferase (AST), alanine amino transferase (ALT), and gamma-glutamyl transferase (GGT) were measured to assess liver function. Education, region, and ethnicity showed significant differences for both blood mercury and lead levels, which all had p-values < 0.001. Creatinine and urea were elevated with higher mercury blood levels. Our findings also suggest a relationship between high mercury blood levels and potential harmful effects on liver and kidney function.

The Effects of Race on Acute Kidney Injury

Racial disparities in incidence and outcomes of acute kidney injury (AKI) are pervasive and are driven in part by social inequities and other factors. It is well-documented that Black patients face higher risk of AKI and seemingly have a survival advantage compared to White counterparts. Various explanations have been advanced and suggested to account for this, including differences in susceptibility to kidney injury, severity of illness, and socioeconomic factors. In this review, we try to understand and further explore the link between race and AKI using the incidence, diagnosis, and management of AKI to illustrate how race is directly related to AKI outcomes, with a focus on Black and White individuals with AKI. In particular, we explore the effect of race-adjusted estimated glomerular filtration rate (eGFR) equation on AKI prediction and discuss racial disparities in the management of AKI and how this might contribute to racial differences in AKI-related mortality among Blacks with AKI. We also identify some opportunities for future research and advocacy.

Serum Cystatin-C is linked to increased prevalence of diabetes and higher risk of mortality in diverse middle-aged and older adults

Objective

Type 2 Diabetes Mellitus (henceforth diabetes) affects roughly 35 million individuals in the US and is a major risk factor for cardiovascular and kidney disease. Serum Cystatin-C is used to monitor renal function and detect kidney damage. Recent research has focused on linking Cystatin-C to cardiovascular risk and disease, but most findings focus on small sample sizes and generalize poorly to diverse populations, thus limiting epidemiological inferences. The aim of this manuscript is to study the association between Cystatin-C, diabetes, and mortality and test for possible sex or racial/ethnic background modifications in these relationships.

Methods

We analyzed 8-years of biennial panel data from Health and Retirement Study participants 50-years and older who self-identified as White (unweighted N (uN) = 5,595), Black (uN = 867), or Latino (uN = 565) for a total of uN = 7,027 individuals. We modeled diabetes and death over 8-years as function of baseline Cystatin-C (log transformed) adjusting for covariates and tested modifications in associations by race/ethnic background and sex.

Results

Mean log Cystatin-C at visit 1 was 0.03±0.32 standard deviation. A 10% increase in Cystatin-C levels was associated with 13% increased relative risk of diabetes at baseline (11% and 9% by years 4 and 8). A 10% increase in Cystatin-C was highly associated with increased relative risk of death (28% and 31% by years 4 and 8). These associations were present even after adjusting for possible confounders and were not modified by sex or racial/ethnic background.

Conclusion

Despite differential risks for diabetes and mortality by racial/ethnic groups, Cystatin-C was equally predictive of these outcomes across groups. Cystatin-C dysregulations could be used as a risk indicator for diabetes and as a warning sign for accelerated risk of mortality.

Etiopathogenesis of kidney disease in minority populations and an updated special focus on treatment in diabetes and hypertension

Diabetes and hypertension are the most common causes of chronic kidney disease (CKD) in the general population as well as in the Black and African American population, who also suffer from high rates of CKD and CKD progression compared to the White population. Progression of CKD can lead to kidney failure, and patients with progressive kidney disease have a high risk of premature mortality, particularly from cardiovascular disease. Screening for early detection of CKD is important as it facilitates the initiation of medications that have been shown to delay the progression of diabetes-related as well as non-diabetes-related CKD, and reduce rates of death from both kidney and cardiovascular disease. The potential adverse effects from use of some of the newer reno- and cardio-protective glucose-lowering medications, such as the sodium glucose cotransporter-2 inhibitors, may be effectively avoided with detailed patient education and monitoring by the healthcare provider. It is important to note that lifestyle modification including regular exercise, diet, and smoking cessation are first-line in the management of diabetes and hypertension. When CKD occurs, co-management by providers using a comprehensive strategy may avert early complications and facilitate appropriate early referral for nephrology specialty care.

Black-White Inequities in Kidney Disease Mortality Across the 30 Most Populous US Cities

OBJECTIVES

To examine city-level kidney disease mortality rates and Black:White racial inequities for the USA and its largest cities, and to determine if these measures changed over the past decade.

METHODS

We used National Vital Statistics System mortality data and American Community Survey population estimates to calculate age-standardized kidney disease mortality rates for the non-Hispanic Black (Black), non-Hispanic White (White), and total populations for the USA and the 30 most populous US cities. We examined two time points, 2008-2013 (T1) and 2014-2018 (T2), and assessed changes in rates and inequities over time. Racial inequities were measured with Black:White mortality rate ratios and rate differences.

RESULTS

Kidney disease mortality rates varied from 2.5 (per 100,000) in San Diego to 24.6 in Houston at T2. The Black kidney disease mortality rate was higher than the White rate in the USA and all cities studied at both time points. In T2, the Black mortality rate ranged from 7.9 in New York to 45.4 in Charlotte, while the White mortality rate ranged from 2.0 in San Diego to 18.6 in Indianapolis. At T2, the Black:White rate ratio ranged from 1.79 (95% CI 1.62-1.99) in Philadelphia to 5.25 (95% CI 3.40-8.10) in Washington, DC, compared to the US rate ratio of 2.28 (95% CI 2.25-2.30). Between T1 and T2, only one city (Nashville) saw a significant decrease in the Black:White mortality gap.

CONCLUSIONS

The largest US cities experience widely varying kidney disease mortality rates and widespread racial inequities. These local data on racial inequities in kidney disease mortality can be used by city leaders and health stakeholders to increase awareness, guide the allocation of limited resources, monitor trends over time, and support targeted population health strategies.

Epidemiology of chronic kidney disease: an update 2022

Chronic kidney disease is a progressive condition that affects >10% of the general population worldwide, amounting to >800 million individuals. Chronic kidney disease is more prevalent in older individuals, women, racial minorities, and in people experiencing diabetes mellitus and hypertension. Chronic kidney disease represents an especially large burden in low- and middle-income countries, which are least equipped to deal with its consequences. Chronic kidney disease has emerged as one of the leading causes of mortality worldwide, and it is one of a small number of non-communicable diseases that have shown an increase in associated deaths over the past 2 decades. The high number of affected individuals and the significant adverse impact of chronic kidney disease should prompt enhanced efforts for better prevention and treatment.

Differences in Inflammation, Treatment, and Outcomes Between Black and Non-Black Patients Hospitalized for COVID-19: A Prospective Cohort Study

PURPOSE

Racial disparities in coronavirus disease 2019 (COVID-19) outcomes have been described. We sought to determine whether differences in inflammatory markers, use of COVID-19 therapies, enrollment in clinical trials, and in-hospital outcomes contribute to racial disparities between Black and non-Black patients hospitalized for COVID-19.

METHODS

We leveraged a prospective cohort study that enrolled 1325 consecutive patients hospitalized for COVID-19, of whom 341 (25.7%) were Black. We measured biomarkers of inflammation and collected data on the use COVID-19-directed therapies, enrollment in COVID-19 clinical trials, mortality, need for renal replacement therapy, and need for mechanical ventilation.

RESULTS

Compared to non-Black patients, Black patients had a higher prevalence of COVID-19 risk factors including obesity, hypertension, and diabetes mellitus and were more likely to require renal replacement therapy (15.8% vs 7.1%, P < .001) and mechanical ventilation (37.2% vs 26.6%, P < .001) during their hospitalization. Mortality was similar between both groups (15.5% for Blacks vs 14.0% for non-Blacks, P = .49). Black patients were less likely to receive corticosteroids (44.9% vs 63.8%, P< .001) or remdesivir (23.8% vs 57.8%, P < .001) and were less likely to be enrolled in COVID-19 clinical trials (15.3% vs 28.2%, P < .001). In adjusted analyses, Black race was associated with lower levels of C-reactive protein and soluble urokinase receptor and higher odds of death, mechanical ventilation, and renal replacement therapy. Differences in outcomes were not significant after adjusting for use of remdesivir and corticosteroids.

CONCLUSIONS

Racial differences in outcomes of patients with COVID-19 may be related to differences in inflammatory response and differential use of therapies.

Health inequities and the inappropriate use of race in nephrology

Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race - a socio-political construct that mediates the effect of structural racism - as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.

National Trends and Disparities in Hospitalization for Acute Hypertension Among Medicare Beneficiaries (1999-2019)

BACKGROUND

In the past 2 decades, hypertension control in the US population has not improved and there are widening disparities. Little is known about progress in reducing hospitalizations for acute hypertension.

METHODS

We conducted serial cross-sectional analysis of Medicare fee-for-service beneficiaries age 65 years or older between 1999 and 2019 using Medicare denominator and inpatient files. We evaluated trends in national hospitalization rates for acute hypertension overall and by demographic and geographical subgroups. We identified all beneficiaries admitted with a primary discharge diagnosis of acute hypertension on the basis of International Classification of Diseases codes. We then used a mixed effects model with a Poisson link function and state-specific random intercepts, adjusting for age, sex, race and ethnicity, and dual-eligible status, to evaluate trends in hospitalizations.

RESULTS

The sample consisted of 397 238 individual Medicare fee-for-service beneficiaries. From 1999 through 2019, the annual hospitalization rates for acute hypertension increased significantly, from 51.5 to 125.9 per 100 000 beneficiary-years; the absolute increase was most pronounced among the following subgroups: adults ≥85 years (66.8-274.1), females (64.9-160.1), Black people (144.4-369.5), and Medicare/Medicaid insured (dual-eligible, 93.1-270.0). Across all subgroups, Black adults had the highest hospitalization rate in 2019, and there was a significant increase in the differences in hospitalizations between Black and White people from 1999 to 2019. Marked geographic variation was also present, with the highest hospitalization rates in the South. Among patients hospitalized for acute hypertension, the observed 30-day and 90-day all-cause mortality rates (95% CI) decreased from 2.6% (2.27-2.83) and 5.6% (5.18-5.99) to 1.7% (1.53-1.80) and 3.7% (3.45-3.84) and 30-day and 90-day all-cause readmission rates decreased from 15.7% (15.1-16.4) and 29.4% (28.6-30.2) to 11.8% (11.5-12.1) and 24.0% (23.5-24.6).

CONCLUSIONS

Among Medicare fee-for-service beneficiaries age 65 years or older, hospitalization rates for acute hypertension increased substantially and significantly from 1999 to 2019. Black adults had the highest hospitalization rate in 2019 across age, sex, race and ethnicity, and dual-eligible strata. There was significant national variation, with the highest rates generally in the South.

Racial and Ethnic Disparities in Outpatient Visit Rates Across 29 Specialties

This cross-sectional study examines US racial/ethnic disparities in outpatient visit rates to 29 physician specialties.

Poverty, Racism, and the Public Health Crisis in America

The purpose of this article is to discuss poverty as a multidimensional factor influencing health. We will also explicate how racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. Poverty is one of the most significant challenges for our society in this millennium. Over 40% of the world lives in poverty. The U.S. has one of the highest rates of poverty in the developed world, despite its collective wealth, and the burden falls disproportionately on communities of color. A common narrative for the relatively high prevalence of poverty among marginalized minority communities is predicated on racist notions of racial inferiority and frequent denial of the structural forms of racism and classism that have contributed to public health crises in the United States and across the globe. Importantly, poverty is much more than just a low-income household. It reflects economic well-being, the ability to negotiate society relative to education of an individual, socioeconomic or health status, as well as social exclusion based on institutional policies, practices, and behaviors. Until structural racism and economic injustice can be resolved, the use of evidence-based prevention and early intervention initiatives to mitigate untoward effects of socioeconomic deprivation in communities of color such as the use of social media/culturally concordant health education, social support, such as social networks, primary intervention strategies, and more will be critical to address the persistent racial/ethnic disparities in chronic diseases.

Association between neighborhood social cohesion, awareness of chronic diseases, and participation in healthy behaviors in a community cohort

BACKGROUND

Neighborhood social cohesion (NSC) is the network of relationships as well as the shared values and norms of residents in a neighborhood. Higher NSC has been associated with improved cardiovascular health, largely among Whites but not African Americans. In a bi-racial cohort, we aimed to study the association between NSC and chronic disease awareness and engagement in healthy self-management behaviors, two potential mechanisms by which NSC could impact cardiovascular health outcomes.

METHODS

Using the Healthy Aging in Neighborhoods of Diversity Across the Lifespan Study (HANDLS), we cross-sectionally examined the association between NSC and awareness of three chronic conditions (diabetes, chronic kidney disease (CKD), and hypertension) and engagement in healthy self-management behaviors including physical activity, healthy eating, and cigarette avoidance.

RESULTS

Study participants (n = 2082) had a mean age of 56.5 years; 38.7% were White and 61.4% African American. Of the participants, 26% had diabetes, 70% had hypertension and 20.2% had CKD. Mean NSC was 3.3 (SD = 0.80) on a scale of 1 (lowest score) to 5 (highest score). There was no significant association between NSC and any chronic disease awareness, overall or by race. However, each higher point in mean NSC score was associated with less cigarette use and healthier eating scores, among Whites (adjusted odds ratio [aOR], 95% confidence interval [CI]: =0.76, 0.61-0.94; beta coefficient [βc]:, 95% CI: 1.75; 0.55-2.97, respectively) but not African Americans (aOR = 0.95, 0.79-1.13; βc: 0.46, - 0.48-1.39, respectively; Pinteraction = 0.08 and 0.06). Among both Whites and African Americans, higher NSC scores were associated with increases in self-reported physical activity (βc: 0.12; 0.08-0.16; Pinteraction = 0.40).

CONCLUSIONS

Community engagement and neighborhood social cohesion may be important targets for promotion of healthy behaviors and cardiovascular disease prevention. More research is needed to understand the different associations of NSC and healthy behaviors by race.

The racist "one drop rule" influencing science: it is time to stop teaching "race corrections" in medicine

Glomerular filtration rate (GFR) is a key index of renal function. The classic method for assessing GFR is the clearance of inulin. Several current methods using isotopic (¹²⁵I-iothalamate, ⁵¹Cr-EDTA, or ⁹⁹Tc-DTPA) or nonisotopic (iohexol or iothalamate) markers are available. Clinically, GFR is estimated (eGFR) from serum creatinine or cystatin C levels. Estimated GFR based on creatinine and/or cystatin are less accurate than measured GFR. The creatinine-based equations calculate higher eGFR values (suggesting better kidney function) for black individuals. This upward adjustment for all black individuals is embedded in eGFR calculations on the belief of higher serum creatinine concentrations among black individuals than among white individuals. Thus "race-corrected" eGFR has become a widely accepted and scientifically valid procedure. However, race is not a genetic or biological category. Rather, race is a social construction defined by region-specific cultural and historical ideas. Furthermore, there is no accepted scientific method for classifying people as black or white individuals. Studies typically rely on self-identification of race. However, any person in the United States with any known black ancestry is considered to be a black individual. This is known as the "one-drop rule," meaning that a single drop of "black blood" makes anyone a black individual. It does not matter if an individual has 50%, 25%, 5%, or 0.5% African ancestry. The limited accuracy and reliability of this approach would not be allowed for any other scientific variable. Admixture and migration have produced such broad variations that race categories should not be used as experimental variables.

Trends in Chronic Kidney Disease Care in the US by Race and Ethnicity, 2012-2019

Importance

Significant racial and ethnic disparities in chronic kidney disease (CKD) progression and outcomes are well documented, as is low use of guideline-recommended CKD care.

Objective

To examine guideline-recommended CKD care delivery by race and ethnicity in a large, diverse population.

Design, Setting, and Participants

In this serial cross-sectional study, adult patients with CKD that did not require dialysis, defined as a persistent estimated glomerular filtration rate less than 60 mL/min/1.73 m2 or a urine albumin-creatinine ratio of 30 mg/g or higher for at least 90 days, were identified in 2-year cross-sections from January 1, 2012, to December 31, 2019. Data from the OptumLabs Data Warehouse, a national data set of administrative and electronic health record data for commercially insured and Medicare Advantage patients, were used.

Exposures

The independent variables were race and ethnicity, as reported in linked electronic health records.

Main Outcomes and Measures

On the basis of guideline-recommended CKD care, the study examined care delivery process measures (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker prescription for albuminuria, statin prescription, albuminuria testing, nephrology care for CKD stage 4 or higher, and avoidance of chronic nonsteroidal anti-inflammatory drug prescription) and care delivery outcome measures (blood pressure and diabetes control).

Results

A total of 452 238 patients met the inclusion criteria (mean [SD] age, 74.0 [10.2] years; 262 089 [58.0%] female; a total of 7573 [1.7%] Asian, 49 970 [11.0%] Black, 15 540 [3.4%] Hispanic, and 379 155 [83.8%] White). Performance on process measures was higher among Asian, Black, and Hispanic patients compared with White patients for angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use (79.8% for Asian patients, 76.7% for Black patients, and 79.9% for Hispanic patients compared with 72.3% for White patients in 2018-2019), statin use (72.6% for Asian patients, 69.1% for Black patients, and 74.1% for Hispanic patients compared with 61.5% for White patients), nephrology care (64.8% for Asian patients, 72.9% for Black patients, and 69.4% for Hispanic patients compared with 58.3% for White patients), and albuminuria testing (53.9% for Asian patients, 41.0% for Black patients, and 52.6% for Hispanic patients compared with 30.7% for White patients). Achievement of blood pressure control to less than 140/90 mm Hg was similar or lower among Asian (71.8%), Black (63.3%), and Hispanic (69.8%) patients compared with White patients (72.9%). Achievement of diabetes control with hemoglobin A1c less than 7.0% was 50.1% in Asian patients, 49.3% in Black patients, and 46.0% in Hispanic patients compared with 50.3% for White patients.

Conclusions and Relevance

Higher performance on CKD care process measures among Asian, Black, and Hispanic patients suggests that differences in medication prescription and diagnostic testing are unlikely to fully explain known disparities in CKD progression and kidney failure. Improving care delivery processes alone may be inadequate for reducing these disparities.

Association between ethnicity and kidney transplant waitlist outcomes beyond estimated post-transplant survival score

White kidney transplant candidates have the highest pre-transplant mortality rate compared to other ethnicities. The reason for a higher mortality rate is not well-understood. Estimated post-transplant survival (EPTS) score has been used to predict patient survival after transplant and may be associated with pre-transplant survival. First-time kidney transplant candidates listed between 2015 and 2018 were identified from the Organ Procurement Transplantation Network database. Individuals listed for multiple organs, at multiple centers, and age <18 years were excluded. We examined the impact of ethnicity on waitlist mortality and delisting. A total of 114 806 candidates were included. The study population was categorized into four groups which were 43% white, 28% Black, 19.2% Hispanic, and 9.8% "other ethnicities." At 5.2 years, the cumulative incidences of death and delist were 32%, 31%, 29%, and 26%, respectively. Compared to whites, adjusted subdistribution hazard ratio (aSHR) for death and delist among Black, Hispanics, and "other ethnicities" were 0.92 (95% CI 0.89-0.95), 0.89 (95% CI 0.85-0.91), and 0.76 (95% CI 0.72-0.80) after adjustment by EPTS along with other factors, respectively. After adjusting for EPTS score along with additional confounding factors and functional status at initial listing, white ethnicity was independently associated with an increased risk for death and delist.

Social Justice as a Tool to Eliminate Inequities in Kidney Disease

Kidney disease has disparate effects on racial and ethnic minority groups, who have higher rates of chronic kidney disease and generally poorer outcomes. These disparate rates and outcomes have been attributed to social determinants of health; however, these social determinants of health are related to governmental and societal structural barriers that have created inequities not only in kidney disease, but also in other chronic diseases and in maternal/fetal health outcomes. The societal barriers to health equity include income inequality, inadequate education, environmental injustice, mass incarceration, and the enduring effects of the legacy of slavery. The approach to reducing disparities in kidney outcomes must be viewed through the lens of social justice to address these societal barriers.

Global Epidemiology of End-Stage Kidney Disease and Disparities in Kidney Replacement Therapy

BACKGROUND

The global epidemiology of end-stage kidney disease (ESKD) reflects each nation's unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs).

SUMMARY

From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Bidirectional association between chronic kidney disease and sleep apnea: a systematic review and meta-analysis

BACKGROUND

Previous data have suggested a link between chronic kidney disease (CKD) and sleep apnea (SA). However, the prevalence and risk association of both disease entities are not uniformly described.

METHODS

Ovid MEDLINE, EMBASE, and the Cochrane Library were searched for eligible publications that included patients aged ≥ 18 years diagnosed with CKD or SA. Included studies were divided into two cohorts: (1) a cohort of CKD or end-stage kidney disease (ESKD) patients reporting the prevalence of SA or odds ratio (OR) for SA (CKD cohort) and (2) a cohort of SA patients reporting the prevalence of CKD/ESKD or OR for CKD/ESKD (SA cohort).

RESULTS

CKD cohort: Of 16 studies (n = 340,587), the pooled estimated prevalence of SA among CKD/ESKD patients was 47.5% (95% CI 28.8-66.9). The pooled adjusted OR for SA among CKD/ESKD patients was 1.961 (95% CI 1.702-2.260). Male sex, history of diabetes, and lower BMI were associated with increased prevalence of SA. SA cohort: Of 12 studies (n = 3,103,074), the pooled prevalence of CKD/ESKD among patients with SA was 8.2% (95% CI 4.7-13.7), whereas the pooled adjusted OR for CKD/ESKD among patients with SA was 2.088 (95% CI 1.777-2.452). Increasing age, higher BMI, male sex, white race, and history of diabetes were associated with higher prevalence of CKD/ESKD.

CONCLUSION

There was a bidirectional association between CKD/ESKD and SA. Interventions aiming to prevent the progression of either CKD or SA are important.

Immigration status and end-stage kidney disease: Role of policy and access to care

Immigration status is an important mitigating factor in determining the provision of dialysis and kidney-related care. Immigrants make up the largest uninsured group in the country. For immigrants with end-stage kidney disease (ESKD), dialysis access varies by insurance type and by state, leading to great variability in the availability of kidney care. In some states, undocumented immigrants may only qualify for hemodialysis when critically ill (emergency hemodialysis), which is associated with higher mortality, hospital length of stay, and cost, in addition to an emotional burden on patients, their caregivers, and healthcare professionals. Barriers to effective care for immigrants with ESKD include immigration status, insurance access, and availability of pre-end stage kidney disease care, vascular access, and transplant. Effective strategies for improving dialysis care for immigrants include advocacy at the state and federal level, broadening definitions under Emergency Medicaid, and improving benefits for home therapies and transplantation options.

Race Disparities in the Use of Prevention, Screening, and Monitoring Services in Michigan Medicare Beneficiaries With Type 2 Diabetes and Combinations of Multiple Chronic Conditions

People with diabetes need routine health care to prevent potential exacerbations of diabetes and detect or prevent the development of additional chronic conditions that can worsen the course of diabetes. Using 2012 Medicare claims data from the State of Michigan for 443,932 beneficiaries with type 2 diabetes, we determined that there are differences between white and racial/ethnic minority people with diabetes in accessing any preventive care and in the amount of service used once they do access care, even after adjusting for the presence of multiple chronic conditions.

Social Determinants of Health and Chronic Kidney Disease

In the United States, chronic kidney disease (CKD) remains a concern to the health of 37 million adults. Prevention is key to combatting this disease before it is able to progress into its advanced stages or end-stage renal disease (ESRD). Awareness of the clinical early detection of CKD is important for healthcare providers, but a look at the causes of this disease can provide for greater evaluation of the patient’s risks. Understanding of social determinants of health (SDOH), the non-clinical aspects of a patient’s life that affect disease onset and progression, and its effects on CKD and ESRD should be greater emphasized in the primary care field. Population groups living with relatively poorer SDOH are disproportionally affected by CKD and ESRD. Although political change is out of the scope of the primary care health provider, efforts in combatting poor social determinants can provide for better outcomes for at-risk or diagnosed patients. Education and screening are two suggestions brought up in literature for tackling SDOH, specifically in the primary care settings most applicable to CKD.

Survival of the Fittest: Addressing the Disparities in the Burden of Chronic Kidney Disease

The prevalence of chronic kidney disease (CKD) is increasingly becoming recognized as a global health concern as well as a critical determinant of poor health outcomes. Decreased access to health care and low socioeconomic status (SES) worsen the adverse effects of biologic or genetic predisposition to CKD. All the studies used were retrieved using the PubMed database. The literature suggests that in developing and developed countries, lower SES is inversely proportional to CKD. It shows an inconsistent relationship between CKD and race; that is, there may or may not be a relationship between these two variables. In the United States (US), the prevalence of the early stages of CKD is similar across different racial/ethnic groups. However, the preponderance of end-stage renal disease (ESRD) is higher for minorities than their non-Hispanic white counterparts.

Further investigation is required to understand the role of racial disparities and CKD as well as to understand the significant difference seen in the incidence when progressing from CKD to ESRD. It is necessary to recognize how lower SES and racial/ethnic disparity may result in the impediment of appropriate disease management. A possible approach is the use of the biopsychosocial model, which integrates biological, individual, and neighborhood factors. A practical method of providing appropriate care to these populations will require economically feasible prevention strategies as well as extending the scope of dialysis by the implementation of cheaper alternatives.

Renal histology in diabetic nephropathy predicts progression to end-stage kidney disease but not the rate of renal function decline

Background

While histopathologic changes correlate with functional impairment in cross-sectional studies of diabetic nephropathy (DN), whether these findings predict future rate of kidney function loss remains uncertain. We thus sought to examine the relationship between kidney histopathology, incidence of end-stage kidney disease (ESKD), and rate of estimated glomerular filtration rate (eGFR) loss in DN.

Methods

In this longitudinal cohort study, we studied 50 adults diagnosed with biopsy-proven DN. We analyzed the histopathologic parameters of each patient’s kidney biopsy, as defined by the Renal Pathology Society classification system for DN, and tracked all available eGFR measurements post-biopsy. We additionally collected baseline clinical parameters (at the time of biopsy), including eGFR, albumin-to-creatinine ratio (ACR), and hemoglobin A_1c. Multivariable linear regression was used to assess the relationship between histologic and clinical parameters at the time of the biopsy and eGFR slope. Kaplan-Meier curves and Cox regression were used to evaluate the association between histologic and clinical parameters and ESKD incidence.

Results

Progression to ESKD was associated with worsening interstitial fibrosis score (p = 0.05), lower baseline eGFR (p = 0.02), higher ACR (p = 0.001), and faster eGFR decline (p < 0.001). The rate of eGFR decline did not associate with any histologic parameter. Baseline ACR was the only studied variable correlating with eGFR slope (rho = − 0.41).

Conclusions

Renal histology predicts ultimate progression to ESKD, but not the rate of progression. Future work is required to identify novel predictors of rapid functional decline in patients with diabetic nephropathy.