The Relationship Between Neighborhood Disadvantage and Kidney Disease Progression in the Chronic Kidney Disease in Children (CKiD) Cohort

Interval healthcare provider contact and blood pressure control in children with chronic kidney disease and hypertension

BACKGROUND

Prior studies in the CKiD (Chronic Kidney Disease in Children) cohort have shown poor blood pressure (BP) control over time. It is unclear whether the lack of BP control is associated with frequency of provider contact between annual study visits.

METHODS

Six hundred eighty-nine CKiD participants with elevated BP or self-reported history of hypertension contributed longitudinal annual data (2,916 total visits). Provider visits were categorized as any well or sick visit, excluding emergency department visits. Repeated measures logistic regression quantified the association between number of visits over the last year (categorized as 0, 1-2, 3-5, 6-10 or > 10 visits) and BP control (defined as non-elevated BP at an annual CKiD visit). Models were unadjusted, minimally adjusted (controlling for sociodemographic factors), and fully adjusted (additionally controlling for chronic kidney disease (CKD) severity).

RESULTS

Compared to those with no interval healthcare provider visits over the prior year, participants with 3-5 visits had significantly greater odds of BP control across all models (unadjusted, OR 1.45, 95% CI 1.10-1.89; minimally adjusted, OR 1.36, 95% CI 1.03-1.79; fully adjusted, OR 1.36, 95% CI 1.01-1.81); those with fewer or more frequent visits did not consistently have significant improvement in BP control.

CONCLUSIONS

In this cohort of youth with CKD and elevated BP, interval healthcare provider contact of 3-5 visits per year between annual CKiD visits was associated with improved BP control; less and more frequent contact was not, even after adjusting for CKD severity. Optimal frequency of health visits by CKD and comorbidity severity deserves further study.

Having more resilience factors only gets you so far in the context of neighborhood disadvantage: understanding differential predictors of internalizing symptoms and body mass index in youth with spina bifida

OBJECTIVE

The primary aim of this study was to determine if neighborhood disadvantage predicted internalizing symptoms and body mass index (BMI) in youth with spina bifida (SB), while accounting for several sociodemographic factors. We also explored whether resilience factors helped explain associations between neighborhood disadvantage and internalizing symptoms or neighborhood disadvantage and BMI.

METHODS

Participants (n = 69, Mage=14.13, Range: 8-20, 51% biological female, 25% Hispanic/Latinx White, 28% Other/Multiracial, 48% non-Hispanic/Latinx White) were drawn from a retrospective chart review of clinical data, including self-reported resilience factors and internalizing symptoms, collected as part of the standard of care in a multidisciplinary pediatric SB clinic. Neighborhood disadvantage scores were extracted from participant addresses. Using structural equation modeling, we examined whether neighborhood disadvantage predicted BMI and internalizing symptoms. We explored whether these paths were mediated by resilience factors.

RESULTS

Higher neighborhood disadvantage predicted higher BMI and lower internalizing symptoms. Higher neighborhood disadvantage predicted higher resilience factors, which predicted lower internalizing symptoms. Higher resilience factors did not predict BMI.

CONCLUSIONS

Neighborhood disadvantage may require youth with SB to navigate their way to additional resilience factors to maintain better psychosocial outcomes. However, having more resilience factors may not help offset the physical health costs of disadvantaged neighborhoods.

Neurocognitive disruption in pediatric kidney transplant candidates: Medical and sociodemographic factors

We evaluated the effects of kidney failure etiology, dialysis, and area deprivation index on the subdomains of neurocognitive functioning in pediatric kidney transplant candidates. The study included 78 pediatric kidney transplant candidates (47.4% male, 70.5% White, M.age = 11.77 years, and 51.3% patients have public insurance) who completed a pre-transplant neuropsychological evaluation between 1/1/2010 and 10/31/2022. Linear regression models were employed to complete data analyses. The mean scores of various neurocognitive functioning domains in pediatric kidney transplant candidates were significantly lower than in the general population (ps < .001). After adjusting for covariates, patients with congenital anomalies of the kidney and urinary tract (M = 87; 95% CI: 80-94) and other etiologies (M = 82; 95% CI: 76-89) had significantly lower processing speed compared to patients with nephrotic syndrome (M = 98; 95% CI: 89-107) (p = .02). Patients living in high-level deprivation neighborhoods showed significantly lower verbal skills (p = .01), working memory performance (p = .02), and full-scale IQ (p = .03) than patients living in median-level and low-level deprivation neighborhoods. Additionally, dialysis did not show significant association with neurocognitive domains ((ps ranged from .07 to .52).

Individual and neighborhood-level social and deprivation factors impact kidney health in the GLOMMS-CORE study

Prospective cohort studies of kidney equity are limited by a focus on advanced rather than early disease and selective recruitment. Whole population studies frequently rely on area-level measures of deprivation as opposed to individual measures of social disadvantage. Here, we linked kidney health and individual census records in the North of Scotland (Grampian area), 2011-2021 (GLOMMS-CORE) and identified incident kidney presentations at thresholds of estimated glomerular filtration rate (eGFR) under 60 (mild/early), under 45 (moderate), under 30 ml/min/1.73m2 (advanced), and acute kidney disease (AKD). Household and neighborhood socioeconomic measures, living circumstances, and long-term mortality were compared. Case-mix adjusted multivariable logistic regression (living circumstances), and Cox models (mortality) incorporating an interaction between the household and the neighborhood were used. Among census respondents, there were 48546, 29081, 16116, 28097 incident presentations of each respective eGFR cohort and AKD. Classifications of socioeconomic position by household and neighborhood were related but complex, and frequently did not match. Compared to households of professionals, people with early kidney disease in unskilled or unemployed households had increased mortality (adjusted hazard ratios: 95% confidence intervals) of (1.26: 1.19-1.32) and (1.77: 1.60-1.96), respectively with adjustment for neighborhood indices making little difference. Those within either a deprived household or deprived neighborhood experienced greater mortality, but those within both had the poorest outcomes. Unskilled and unemployed households frequently reported being limited by illness, adverse mental health, living alone, basic accommodation, lack of car ownership, language difficulties, and visual and hearing impairments. Thus, impacts of deprivation on kidney health are spread throughout society-complex, serious, and not confined to those living in deprived neighborhoods.

Neighborhood Socioeconomic Deprivation is Associated with Worse Outcomes in Pediatric Kidney Transplant Recipients

Key Points

This is the largest US cohort study investigating neighborhood socioeconomic deprivation and outcomes among pediatric kidney transplant recipients. High neighborhood deprivation was associated with worse graft survival and lower access to preemptive and living donor transplantation. Findings demonstrate inequities in pediatric kidney transplantation associated with neighborhood-level factors that warrant intervention.

Background

Social determinants of health shape a child's transplant course. We describe the association between neighborhood socioeconomic deprivation, transplant characteristics, and graft survival in US pediatric kidney transplant recipients.

Methods

US recipients younger than 18 years at the time of listing transplanted between January 1, 2010, and May 31, 2022 (N =9178) were included from the Scientific Registry of Transplant Recipients. Recipients were stratified into three groups according to Material Community Deprivation Index score, with greater score representing higher neighborhood socioeconomic deprivation. Outcomes were modeled using multivariable logistic regression and Cox proportional hazards models.

Results

Twenty-four percent (n =110) of recipients from neighborhoods of high socioeconomic deprivation identified as being of Black race, versus 12% (n =383) of recipients from neighborhoods of low socioeconomic deprivation. Neighborhoods of high socioeconomic deprivation had a much greater proportion of recipients identifying as being of Hispanic ethnicity (67%, n =311), versus neighborhoods of low socioeconomic deprivation (17%, n =562). The hazard of graft loss was 55% higher (adjusted hazards ratio [aHR], 1.55; 95% confidence interval [CI], 1.24 to 1.94) for recipients from neighborhoods of high versus low socioeconomic deprivation when adjusted for base covariates, race and ethnicity, and insurance status, with 59% lower odds (adjusted odds ratio [aOR], 0.41; 95% CI, 0.30 to 0.56) of living donor transplantation and, although not statistically significant, 8% lower odds (aOR, 0.92; 95% CI, 0.72 to 1.19) of preemptive transplantation. The hazard of graft loss was 41% higher (aHR, 1.41; 95% CI, 1.25 to 1.60) for recipients from neighborhoods of intermediate versus low socioeconomic deprivation when adjusted for base covariates, race and ethnicity, and insurance status, with 27% lower odds (aOR, 0.73; 95% CI, 0.66 to 0.81) of living donor transplantation and 11% lower odds (aOR, 0.89; 95% CI, 0.80 to 0.99) of preemptive transplantation.

Conclusions

Children from neighborhoods of high socioeconomic deprivation have worse graft survival and lower utilization of preemptive and living donor transplantation. These findings demonstrate inequities in pediatric kidney transplantation that warrant further intervention.

Social Deprivation and Incidence of Pediatric Kidney Failure in France

Introduction

Approximately 8 per million children and young adults aged < 20 years initiate kidney replacement therapy (KRT) per year in France. We hypothesize that social deprivation could be a determinant of childhood-onset kidney failure. The objective of this study was to estimate the incidence of pediatric KRT in France according to the level of social deprivation.

Methods

All patients < 20 years who initiated KRT from 2010 to 2015 in metropolitan France were included. Data were collected from the comprehensive French registry of KRT French Renal Epidemiology and Information network (REIN). We used a validated ecological index to assess social deprivation, the 2011 French version of the European Deprivation Index (EDI). We estimated the age standardized incidence rates according to the quintiles of EDI using direct standardization and incidence rate ratio using Poisson regression.

Results

We included 672 children with kidney failure (58.6% males, 30.7% with glomerular or vascular disease, 43.3% starting KRT between 11 and 17 years). 38.8% were from the most deprived areas (quintile 5 of EDI). The age standardized incidence rate increased with quintile of EDI, from 5.45 (95% confidence interval [CI] = 4.25-6.64) per million children per year in the least deprived quintile to 8.46 (95% CI = 7.41-9.51) in the most deprived quintile of EDI (incidence rates ratio Q5 vs. Q1 1.53-fold; 95% CI = 1.18-2.01).

Conclusion

This study showed that even in a country with a universal health care system, there is a strong association between the incidence of pediatric KRT and social deprivation showing that social health inequalities appear from KRT initiation. This study highlights the need to look further into social inequalities in the earliest stage of chronic kidney disease (CKD).

Socioeconomic Position and Health Among Children and Adolescents With CKD Across the Life-Course

Children and adolescents in families of lower socioeconomic position (SEP) experience an inequitable burden of reduced access to healthcare and poorer health. For children living with chronic kidney disease (CKD), disadvantaged SEP may exacerbate their considerable disease burden. Across the life-course, CKD may also compromise the SEP of families and young people, leading to accumulating health and socioeconomic disadvantage. This narrative review summarizes the current evidence on relationships of SEP with kidney care and health among children and adolescents with CKD from a life-course approach, including impacts of family SEP on kidney care and health, and bidirectional impacts of CKD on SEP. It highlights relevant conceptual models from social epidemiology, current evidence, clinical and policy implications, and provides directions for future research. Reflecting the balance of available evidence, we focus primarily on high-income countries (HICs), with an overview of key issues in low- and middle-income countries (LMICs). Overall, a growing body of evidence indicates sobering socioeconomic inequities in health and kidney care among children and adolescents with CKD, and adverse socioeconomic impacts of CKD. Dedicated efforts to tackle inequities are critical to ensuring that all young people with CKD have the opportunity to live long and flourishing lives. To prevent accumulating disadvantage, the global nephrology community must advocate for local government action on upstream social determinants of health; and adopt a life-course approach to kidney care that proactively identifies and addresses unmet social needs, targets intervening factors between SEP and health, and minimizes adverse socioeconomic outcomes across financial, educational and vocational domains.

The impact of rural status on pediatric chronic kidney disease

Children and adolescents in rural areas with chronic kidney disease (CKD) face unique challenges related to accessing pediatric nephrology care. Challenges to obtaining care begin with living increased distances from pediatric health care centers. Recent trends of increasing centralization of pediatric care mean fewer locations have pediatric nephrology, inpatient, and intensive care services. In addition, access to care for rural populations expands beyond distance and encompasses domains of approachability, acceptability, availability and accommodation, affordability, and appropriateness. Furthermore, the current literature identifies additional barriers to care for rural patients that include limited resources, including finances, education, and community/neighborhood social resources. Rural pediatric kidney failure patients have barriers to kidney replacement therapy options that may be even more limited for rural pediatric kidney failure patients when compared to rural adults with kidney failure. This educational review identifies possible strategies to improve health systems for rural CKD patients and their families: (1) increasing rural patient and hospital/clinic representation and focus in research, (2) understanding and mediating gaps in the geographic distribution of the pediatric nephrology workforce, (3) introducing regionalization models for delivering pediatric nephrology care to geographic areas, and (4) employing telehealth to expand the geographic reach of services and reduce family time and travel burden.

Differences in Outcomes by Place of Origin among Hispanic Patients with Kidney Failure

SIGNIFICANCE STATEMENT

Hispanic patients are known to have a higher risk of kidney failure and lower rates of home dialysis use and kidney transplantation than non-Hispanic White patients. However, it is unknown whether these outcomes differ within the Hispanic community, which is heterogeneous in its members' places of origins. Using United States Renal Data System data, the authors found similar adjusted rates of home dialysis use for patients originating from places outside the United States and US-born Hispanic patients, whereas the adjusted risk of mortality and likelihood of transplantation differed depending on place (country or territory) of origin. Understanding the heterogeneity in kidney disease outcomes and treatment within the Hispanic community is crucial in designing interventions and implementation strategies to ensure that Hispanic individuals with kidney failure have equitable access to care.

BACKGROUND

Compared with non-Hispanic White groups, Hispanic individuals have a higher risk of kidney failure yet lower rates of living donor transplantation and home dialysis. However, how home dialysis, mortality, and transplantation vary within the Hispanic community depending on patients' place of origin is unclear.

METHODS

We identified adult Hispanic patients from the United States Renal Data System who initiated dialysis in 2009-2017. Primary exposure was country or territory of origin (the United States, Mexico, US-Puerto Rico, and other countries). We used logistic regression to estimate differences in odds of initiating home dialysis and competing risk models to estimate subdistribution hazard ratios (SHR) of mortality and kidney transplantation.

RESULTS

Of 137,039 patients, 44.4% were US-born, 30.9% were from Mexico, 12.9% were from US-Puerto Rico, and 11.8% were from other countries. Home dialysis rates were higher among US-born patients, but not significantly different after adjusting for demographic, medical, socioeconomic, and facility-level factors. Adjusted mortality risk was higher for individuals from US-Puerto Rico (SHR, 1.04; 95% confidence interval [CI], 1.01 to 1.08) and lower for Mexico (SHR, 0.80; 95% CI, 0.78 to 0.81) and other countries (SHR, 0.83; 95% CI, 0.81 to 0.86) compared with US-born patients. The adjusted rate of transplantation for Mexican or US-Puerto Rican patients was similar to that of US-born patients but higher for those from other countries (SHR, 1.22; 95% CI, 1.15 to 1.30).

CONCLUSIONS

Hispanic people from different places of origin have similar adjusted rates of home dialysis but different adjusted rates of mortality and kidney transplantation. Further research is needed to understand the mechanisms underlying these observed differences in outcomes.

Association of chronic kidney disease with all-cause mortality in patients hospitalized for atrial fibrillation and impact of clinical and socioeconomic factors on this association

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) often co-occur, and many of the same clinical factors and indicators of socioeconomic status (SES) are associated with both diseases. The effect of the estimated glomerular filtration rate (eGFR) on all-cause mortality in AF patients and the impact of SES on this relationship are uncertain.

Materials and methods

This retrospective study examined 968 patients who were admitted for AF. Patients were divided into four groups based on eGFR at admission: eGFR-0 (normal eGFR) to eGFR-3 (severely decreased eGFR). The primary outcome was all-cause mortality. Cox regression analysis was used to identify the effect of eGFR on mortality, and subgroup analyses to determine the impact of confounding factors.

Results

A total of 337/968 patients (34.8%) died during follow-up. The average age was 73.70 ± 10.27 years and there were 522 males (53.9%). More than 39% of these patients had CKD (eGFR < 60 mL/min/1.73 m²), 319 patients with moderately decreased eGFR and 67 with severely decreased eGFR. After multivariate adjustment and relative to the eGFR-0 group, the risk for all-cause death was greater in the eGFR-2 group (HR = 2.416, 95% CI = 1.366-4.272, p = 0.002) and the eGFR-3 group (HR = 4.752, 95% CI = 2.443-9.242, p < 0.00001), but not in the eGFR-1 group (p > 0.05). Subgroup analysis showed that moderately to severely decreased eGFR only had a significant effect on all-cause death in patients with low SES.

Conclusion

Moderately to severely decreased eGFR in AF patients was independently associated with increased risk of all-cause mortality, especially in those with lower SES.

Care processes and outcomes of deprivation across the clinical course of kidney disease: findings from a high-income country with universal healthcare

BACKGROUND

No single study contrasts the extent and consequences of inequity of kidney care across the clinical course of kidney disease.

METHODS

This population study of Grampian (UK) followed incident presentations of AKI, and incident eGFR thresholds of < 60, <45 and < 30 in separate cohorts (2011-2021). The key exposure was area-level deprivation (lowest quintile of the Scottish Index of Multiple Deprivation). Outcomes were care processes (monitoring, prescribing, appointments, unscheduled care); long-term mortality; and kidney failure. Modelling involved multivariable logistic regression, negative binomial regression, and cause specific Cox models with/without adjustment of comorbidities.

RESULTS

There were 41 313, 51 190, 32 171, and 17 781 new presentations of AKI, and eGFR thresholds < 60, <45 and < 30. 6.1-7.8% were from deprived areas, and (vs all others) presented on average five years younger, with more diabetes, pulmonary and liver disease. Those from deprived areas were more likely to present initially in hospital, less likely to receive community monitoring, less likely to attend appointments, and more likely to have an unplanned emergency department or hospital admission episode. Deprivation had greatest association with long-term kidney failure at the eGFR < 60 threshold (adjusted HR 1.48, 1.17-1.87), and this association attenuated with advancing disease severity (HR 1.09, 0.93-1.28 at eGFR < 30); with a similar pattern for mortality. Across all analyses the most detrimental associations of deprivation were at an eGFR < 60 threshold, AKI, males, and those aged < 65 years.

CONCLUSIONS

Even in a high-income country with universal healthcare, serious and consistent inequities of kidney care exist. The poorer care and outcomes with area-level deprivation were greater earlier in the disease course.