Disparities in chronic kidney disease-the state of the evidence

Adapting a pain coping skills training intervention for people with chronic pain receiving maintenance hemodialysis for end stage Kidney disease

Pain Coping Skills Training (PCST) is a first-line cognitive-behavioral, non-pharmacological treatment for chronic pain and comorbid symptoms. PCST has been shown to be effective in racially and ethnically diverse cohorts across several chronic medical conditions. However, PCST has not been evaluated in those with end stage kidney disease (ESKD) receiving in-center maintenance hemodialysis. Due to the high rates of morbidity associated with ESKD, and time-intensive treatment, an adaptation of PCST was warranted to address the unique challenges experienced by people living with ESKD. Using current guidelines developed by Card and colleagues for intervention adaptation, PCST was adapted so that it could be implemented among people living with ESKD in a national multisite trial. The objective of this paper was to describe the adaption process outlined by Card and colleagues including how the team selected an effective intervention to adapt, developed a program model, identified mismatches in the original intervention and study population, and then adapted the intervention for those with ESKD treated with in-center maintenance hemodialysis. Finally, we briefly describe future directions for clinical practice and research with the adapted PCST intervention for those with ESKD.Trial registration: ClinicalTrials.gov #NCT04571619.

Forearm Versus Upper Arm Location of Arteriovenous Access Used at Hemodialysis Initiation: Temporal Trends and Racial Disparities

RATIONALE & OBJECTIVE

Race and ethnicity differences exist in the type of arteriovenous access (AVA, including fistulas and grafts) used at hemodialysis (HD) initiation. The preferred anatomic location for the creation of an initial HD AVA is typically in the forearm We evaluated race and ethnicity differences in the use of an AVA in the forearm location at HD initiation.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Using records from DaVita Kidney Care linked to the US Renal Data System (USRDS), we evaluated patients aged≥16 years who initiated in-center HD with an AVA between 2006 and 2019.

PREDICTOR

Race and ethnicity, categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other.

OUTCOME

Forearm versus upper arm AVA location.

ANALYTICAL APPROACH

Multivariable modified Poisson regression to estimate adjusted trends in AVA location over time and race and ethnicity differences in AVA location. Nested models helped assess the relative confounding by groups of variables on estimates of race and ethnicity differences.

RESULTS

Among 70,147 patients (51.7% White, 28.8% Black, 12.6% Hispanic, 6.9% Other), White patients were older and more likely to have peripheral vascular disease but less likely to have diabetes compared with the other groups. The proportion initiating HD using a forearm AVA decreased from 49% in 2006 to 29% in 2019 and by 3.6% (95% CI, 3.3%-3.9%) annually, with no difference in this trend among groups (race and ethnicity by calendar year interaction P=0.32). Black patients were 13% (95% CI, 10%-15%) less likely and Hispanic patients were 5% (95% CI, 1%-9%) less likely than White patients to initiate HD with a forearm AVA.

LIMITATIONS

Findings may not apply to home HD.

CONCLUSIONS

Use of a forearm AVA for HD initiation has declined and racial differences have persisted, with Black and Hispanic patients being less likely than White patients to have an AVA in the forearm location. Research toward understanding the causes and consequences of these trends and disparities is warranted.

Getting the most out of remote care: Co-developing a Toolkit to improve the delivery of remote kidney care appointments for underserved groups

BACKGROUND

Telephone and video appointments are still common post-pandemic, with an estimated 25%-50% of kidney appointments in the United Kingdom still conducted remotely. This is important as remote consultations may exacerbate pre-existing inequalities in those from underserved groups. Those from underserved groups are often not represented in health research and include those with learning disability, mental health needs, hearing/sight problems, young/older people, those from ethnic minority groups.

OBJECTIVES

The aim was to develop a Toolkit to improve the quality of remote kidney care appointments for people from different underserved groups.

DESIGN

A parallel mixed methods approach with semistructured interviews/focus groups and survey. We also conducted workshops to develop and validate the Toolkit.

PARTICIPANTS

Seventy-five renal staff members completed the survey and 21 patients participated in the interviews and focus groups. Patients (n = 11) and staff (n = 10) took part in the Toolkit development workshop, and patients (n = 13) took part in the Toolkit validation workshop.

RESULTS

Four themes from interviews/focus groups suggested areas in which remote appointments could be improved. Themes were quality of appointment, patient empowerment, patient-practitioner relationship and unique needs for underserved groups. Staff reported difficulty building rapport, confidentiality issues, confidence about diagnosis/advice given, technical difficulties and shared decision making.

CONCLUSION

This study is the first to explore experiences of remote appointments among both staff and those from underserved groups living with kidney disease in the United Kingdom. While remote appointments can be beneficial, our findings indicate that remote consultations need optimisation to meet the needs of patients. The project findings informed the development of a Toolkit which will be widely promoted and accessible in the United Kingdom during 2024.

Multimodal approaches for inequality in kidney care: turning social determinants of health into opportunities

PURPOSE OF REVIEW

Kidney disease is associated with major health and economic burdens worldwide, disproportionately carried by people in low and middle socio-demographic index quintile countries and in underprivileged communities. Social determinants such as education, income and living and working conditions strongly influence kidney health outcomes. This review synthesised recent research into multimodal interventions to promote kidney health equity that focus on the social determinants of health.

RECENT FINDINGS

Inequity in kidney healthcare commonly arises from nationality, race, sex, food insecurity, healthcare access and environmental conditions, and affects kidney health outcomes such as chronic kidney disease progression, dialysis and transplant access, morbidity and mortality. Multimodal approaches to addressing this inequity were identified, targeted to: patients, families and caregivers (nutrition, peer support, financial status, patient education and employment); healthcare teams (workforce, healthcare clinician education); health systems (data coding, technology); communities (community engagement); and health policy (clinical guidelines, policy, environment and research).

SUMMARY

The engagement of diverse patients, families, caregivers and communities in healthcare research and implementation, as well as clinical care delivery, is vital to counteracting the deleterious effects of social determinants of kidney health.

Diabetic Kidney Disease Prevention Care Model Development

More than one-third of people with diabetes develop diabetic kidney disease (DKD), which substantially increases risks of kidney failure, cardiovascular disease (CVD), hypoglycemia, death, and other adverse health outcomes. A multifaceted approach incorporating self-management education, lifestyle optimization, pharmacological intervention, CVD prevention, and psychosocial support is crucial to mitigate the onset and progression of DKD. The American Diabetes Association convened an expert panel to develop the DKD Prevention Model presented herein. This model addresses prevention and treatment, including screening guidelines, diagnostic tools, and management approaches; comprehensive, holistic interventions; well-defined roles for interdisciplinary health care professionals; community engagement; and future directions for research and policy.

Health inequities in dialysis care: A scoping review

MAIN PROBLEM

We aim to look at potential gaps in current dialysis literature on inequities and explore future research that could contribute to more equitable care.

METHODS

Following guidelines from the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic reviews and Meta Analyses extension for Scoping Reviews (PRISMA-ScR), we conducted a scoping review of health inequities in dialysis. PubMed and Ovid Embase were searched in July 2022 for articles published between 2016 and 2022 that examined at least one of the following NIH defined health inequities: race/ethnicity, sex/gender, LGBTQ+ identity, underserved rural populations, education level, income, and occupation status. Frequencies of each health inequity as well as trends over time of the four most examined inequities were analyzed.

RESULTS

In our sample of 69 included studies, gaps were identified in LGBTQ+ identity and patient education. Inequities pertaining to race/ethnicity, sex/gender, underserved rural populations, and income were sufficiently reported. No trends between inequities investigated over time were identified.

CONCLUSIONS

Our scoping review examined current literature on health inequities pertaining to dialysis and found gaps concerning LGBTQ+ and patients with lower levels of education. To help fill these gaps, and possibly alleviate additional burden to these patients, we recommend cultural competency training for providers and dialysis center staff as well as community-based educational programs to improve dialysis patients' health literacy.

Progression of chronic kidney disease among black patients attending a tertiary hospital in Johannesburg, South Africa

BACKGROUND

Chronic kidney disease (CKD) is a major public health issue worldwide and is an important contributor to the overall non-communicable disease burden. Chronic kidney disease is usually asymptomatic, and insidiously and silently progresses to advanced stages in resource limited settings.

METHODOLOGY

A prospective longitudinal study was carried out on black patients with CKD attending the kidney outpatient clinic at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in South Africa, between September 2019 to March 2022. Demographic and clinical data were extracted from the ongoing continuous clinic records, as well as measurements of vital signs and interviews at baseline and at follow up. Patients provided urine and blood samples for laboratory investigations as standard of care at study entry (0) and at 24 months, and were followed up prospectively for two (2) years. Data were descriptively and inferentially entered into REDcap and analysed using STATA version 17, and multivariable logistic regression analysis was used to identify predictors of CKD progression.

RESULTS

A total of 312 patients were enrolled into the study, 297 (95.2%) patients completed the study, 10 (3.2%) patients were lost to follow and 5 (1.6%) patients died during the study period. The prevalence of CKD progression was 49.5%, while that of CKD remission was 33% and CKD regression was 17.5%. For patients with CKD progression the median age at baseline was 58 (46-67) years, the median eGFR was 37 (32-51) mL/min/1.73 m2, median urine protein creatinine ratio (uPCR) was 0.038 (0.016-0.82) g/mmol and the median haemoglobin (Hb) was 13.1 (11.7-14.4) g/dl; 95.2% had hypertension, 40.1% patients had diabetes mellitus and 39.5% had both hypertension and diabetes mellitus. Almost half (48.3%) of patients with CKD progression had severely increased proteinuria and 45.6% had anaemia. Variables associated with higher odds for CKD progression after multivariable logistic regression analysis were severely increased proteinuria (OR 32.3, 95% CI 2.8-368.6, P = 0.005), moderately increased proteinuria (OR 23.3, 95% CI 2.6-230.1, P = 0.007), hypocalcaemia (OR 3.8, 95% CI 1.0-14.8, P = 0.047), hyponatraemia (OR 4.5, 95% CI 0.8-23.6, P = 0.042), anaemia (OR 2.1, 95% CI 1.0-4.3, P = 0.048), diabetes mellitus (OR 1.8, 95% CI 0.9-3.6, P = 0.047), elevated HbA1c (OR 1.8, 95% CI 1.2-2.8, P = 0.007) and current smoking (OR 2.8, 95% CI 0.9-8.6, P = 0.049).

CONCLUSION

Our study identified a higher prevalence of CKD progression in a prospective longitudinal study of black patients with CKD compared with literature reports. CKD Progression was associated with proteinuria, diabetes mellitus, elevated HbA1c, anaemia, hypocalcaemia, hyponatraemia and current smoking in a cohort of black patients with CKD who had controlled hypertension and diabetes mellitus at baseline.

Impact of Social Determinants of Health in Spine Surgery

PURPOSE OF REVIEW

Social determinants of health (SDH) are factors that affect patient health outcomes outside the hospital. SDH are "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." Current literature has shown SDH affecting patient reported outcomes in various specialties; however, there is a dearth in research relating spine surgery with SDH. The aim of this review article is to identify connections between SDH and post-operative outcomes in spine surgery. These are important, yet understudied predictors that can impact health outcomes and affect health equity.

RECENT FINDINGS

Few studies have shown associations between SDH pillars (environment, race, healthcare, economic, and education) and spine surgery outcomes. The most notable relationships demonstrate increased disability, return to work time, and pain with lower income, education, environmental locations, healthcare status and/or provider. Despite these findings, there remains a significant lack of understanding between SDH and spine surgery. Our manuscript reviews the available literature comparing SDH with various spine conditions and surgeries. We organized our findings into the following narrative themes: 1) education, 2) geography, 3) race, 4) healthcare access, and 5) economics.

Treatment Adherence in CKD and Support From Health care Providers: A Qualitative Study

Rationale & Objective

Adherence to recommended medical treatment is critical in chronic kidney disease (CKD) to prevent complications and progression to kidney failure. Overall adherence to treatment is low in CKD, and as few as 40% of patients with kidney failure receive any documented CKD-related care. The purpose of this study was to explore the experiences of patients with CKD and their adherence to CKD treatment plans, and the role their health care providers played in supporting their adherence.

Study Design

One-on-one interviews were conducted in 2019-2020 using a semi-structured interview guide. Participants described experiences with adherence to treatment plans and what they did when experiencing difficulty.

Setting & Participants

Participants were recruited from the Chronic Renal Insufficiency Cohort (CRIC) study. All CRIC participants were older than 21 years with CKD stages 2-4; this sample consisted of participants from the University of Pennsylvania CRIC site.

Analytical Approach

Interviews were recorded, transcribed, and coded using conventional content analysis. Data were organized into themes using NVivo 12.

Results

The sample (n = 32) had a mean age of 67 years, 53% were women, 59% were non-White, with a mean estimated glomerular filtration rate of 56.6 mL/min/1.73 m2. From analysis of factors relevant to treatment planning and adherence, following 4 major themes emerged: patient factors (multiple chronic conditions, motivation, outlook), provider factors (attentiveness, availability/accessibility, communication), treatment planning factors (lack of plan, proactive research, provider-focused treatment goals, and shared decision making), and treatment plan responses (disagreeing with treatment, perceived capability deficit, lack of information, and positive feedback).

Limitations

The sample was drawn from the CRIC study, which may not be representative of the general population with CKD.

Conclusions

These themes align with Behavioral Learning Theory, which includes concepts of internal antecedents (patient factors), external antecedents (provider factors), behavior (treatment planning factors), and consequences (treatment plan responses). In particular, the treatment plan responses point to innovative potential intervention approaches to support treatment adherence in CKD.

Returning Individual Research Results to Vulnerable Individuals

Although issues associated with returning individual research results to study participants have been well explored, these issues have been less thoroughly investigated in vulnerable individuals and populations. Considerations regarding return of research results to these individuals and populations, including how best to ensure truly informed consent, how to minimize the risks and benefits of the return of research results, and how best to ensure justice may differ from those of the population at large. This article discusses the issues and challenges associated with the return of individual research results (such as genomic, proteomic, or other biomarker data) to potentially vulnerable individuals and populations, including those who may be vulnerable for cognitive, communicative, institutional, social, deferential, medical, economic, or social reasons. It explores factors that should be considered in the design, conduct, and oversight of ethically responsible research involving the return of research results to vulnerable individuals and populations and discuss recommendations for those engaged in this work.

A Study on CKD Progression and Health Disparities Using System Dynamics Modeling

Chronic kidney disease (CKD) is one of the most prevalent national health problems in the United States. According to the Center for Disease Control and Prevention (CDC), as of 2019, 37 million of the US’s adult population have been estimated to have CKD. In this respect, health disparities are major national concerns regarding the treatments for patients with CKD nationwide. The disparities observed in the healthcare interventions for patients with this disease usually indicate some significant healthcare gaps in the national public health system. However, there is a need for immediate intervention to improve the present healthcare conditions of minorities experiencing CKD nationwide. In this research, the application of system dynamics modeling is proposed to model the CKD progression and health disparities. This process is based on the health interventions administered to minorities experiencing CKD. The graphical results from the model show that there are relationships among the dynamic factors influencing the incidence and prevalence of CKD. Hence, healthcare disparities are inherent challenges in the treatment and management of this disease.

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.

Sex-Based Differences in Risk Factors and Complications of Chronic Kidney Disease

Globally, females are ∼30% more likely to have pre-dialysis chronic kidney disease (CKD) than males for reasons that are not fully understood. CKD is associated with numerous adverse health outcomes which makes understanding and working to eradicating sex based disparities in CKD prevalence essential. This review maps both what is known, and what is unknown, about the way sex and gender impacts (1) the epidemiology and risk factors for CKD including age, diabetes, hypertension, obesity, smoking, and cerebrovascular disease, and (2) the complications from CKD including kidney disease progression, cardiovascular disease, CKD mineral and bone disorders, anaemia, quality-of-life, cancer and mortality. This mapping can be used to guide future research.

Temporal Trends in Renal Replacement Therapy in Community-Based People with or without Type 2 Diabetes: The Fremantle Diabetes Study

Background: Although rates of cardiovascular disease complicating type 2 diabetes are declining, equivalent data for renal replacement therapy (RRT) are conflicting. The aim of this study was to characterize temporal changes in RRT incidence rates (IRs) in Australians with or without type 2 diabetes. Methods: Participants with type 2 diabetes from the Fremantle Diabetes Study Phases I (FDS1; n = 1291 recruited 1993–1996) and II (FDS2; n = 1509 recruited 2008–2011) were age-, sex- and postcode-matched 1:4 to people without diabetes and followed for first hospitalization for/with RRT. Five-year IRs, IR ratios (IRRs) for those with versus without diabetes in FDS1 and FDS2, and IR differences (IRDs), were calculated. Results: The 13,995 participants had a mean age of 64.8 years and 50.4% were males. For the type 2 diabetes cohorts, the 5-year RRT IR was nearly threefold higher in FDS2 versus FDS1 (IRR (95% CI): 2.85 (1.01–9.87)). Sixteen more participants with type 2 diabetes/10,000 person-years received RRT in FDS2 than FDS1 compared with an IRD of 2/10,000 person-years in those without diabetes. Type 2 diabetes increased RRT risk at least 5-fold. This increased risk was greater in Aboriginal participants who were relatively young when RRT was initiated and more prone to rapid progression to RRT. Multivariable analysis using the combined FDS type 2 diabetes cohorts confirmed albuminuria as a strong independent RRT risk factor. Conclusions: The incidence of RRT is increasing substantially in Australians with type 2 diabetes, especially in Aboriginals who progress to RRT more rapidly at a younger age than non-Aboriginals.

Burden of chronic kidney disease and its risk-attributable burden in 137 low-and middle-income countries, 1990-2019: results from the global burden of disease study 2019

BACKGROUND

Chronic kidney disease (CKD) is a global public health concern, but its disease burden and risk-attributable burden in CKD has been poorly studied in low - and middle-income countries (LMICs). This study aimed to estimate CKD burden and risk-attributable burden in LMICs from 1990 to 2019.

METHODS

Data were collected from the Global Burden of Disease (GBD) Study 2019, which measure CKD burden using the years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs) and calculate percentage contributions of risk factors to age-standardized CKD DALY using population attributable fraction (PAF) from 1990 to 2019. Trends of disease burden between 1990 and 2019 were evaluated using average annual percent change (AAPC). The 95% uncertainty interval (UI) were calculated and reported for YLDs, YLLs, DALYs and PAF.

RESULTS

In 2019, LICs had the highest age-standardized DALY rate at 692.25 per 100,000 people (95%UI: 605.14 to 785.67), followed by Lower MICs (684.72% (95%UI: 623.56 to 746.12)), Upper MICs (447.55% (95%UI: 405.38 to 493.01)). The age-standardized YLL rate was much higher than the YLD rate in various income regions. From 1990 to 2019, the age-standardized DALY rate showed a 13.70% reduction in LICs (AAPC = -0.5, 95%UI: - 0.6 to - 0.5, P < 0.001), 3.72% increment in Lower MICs (AAPC = 0.2, 95%UI: 0.0 to 0.3, P < 0.05). Age-standardized YLD rate was higher in females than in males, whereas age-standardized rates of YLL and DALY of CKD were all higher in males than in females in globally and LMICs. Additionally, the YLD, YLL and DALY rates of CKD increased with age, which were higher in aged≥70 years in various income regions. In 2019, high systolic blood pressure, high fasting plasma glucose, and high body-mass index remained the major causes attributable age-standardized CKD DALY. From 1990 to 2019, there were upward trends in the PAF of age-standardized DALY contributions of high fasting plasma glucose, high systolic blood pressure, and high body-mass index in Global, LICs, Lower MICs and Upper MICs. The greatest increase in the PAF was high body-mass index, especially in Lower MICs (AAPC = 2.7, 95%UI: 2.7 to 2.8, P < 0.001). The PAF of age-standardized DALY for high systolic blood pressure increased the most in Upper MICs (AAPC = 0.6, 95%UI: 0.6 to 0.7, P < 0.001).

CONCLUSIONS

CKD burden remains high in various income regions, especially in LICs and Lower MICs. More effective and targeted preventive policies and interventions aimed at mitigating preventable CKD burden and addressing risk factors are urgently needed, particularly in geographies with high or increasing burden.