Social Determinants of Health Are Associated with Markers of Renal Injury in Adolescents with Type 1 Diabetes

Laura A.M Cummings,Antoine Clarke,Etienne Sochett,Denis Daneman,David Z Cherney,Heather N Reich,James W Scholey,David B Dunger,Farid H Mahmud

doi:10.1016/j.jpeds.2018.03.030

Abstract

ObjectiveTo examine the relationship between the social determinants of health and markers of early renal injury in adolescent patients with type 1 diabetes (T1D).Study designRenal outcomes included estimated glomerular filtration rate (eGFR) and albumin–creatinine excretion ratio (ACR). Differences in urinary and serum inflammatory markers also were assessed in relation to social determinants of health. Regression analysis was used to evaluate the association between the Ontario Marginalization Index (ON-Marg) as a measure of the social determinants of health, patient characteristics, ACR, eGFR, and renal filtration status (hyperfiltration vs normofiltration).ResultsParticipants with T1D (n = 199) with a mean age of 14.4 ± 1.7 years and diabetes duration of 7.2 ± 3.1 years were studied. Mean eGFR was 122.0 ± 19.4 mL/min/1.73 m2. Increasing marginalization was positively associated with eGFR (P < .0001) but not with ACR (P = .605). Greater marginalization was associated with greater median levels of urinary interleukin (IL)-2, IL-12 (p40), macrophage-derived chemokine, monocyte chemoattractant protein-3, and tumor necrosis factor-β and serum IL-2. ON-Marg was significantly associated with eGFR after we controlled for age, sex, body mass index z score, ethnicity, serum glucose, and hemoglobin A1c in linear regression. A similar association between hyperfiltration and ON-Marg score was observed in multivariable logistic regression.ConclusionIncreasing marginalization is significantly associated with both eGFR and hyperfiltration in adolescents with T1D and is associated with significant changes in urinary inflammatory biomarkers. These findings highlight a potentially important interaction between social and biological determinants of health in adolescents with T1D.

Highlights

Ontario Marginalization Index (ON-Marg) was significantly associated with estimated glomerular filtration rate (eGFR) after we controlled for age, sex, body mass index z score, ethnicity, serum glucose, and hemoglobin A1c in linear regression
Diabetic nephropathy is associated with morbidity and mortality in patients with type 1 diabetes (T1D)[1] and will develop in approximately one-third of patients with T1D
Correlations between ON-Marg Scores and Renal Measures eGFRZappitelli was significantly correlated with multiple social determinants of health dimensions and ON-Marg summary score (R = 0.323; P < .0001)

Summary

Methods

This study evaluated participant data from an existing cohort of adolescents with T1D from the observational arm of the Canadian Adolescent Diabetes Cardiorenal Intervention Trial (AdDIT),[22,23] linked to population-level census data from Ontario, Canada. Patient-level data were obtained from participants with T1D receiving care at the Hospital for Sick Children and affiliated regional diabetes care centers in Toronto, Ontario, who were enrolled in the observational arm of the AdDIT clinical trial. The Ontario Marginalization Index (ON-Marg) was used as an area-level measure of the social determinants of health. Detailed descriptions of the AdDIT study population and methods have been published previously.[22,23] This population has been shown to be representative of the greater Toronto population in terms of the social determinants of health.[24]

Results

Discussion

Conclusion