Disparities In Chronic Kidney Disease Research Articles

Abstract P416: Higher Household Income is Protective Against Chronic Kidney Disease Among White but Not Black Adults: An Analysis of 2017-2020 NHANES

Introduction: Chronic kidney disease (CKD) disproportionately affects Black adults in the U.S. Prior work suggests that lower income is a risk factor for CKD among Black but not White adults; however, this has not been examined in a nationally representative population, using the updated, race-free kidney function equation. Objective: To examine the relationship between household income and CKD between Black and White adults. Methods: We used data from the 2017-2020 NHANES. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m 2 based on the race-free CKD-EPI equation and/or a urine albumin-creatinine ratio >30 mg/g. The poverty income ratio (PIR) (ranging from 0 to ≥5) was reported in NHANES (calculated as a multiple of interviewees self-reported income in dollars as compared to the federal poverty line). We examined the association between PIR and CKD using survey-weighted Poisson regression models, adjusted for age, sex, education, marital status, and medical comorbidities. We also examined how this association differed between Black and White adults aged ≥18 years old in separate subgroup analyses via interaction terms. Results: The weighted sample was 51.7% female, 15.5% Black, and 84.5% White with mean age (±SE) of 47.5±0.3 years. In the total sample, and among White adults, higher household income was associated with a lower prevalence of CKD ( Table ). A one-unit higher PIR was associated with a 11% (95% CI: 5%, 16%) lower prevalence of CKD in the total sample and a 12% (95% CI: 6%, 18%) lower prevalence of CKD among White adults. However, this association was not significant for Black adults. The interaction term for race and income was significant ( P = 0.001). Conclusion: Higher income was associated with a lower risk of CKD among White, but not Black adults. Further work is needed to characterize the complex relationship between socioeconomic status and race to address disparities in CKD.

Pharmacist's role in reducing medication‐related racial disparities in African American patients with chronic kidney disease

AbstractRacial/ethnic disparities in chronic kidney disease have been well established. African Americans experience faster progression to end‐stage kidney disease and a higher prevalence of kidney‐related diseases due to social determinants of health and systemic racism. As the most accessible health care professionals, pharmacists have a responsibility to diminish racial health disparities by putting efforts into leading diversity initiatives, committees, task forces, and community outreach events. To effectively engage African American communities, pharmacists must first understand the historical context of distrust in health care, kidney‐related health and medication‐related disparities experienced by African Americans, and how socioeconomic deprivation impacts the progression of kidney disease. In this article, we review available literature pertaining to these topics and give suggestions on what pharmacists can do to help reduce health care disparities in African Americans with kidney disease and to build trust with individuals and their communities to improve their health care outcomes.

MO491: Low Income is Associated With Late Nephrology Referral in Portugal: A Retrospective Study

Abstract BACKGROUND AND AIMS Social disparities in chronic kidney disease (CKD) are a reality. Low socioeconomic status is associated with an increased incidence of CKD and overall worse outcomes. In Portugal, similarly to many European countries, a National Health System (NHS) was established to provide equity in healthcare access, but its impact in specialized CKD care is unclear. This study aims to compare the effects of economic insufficiency in referral and overall specialized kidney care in a Portuguese centre. METHOD Retrospective cohort study evaluating maintenance haemodialysis patients of a Public Portuguese Nephrology Centre from 2017 through 2021. Medical records were compared for the presence of Low-Income status (LIs), with primary outcome as baseline estimated glomerular filtration rate (eGFR) at nephrology referral and secondary outcomes as presence of kidney replacement therapy options appointment (KRTOa), timely vascular access assessment and time to dialysis from referral. RESULTS A total of 212 participants were evaluated, 96 with LIs. This group presented higher sCr and lower eGFR at referral (2.35 versus 3.29 mg/dL, P < .001; 27.63 versus 18.47 mL/min/1.73 m2 P <.001, respectively). LIs associated with absence of KRTOa {OR: 2.7, [95% confidence interval (95% CI): 1.44–5.08]; P = .003} and late vascular access evaluation (OR: 2.77, 95% CI: 1.55–4.98; P = .001). Dialysis-free survival analysis revealed shorter time to dialysis in the LIs group (15.77 versus 20.71 months; P < .001) with a higher cumulative incidence in dialysis at 24 months (HR: 2.11, 95% CI: 1.39–3.21; P < .001), a difference that was not verified after adjusting for eGFR at referral (HR: 1.16, 95% CI: 0.74–1.80; P = .53). CONCLUSION Low-Income CKD Portuguese patients are at risk of late nephrology referral, an established factor for adverse outcomes. Shorter time to dialysis appears significative in reducing adequate kidney care access, which can be attenuated through education of primary care providers and general population for CKD.

Dialysis symptom index burden and symptom clusters in a prospective cohort of dialysis patients

BackgroundDialysis patients experience a high symptom burden, which may adversely impact their quality of life. Whereas other specialties emphasize routine symptom assessment, symptom burden is not well-characterized in dialysis patients. We sought to examine the prevalence and severity of unpleasant symptoms in a prospective hemodialysis cohort.MethodsAmong 122 hemodialysis patients from the prospective Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease (CKD) study, CKD-associated symptoms were ascertained by the Dialysis Symptom Index, a validated survey assessing symptom burden/severity (with higher scores indicating greater symptom severity), over 6/2020–10/2020. We examined the presence of (1) individual symptoms and symptom severity scores, and (2) symptom clusters (defined as ≥ 2 related concurrent symptoms), as well as correlations with clinical characteristics.ResultsSymptom severity scores were higher among non-Hispanic White and Hispanic patients, whereas scores were lower in Black and Asian/Pacific Islander patients. In the overall cohort, the most common individual symptoms included feeling tired/lack of energy (71.3%), dry skin (61.5%), trouble falling asleep (44.3%), muscle cramps (42.6%), and itching (42.6%), with similar patterns observed across racial/ethnic groups. The most prevalent symptom clusters included feeling tired/lack of energy + trouble falling asleep (37.7%); trouble falling asleep + trouble staying asleep (34.4%); and feeling tired/lack of energy + trouble staying asleep (32.0%). Lower hemoglobin, iron stores, and dialysis adequacy correlated with higher individual and overall symptom severity scores.ConclusionWe observed a high prevalence of unpleasant symptoms and symptom clusters in a diverse hemodialysis cohort. Further studies are needed to identify targeted therapies that ameliorate symptom burden in CKD.Graphical abstract

Low income is associated with late nephrology referral in Portugal: A retrospective study

Introduction: Social disparities in chronic kidney disease are a reality. Low socioeconomic status is associated with increased incidence of chronic kidney disease and overall worse outcomes. In Portugal, similarly to many European countries, a National Health System was established to provide equity in healthcare access, but its impact in specialized chronic kidney disease care is unclear. This study aims to compare the effects of economic insufficiency in referral and overall specialized kidney care in a Portuguese center. Subjects and Methods: Retrospective cohort study evaluating maintenance hemodialysis patients of a Public Portuguese Nephrology Center from 2017 through 2021. Medical records were compared for presence of low-income status, with primary outcome as baseline estimated glomerular filtration rate at Nephrology referral and secondary outcomes as presence of kidney replacement therapy options appointment, timely vascular access assessment and time to dialysis from referral. Results: A total of 212 participants were evaluated, 96 with low-income status. This group presented higher serum creatinine and lower estimated glomerular filtration rate at referral (2.35 vs. 3.29 mg/dl, p<0.001; 27.63 vs. 18.47 ml/min/1.73 m2, p<0.001; respectively). Low-income status associated with absence of kidney replacement therapy options appointment (OR 2.7, 95% CI: 1.44-5.08; p=0.003) and late vascular access evaluation (OR 2.77, 95% CI: 1.55-4.98, p=0.001). Dialysis-free survival analysis revealed shorter time to dialysis in the low-income status group (15.77 vs. 20.71 months, p<0.001) with a higher cumulative incidence in dialysis at 24 months (HR: 2.11, 95% CI: 1.39-3.21, p < 0.001), a difference that was not verified after adjusting for estimated glomerular filtration rate at referral (HR: 1.16, 95 % CI: 0.74 – 1.80, p = 0.53). Conclusion: Low-Income chronic kidney disease Portuguese patients are at risk for late Nephrology referral, an established factor for adverse outcomes. Shorter time to dialysis appears significative in reducing adequate kidney care access, which can be attenuated through education of primary care providers and general population for chronic kidney disease.

Nephrologists’ Perspectives on Gender Disparities in CKD and Dialysis

IntroductionGlobally, there are more women with chronic kidney disease (CKD), yet they comprise only 40% of patients receiving kidney replacement therapy by dialysis. We aimed to describe the perspectives of nephrologists on gender disparities in access to care and outcomes in CKD and dialysis.MethodsWe conducted semistructured interviews with 51 nephrologists (28, 55% women) from 22 countries from October 2019 to April 2020. Transcripts were analyzed thematically.ResultsWe identified 6 themes. Related to women were primary commitment to caregiving (with subthemes of coordinating care, taking charge of health management, deprioritizing own health, centrality of family in decision-making); vigilance and self-reliance (diligence and conscientiousness, stoicism and tolerating symptoms, avoiding burden on family, isolation and coping alone); and stereotyping, stigma, and judgment (body image, dismissed as anxiety, shame and embarrassment, weakness and frailty). Related to men was protecting masculinity (safeguarding the provider role, clinging to control, self-regard, and entitled). Decisional power and ownership included men’s dominance in decision-making and women’s analytical approach in treatment decisions. Inequities compounded by social disadvantage (financial and transport barriers, without social security, limited literacy, entrenched discrimination, vulnerability) were barriers to care for women, particularly in socioeconomically disadvantaged communities.ConclusionNephrologists perceived that women with CKD faced many challenges in accessing care related to social norms and roles of caregiving responsibilities, disempowerment, lack of support, stereotyping by clinicians, and entrenched social and economic disadvantage. Addressing power differences, challenging systemic patriarchy, and managing unconscious bias may help to improve equitable care and outcomes for all people with CKD.

Racial and Socioeconomic Disparities in CKD in the Context of Universal Health Care Provided by the Military Health System

Rationale & ObjectiveHealth-impeding social determinants of health—including reduced access to care—contribute to racial and socioeconomic disparities in chronic kidney disease (CKD). The Military Health System (MHS) provides an opportunity to assess a large, diverse population for CKD disparities in the context of universal health care.Study DesignCross-sectional study.Setting & ParticipantsMHS beneficiaries aged 18 to 64 years receiving care between October 1, 2015, and September 30, 2018.PredictorsRace, sponsor’s rank (a proxy for socioeconomic status and social class), median household income by sponsor’s zip code, and marital status.OutcomeCKD prevalence, defined by International Classification of Diseases, Tenth Revision codes and/or a validated, laboratory value-based electronic phenotype.Analytical ApproachMultivariable logistic regression compared CKD prevalence by predictors, controlling separately for confounders (age, sex, active-duty status, sponsor’s service branch, and depression) and mediators (hypertension, diabetes, HIV, and body mass index).ResultsOf 3,330,893 beneficiaries, 105,504 (3.2%) had CKD. In confounder-adjusted models, the CKD prevalence was higher in Black versus White beneficiaries (OR, 1.67; 95% CI, 1.64-1.70), but lower in single versus married beneficiaries (OR, 0.77; 95% CI, 0.76-0.79). The prevalence of CKD was increased among those with a lower military rank and among those with a lower median household income in a nearly dose-response fashion (P < 0.0001). Associations were attenuated when further adjusting for suspected mediators.LimitationsThe cross-sectional design prevents causal inferences. We may have underestimated the CKD prevalence, given a lack of data for laboratory tests conducted outside the MHS and the use of a specific CKD definition. The transient nature of the MHS population may limit the accuracy of zip code–level median household income data.ConclusionsRacial and socioeconomic CKD disparities exist in the MHS despite universal health care coverage. The existence of CKD disparities by rank and median household income suggests that social risks may contribute to both racial and socioeconomic disparities despite access to universal health care coverage.

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

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. To examine guideline-recommended CKD care delivery by race and ethnicity in a large, diverse population. 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. The independent variables were race and ethnicity, as reported in linked electronic health records. 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). 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. 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.

Disparities in chronic kidney disease-the state of the evidence.

The purpose of this review was to assess the prevalence of United States chronic kidney disease (CKD) health disparities, focusing on racial/ethnic groups, immigrants and refugees, sex or gender, and older adults. There are major racial/ethnic disparities in CKD, with possible contributions from the social determinants of health, socioeconomics, and racial discrimination. Racial/ethnic minority patients experience faster progression to end-stage kidney disease (ESKD) and higher mortality predialysis, however, once on dialysis, appear to live longer. Similarly, men are quicker to progress to ESKD than women, with potential biological, behavioral, and measurement error factors. There is a lack of substantial evidence for intersex, nonbinary, or transgender patients. There are also strikingly few studies about US immigrants or older adults with CKD despite the fact that they are at high risk for CKD due to a variety of factors. As providers and scientists, we must combat both conscious and unconscious biases, advocate for minority patient populations, and be inclusive and diverse in our treatment regimens and provision of care. We need to acknowledge that sufficient evidence exists to change treatment guidelines, and that more is required to support the diversity of our patient population.

Dietary Potassium Intake and Mortality in a Prospective Hemodialysis Cohort

Among hemodialysis patients, clinical practice guidelines recommend dietary potassium restriction given concerns about potential hyperkalemia leading to malignant arrhythmias and mortality. However, there are sparse data informing recommendations for dietary potassium intake in this population. We thus sought to examine the relationship between dietary potassium intake and death risk in a prospective cohort of hemodialysis patients. Among 415 hemodialysis patients from the prospective "Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease" cohort recruited across 16 outpatient dialysis clinics, information regarding dietary potassium intake was obtained using Food Frequency Questionnaires administered over October 2011 to March 2015. We first examined associations of baseline dietary potassium intake categorized as tertiles with mortality risk using Cox regression. We then examined clinical characteristics associated with low dietary potassium intake (defined as the lowest tertile) using logistic regression. In expanded case-mix Cox analyses, patients whose dietary potassium intake was in the lowest tertile had higher mortality (ref: highest tertile) (adjusted hazard ratio 1.74, 95% confidence interval 1.14-2.66). These associations had even greater magnitude of risk following adjustment for laboratory and nutritional covariates (adjusted hazard ratio 2.65, 95% confidence interval 1.40-5.04). In expanded case-mix restricted cubic spline analyses, there was a monotonic increase in mortality risk with incrementally lower dietary potassium intake. In expanded case-mix logistic regression models, female sex; higher serum bicarbonate; and lower dietary energy, protein, and fiber intake were associated with low dietary potassium intake. In a prospective cohort of hemodialysis patients, lower dietary potassium intake was associated with higher mortality risk. These findings suggest that excessive dietary potassium restriction may be deleterious in hemodialysis patients, and further studies are needed to determine the optimal dietary potassium intake in this population.

Associations of Genetic Factors, Educational Attainment, and Their Interaction With Kidney Function Outcomes

Both genetic predisposition and low educational attainment (EA) are associated with higher risk of chronic kidney disease. We examined the interaction of EA and genetic risk in kidney function outcomes. We included 3,597 participants from the Prevention of Renal and Vascular End-Stage Disease Cohort Study, a longitudinal study in a community-based sample from Groningen, the Netherlands (median follow-up, 11 years; 1997–2012). Kidney function was approximated by obtaining estimated glomerular filtration rate (eGFR) from serum creatinine and cystatin C. Individual longitudinal linear eGFR trajectories were derived from linear mixed models. Genotype data on 63 single-nucleotide polymorphisms, with known associations with eGFR, were used to calculate an allele-weighted genetic score (WGS). EA was categorized into high, medium, and low. In ordinary least squares analysis, higher WGS and lower EA showed additive effects on reduced baseline eGFR; the interaction term was nonsignificant. In analysis of eGFR decline, the significant interaction term suggested amplification of genetic risk by low EA. Adjustment for known renal risk factors did not affect our results. This study presents the first evidence of gene-environment interaction between EA and a WGS for eGFR decline and provides population-level insights into the mechanisms underlying socioeconomic disparities in chronic kidney disease.

Association of Fitness With Racial Differences in Chronic Kidney Disease

Non-white minorities are at higher risk for chronic kidney disease than non-Hispanic whites. Better cardiorespiratory fitness is associated with slower declines in estimated glomerular filtration rate and a lower incidence of chronic kidney disease. Little is known regarding associations of fitness with racial disparities in chronic kidney disease. A prospective cohort of 3,842 young adults without chronic kidney disease completed a maximal treadmill test at baseline in 1985-1986. Chronic kidney disease status was defined as estimated glomerular filtration rate of <60 mL/min/1.73 m2 during 10-, 15-, 20-, 25-, and 30-year follow-up assessments (through 2006). Analyses were completed in 2019. Multivariable Cox models were used to determine hazard ratios and 95% CI for incidence of chronic kidney disease. Multivariable models included race, gender, age, field center, education, baseline estimated glomerular filtration rate, and time-varying covariates of healthy diet index, smoking status, alcohol intake, BMI, systolic blood pressure, and fasting glucose. Percent attenuation quantified the association of fitness to racial disparities in chronic kidney disease. Chronic kidney disease incidence was higher among blacks (n=83/1,941, 1.61 per 1,000 person years) than whites (43/1,901, 0.82 per 1,000 person years). Every 1-minute shorter treadmill duration was associated with 1.14 (95% CI=1.04, 1.25) times higher risk of chronic kidney disease. Blacks were 1.72 (95% CI=1.13, 2.63) times more likely to develop chronic kidney disease compared with whites. The risk was reduced to 1.54 (95% CI=1.01, 2.39) with fitness added. This suggests that fitness is associated with 20.4% (95% CI=5.8, 43.0%) of the excess risk of chronic kidney disease attributable to race. Low fitness is a modifiable factor that may contribute to the racial disparity in chronic kidney disease.

BURDEN, ACCESS, AND DISPARITIES IN KIDNEY DISEASE

Racial/ethnic and socioeconomic disparities in chronic kidney disease (CKD) have been documented for decades, yet little progress has been made in mitigating them. Several recent studies offer new insights into the root causes of these disparities, point to areas where future research is warranted and identify opportunities for changes in policy and clinical practice. Recently published evidence suggests that geographic disparities in CKD prevalence exist and vary by race. CKD progression is more rapid for racial/ethnic minority groups as compared to whites and may be largely, but not completely, explained by genetic factors. Stark socioeconomic disparities in outcomes for dialysis patients exist, and vary by race, place of residence and treatment facility. Disparities in access to living kidney donation may be driven primarily by the socioeconomic status of the donor as opposed to recipient factors. Recent studies highlight opportunities to eliminate disparities in CKD, including efforts to direct resources to areas and populations where disparities are most prevalent, efforts to understand how to best use emerging information on the contribution of genetic factors to disparities, and continued work to identify modifiable environmental, social, and behavioral factors for targeted interventions among high-risk populations.

Low use of routine medical care among African Americans with high CKD risk: the Jackson Heart Study

BackgroundUse of routine medical care (RMC) is advocated to address ethnic/racial disparities in chronic kidney disease (CKD) risks, but use is less frequent among African Americans. Factors associated with low RMC use among African Americans at risk of renal outcomes have not been well studied.MethodsWe examined sociodemographic, comorbidity, healthcare access, and psychosocial (discrimination, anger, stress, trust) factors associated with low RMC use in a cross-sectional study. Low RMC use was defined as lack of a physical exam within one year among participants with CKD (estimated glomerular filtration rate < 60 mL/min/1.73m2 or urine albumin-to-creatinine ratio > 30 mg/g) or CKD risk factors (diabetes or hypertension). We used multivariable logistic regression to estimate the odds of low RMC use at baseline (2000–2004) for several risk factors.ResultsAmong 3191 participants with CKD, diabetes, or hypertension, 2024 (63.4%) were ≥ 55 years of age, and 700 (21.9%) reported low RMC use. After multivariable adjustment, age < 55 years (OR 1.61 95% CI 1.31–1.98), male sex (OR 1.71; 1.41–2.07), <high school diploma (OR 1.31; 1.07–1.62), absence of hypertension (OR 1.74; 1.27–2.39) or diabetes (OR 1.34; 1.09–1.65), and tobacco use (OR 1.43; 1.18–1.72) were associated with low RMC use. Low trust in providers (OR 2.16; 1.42–3.27), high stress (OR 1.41; 1.09–1.82), high daily discrimination (OR 1.30; 1.01–1.67) and low burden of lifetime discrimination (OR 1.52; 1.18–1.94), were also associated with low RMC use.ConclusionsHigh-risk African Americans who were younger, male, less-educated, and with low trust in providers were more likely to report low RMC use. Efforts to improve RMC use by targeting these populations could mitigate African Americans’ disparities in CKD risks.

Abstract 044: Cardiorespiratory Fitness May Explain a Proportion of Observed Racial Disparity in Incident Chronic Kidney Disease over 30 Years: Results From the CARDIA Study

Introduction: Racial and ethnic minorities are at higher risk for Chronic Kidney Disease (CKD). Higher levels of cardiorespiratory fitness (CRF) can reduce the risk of a rapid decline in estimated glomerular filtration rate (eGFR) and incidence of CKD. Little is known regarding how CRF contributes to racial disparities in CKD. Hypotheses: We hypothesized that: 1) baseline CRF is inversely associated with the risk of incident CKD after adjustment for covariates and 2) differences in baseline CRF account for a proportion of the disparity in incident CKD between blacks and whites. Methods: A total of 4328 young adults without CKD (age 24.8±3.6 years, 52.8% (n=2285) women, 51.9% (n=2247 black) completed a maximal graded treadmill test at baseline. We calculated eGFR using the CKD-EPI formula (baseline eGFR: 102.1±17.9 and 92.3±14.1 mL/minute/1.73 m 2 for blacks and whites, respectively). We defined CKD status as eGFR of &lt;60 mL/minute/1.73 m 2 during 10, 15, 20, 25, and 30 year follow-up assessments. Multivariable Cox models examined hazard ratios (HR) and 95% confidence intervals (CI) for incidence of CKD. Models adjusted for baseline race, sex, age, field center, alcohol intake, smoking status, healthy eating index, eGFR, maximal educational attainment, and time-varying BMI, diabetes, and hypertension. The percent reduction in parameter estimates determined the excess risk explained according to CRF. Results: During the 30 years of follow-up, 84 blacks and 43 whites developed CKD. Every 1-minute lower treadmill duration associated with 12% higher rate of CKD (HR=1.12 (1.01-1.22)). Blacks were 1.89 times more likely to develop CKD compared to whites (HR=1.89 (1.23-2.91)). This was reduced to 1.75 (1.13-2.70) with CRF added to the model. This corresponds to a β reduction of 14.3% for race according to CRF. Conclusion: Both low fitness during young adulthood and black race are associated with higher incidence of CKD later in life. Fitness is a modifiable factor that could be targeted to address a portion of the disparity gap in CKD.

Ethnic Disparities in Chronic Kidney Disease in the Netherlands

Ethnic Disparities in Chronic Kidney Disease in the Netherlands

Ethnic Disparities in CKD in the Netherlands: The Healthy Life in an Urban Setting (HELIUS) Study

Evidence suggesting important ethnic differences in chronic kidney disease (CKD) prevalence comes mainly from the United States, and data among various ethnic groups in Europe are lacking. We therefore assessed differences in CKD in 6 ethnic groups living in the Netherlands and explored to what extent the observed differences could be accounted for by differences in conventional cardiovascular risk factors (smoking, physical activity, obesity, hypertension, diabetes, and hypercholesterolemia). Cross-sectional analysis of baseline data from the Healthy Life in an Urban Setting (HELIUS) cohort study. A random sample of 12,888 adults (2,129 Dutch, 2,273 South Asian Surinamese, 2,159 African Surinamese, 1,853 Ghanaians, 2,255 Turks, and 2,219 Moroccans) aged 18 to 70 years living in Amsterdam, the Netherlands. Ethnicity. CKD status was defined using the 2012 KDIGO (Kidney Disease: Improving Global Outcomes) severity of CKD classification. CKD was defined as albumin-creatinine ratio ≥ 3mg/mmol (category ≥ A2) or glomerular filtration rate < 60mL/min/1.73m(2) (category ≥ G3). Comparisons among groups were made using prevalence ratios (PRs). The age-standardized prevalence of CKD was higher in all ethnic minority groups, ranging from 4.6% (95% CI, 3.8%-5.5%) in African Surinamese to 8.0% (95% CI, 6.7%-9.4%) in Turks, compared with 3.0% (95% CI, 2.3%-3.7%) in Dutch. Adjustment for conventional risk factors reduced the PR substantially, but ethnic differences remained for all ethnic minority groups except African Surinamese, with the PR ranging from 1.48 (95% CI, 1.12-1.97) in Ghanaians to 1.75 (95% CI, 1.33-2.30) in Turks compared with Dutch. Similar findings were found when CKD was stratified into a moderately increased and a combined high/very high risk group. Among the combined high/very high CKD risk group, conventional risk factors accounted for most of the ethnic differences in CKD except for South Asian Surinamese (PR, 2.60; 95% CI, 1.26-5.34) and Moroccans (PR, 2.33; 95% CI, 1.05-5.18). Cross-sectional design. These findings suggest ethnic inequalities in CKD for most groups even after adjustment for conventional risk factors. These findings highlight the need for further research to identify other potential factors contributing to the ethnic inequalities in CKD.

Socioeconomic Disparities in Chronic Kidney Disease

Evidence on the strength of the association between low SES and chronic kidney disease (CKD; measured by low estimated glomerular filtration rate [eGFR], high albuminuria, low eGFR/high albuminuria, and renal failure) is scattered and sometimes conflicting. Therefore, a systematic review and meta-analysis was performed to summarize the strength of the associations between SES and CKD and identify study-level characteristics related to this association. Studies published through January 2013 in MEDLINE and Embase were searched. From 35 studies that met the inclusion criteria, association estimates were pooled per CKD measure in the meta-analysis (performed between 2013 and 2014). Meta-regression analysis was used to identify study-level characteristics related to the strength of the SES-CKD association. Low SES was associated with low eGFR (OR=1.41, 95% CI=1.21, 1.62), high albuminuria (OR=1.52, 95% CI=1.22, 1.82), low eGFR/high albuminuria (OR=1.38, 95% CI=1.03, 1.74), and renal failure (OR=1.55, 95% CI=1.40, 1.71). Differences in SES measures across studies were not related to the strength of associations between low SES and any of the CKD measures (low GFR, p=0.63; high albuminuria, p=0.29; low eGFR/high albuminuria, p=0.54; renal failure, p=0.31). Variations in the strength of associations were related to the level of covariate adjustment for low eGFR (p<0.001) and high albuminuria (p<0.001). Socioeconomic disparities in CKD were fairly strong, irrespective of how SES was measured. Variations in the strength of the associations were related to the level of covariate adjustment, particularly for low eGFR and high albuminuria.

Association of Adiponectin With Body Composition and Mortality in Hemodialysis Patients

In the general population, circulating adiponectin is associated with a favorable cardiovascular risk profile (eg, lower triglycerides and body fat) and decreased mortality. Hemodialysis (HD) patients have comparatively higher adiponectin concentrations, but prior studies examining the adiponectin-mortality association in this population have not accounted for body composition or shown a consistent relationship. Prospective cohort study. We examined baseline serum adiponectin concentrations in 501 HD patients across 13 dialysis centers from the prospective MADRAD (Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease) cohort (entry period, October 2011 to February 2013; follow-up through August 2013). Serum adiponectin concentration in tertiles (tertiles 1, 2, and 3 defined as ≤16.1, >16.1-<30.1, and ≥30.1-100.0 μg/mL, respectively). Adjustment variables included case-mix and laboratory test results (age, sex, race, ethnicity, vintage, diabetes, serum albumin, total iron-binding capacity, serum creatinine, white blood cell count, phosphate, hemoglobin, and normalized protein catabolic rate), body composition surrogates (subcutaneous, visceral, and total-body fat and lean body mass), and serum lipid levels (cholesterol, high-density lipoprotein cholesterol, and triglycerides). All-cause mortality using survival (Cox) models incrementally adjusted for case-mix and laboratory test results. Among 501 HD patients, 50 deaths were observed during 631.1 person-years of follow-up. In case-mix- and laboratory-adjusted Cox analyses, the highest adiponectin tertile was associated with increased mortality versus the lowest tertile (HR, 3.35; 95% CI, 1.50-7.47). These associations were robust in analyses that additionally accounted for body composition (HR, 3.18; 95% CI, 1.61-8.24) and lipid levels (HR, 3.64; 95% CI, 1.34-7.58). Residual confounding cannot be excluded. Higher adiponectin level is associated with a 3-fold higher death risk in HD patients independent of body composition and lipid levels. Future studies are needed to elucidate underlying mechanisms and determine therapeutic targets associated with improved outcomes in HD patients.

Addressing health disparities in chronic kidney disease.

According to the official health statistics, Taiwan has the highest prevalence of end stage renal disease (ESRD) in the world. Each year, around 60,000 ESRD patients in Taiwan consume 6% of the national insurance budget for dialysis treatment. The prevalence of chronic kidney disease (CKD) has been climbing during 2008–2012. However, the spatial disparities and clustering of CKD at the public health level have rarely been discussed. The aims of this study are to explore the possible population level risk factors and identify any clusters of CKD, using the national health insurance database. The results show that the ESRD prevalence in females is higher than that in males. ESRD medical expenditure constitutes 87% of total CKD medical expenditure. Pre-CKD and pre-ESRD disease management might slow the progression from CKD to ESRD. After applying ordinary least-squares regression, the percentages of high education status and the elderly in the townships are positively correlated with CKD prevalence. Geographically weighted regression and Local Moran’s I are used for identifying the clusters in southern Taiwan. The findings can be important evidence for earlier and targeted community interventions and reducing the health disparities of CKD.