End stage renal disease risk and neighbourhood deprivation: a nationwide cohort study in Sweden

Components of Residential Neighborhood Deprivation and Their Impact on the Likelihood of Live-Donor and Preemptive Kidney Transplantation

INTRODUCTION

Adults residing in deprived neighborhoods face various socioeconomic stressors, hindering their likelihood of receiving live-donor kidney transplantation (LDKT) and preemptive kidney transplantation (KT). We quantified the association between residential neighborhood deprivation index (NDI) and the likelihood of LDKT/preemptive KT, testing for a differential impact by race and ethnicity.

METHODS

We studied 403 937 adults (age ≥ 18) KT candidates (national transplant registry; 2006-2021). NDI and its 10 components were averaged at the ZIP-code level. Cause-specific hazards models were used to quantify the adjusted hazard ratio (aHR) of LDKT and preemptive KT across tertiles of NDI and its 10 components.

RESULTS

Candidates residing in high-deprivation neighborhoods were more likely to be female (40.1% vs. 36.2%) and Black (41.9% vs. 17.7%), and were less likely to receive both LDKT (aHR = 0.66, 95% confidence interval [CI]: 0.64-0.67) and preemptive KT (aHR = 0.60, 95% CI: 0.59-0.62) than those in low-deprivation neighborhoods. These associations differedby race and ethnicity (Black: aHRLDKT = 0.58, 95% CI: 0.55-0.62; aHRpreemptive KT = 0.68, 95% CI: 0.63-0.73; Pinteractions: LDKT < 0.001; Preemptive KT = 0.002). All deprivation components were associated with the likelihood of both LDKT and preemptive KT (except median home value): for example, higher median household income (LDKT: aHR = 1.08, 95% CI: 1.07-1.09; Preemptive KT: aHR = 1.10, 95% CI: 1.08-1.11) and educational attainments (≥high school [LDKT: aHR = 1.17, 95% CI: 1.15-1.18; Preemptive KT: aHR = 1.23, 95% CI: 1.21-1.25]).

CONCLUSION

Residence in socioeconomically deprived neighborhoods is associated with a lower likelihood of LDKT and preemptive KT, differentially impacting minority candidates. Identifying and understanding which neighborhood-level socioeconomic status contributes to these racial disparities can be instrumental in tailoring interventions to achieve health equity in LDKT and preemptive KT.

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).

Chronic kidney disease and the global public health agenda: an international consensus

Early detection is a key strategy to prevent kidney disease, its progression and related complications, but numerous studies show that awareness of kidney disease at the population level is low. Therefore, increasing knowledge and implementing sustainable solutions for early detection of kidney disease are public health priorities. Economic and epidemiological data underscore why kidney disease should be placed on the global public health agenda - kidney disease prevalence is increasing globally and it is now the seventh leading risk factor for mortality worldwide. Moreover, demographic trends, the obesity epidemic and the sequelae of climate change are all likely to increase kidney disease prevalence further, with serious implications for survival, quality of life and health care spending worldwide. Importantly, the burden of kidney disease is highest among historically disadvantaged populations that often have limited access to optimal kidney disease therapies, which greatly contributes to current socioeconomic disparities in health outcomes. This joint statement from the International Society of Nephrology, European Renal Association and American Society of Nephrology, supported by three other regional nephrology societies, advocates for the inclusion of kidney disease in the current WHO statement on major non-communicable disease drivers of premature mortality.

Income Level and Impaired Kidney Function Among Working Adults in Japan

Importance

Chronic kidney disease (CKD) is a major public health issue, affecting 850 million people worldwide. Although previous studies have shown the association between socioeconomic status and CKD, little is known about whether this association exists in countries such as Japan where universal health coverage has been mostly achieved.

Objective

To identify any association of income-based disparity with development of impaired kidney function among the working population of Japan.

Design, Setting, and Participants

This was a nationwide retrospective cohort study of adults aged 34 to 74 years who were enrolled in the Japan Health Insurance Association insurance program, which covers approximately 40% of the working-age population (30 million enrollees) in Japan. Participants whose estimated glomerular filtration rate (eGFR) had been measured at least twice from 2015 to 2022 were included in the analysis, which was conducted from September 1, 2021, to March 31, 2023.

Exposure

Individual income levels (deciles) in the fiscal year 2015.

Main Outcomes and Measures

Odds ratios were calculated for rapid CKD progression (defined as an annual eGFR decline of more than 5 mL/min/1.73 m2), and hazard ratios, for the initiation of kidney replacement therapy (dialysis or kidney transplant) by income level deciles in the fiscal year 2015.

Results

The study population totaled 5 591 060 individuals (mean [SD] age, 49.2 [9.3] years) of whom 33.4% were female. After adjusting for potential confounders, the lowest income decile (lowest 10th percentile) demonstrated a greater risk of rapid CKD progression (adjusted odds ratio, 1.70; 95% CI, 1.67-1.73) and a greater risk of kidney replacement therapy initiation (adjusted hazard ratio, 1.65; 95% CI, 1.47-1.86) compared with the highest income decile (top 10th percentile). A negative monotonic association was more pronounced among males and individuals without diabetes and was observed in individuals with early (CKD stage 1-2) and advanced (CKD stage 3-5) disease.

Conclusions and Relevance

The findings of this retrospective cohort study suggest that, even in countries with universal health coverage, there may be a large income-based disparity in the risk of rapid CKD progression and initiation of kidney replacement therapy. These findings highlight the importance of adapting CKD prevention and management strategies according to an individual's socioeconomic status, even when basic health care services are financially guaranteed.

Neighbourhood-level material deprivation and response to combination antiretroviral therapy in the Canadian Observational Cohort (CANOC): a longitudinal cohort study

BACKGROUND

Socioeconomic status has been associated with higher viral loads and lower CD4 cell counts among people living with HIV. The objective of this study was to evaluate the relation between neighbourhood-level material deprivation and immunologic and virologic response to combination antiretroviral therapy (ART) among people living with HIV in Canada.

METHODS

The Canadian Observational Cohort (CANOC) is a longitudinal cohort of people living with HIV, containing data from 2000-2016 from 5 Canadian provinces. We defined response to combination ART as positive if the CD4 cell count increased by 50 cells/mm³ (0.05 cells × 10⁹/L) or more (CD4+) and viral load decreased to 50 copies/mL or less (VL+) within 6 months of treatment initiation. We further categorized response to therapy as concordant positive (CD4+/VL+), concordant negative (CD4-/VL-) or discordant (CD4+/VL- or CD4-/VL+). We used adjusted multinomial logistic regression to quantify the relation between neighbourhood-level material deprivation and immunologic and virologic response.

RESULTS

This study included 8274 people living with HIV, of which 1754 (21.2%) lived in the most materially deprived neighbourhoods. Most individuals (62.2%) showed a concordant positive response to combination ART. After adjustment, living in the most materially deprived neighbourhoods was associated with a CD4-/VL+ discordant response (adjusted odds ratio [OR] 1.31, 95% confidence interval [CI] 1.06-1.62) and a concordant negative response (adjusted OR 1.45, 95% CI 1.13-1.86), using a concordant positive response as the reference. No other deprivation quartile was independently associated with a particular response.

INTERPRETATION

People living with HIV from the most materially deprived neighbourhoods had increased odds of poor immunologic or virologic response to combination ART. These results motivate further study of the specific socioeconomic factors that potentially affect response to combination ART among people living with HIV in Canada.

Incidence and risk factors for mortality and end-stage renal disease in people with type 2 diabetes and diabetic kidney disease: a population-based cohort study in the UK

INTRODUCTION

We aimed to determine the incidence of, and risk factors for all-cause/cardiovascular disease (CVD) mortality, and end-stage renal disease (ESRD) among people with type 2 diabetes with/without diabetic kidney disease (DKD) in the UK general population.

RESEARCH DESIGN AND METHODS

We undertook a population-based cohort study using primary care UK electronic health records. We followed 8413 people with type 2 diabetes and DKD and a matched comparison cohort of people with type 2 diabetes without DKD. Risk factors for all-cause/CVD mortality (using both cohorts) and ESRD (DKD cohort only) were evaluated by estimating HRs with 95% CIs using Cox regression.

RESULTS

In the DKD cohort (mean age 66.7 years, 62.4% male), incidence rates per 1000 person-years were 50.3 (all-cause mortality), 8.0 (CVD mortality) and 6.9 (ESRD). HRs (95% CIs; DKD vs comparison cohort) were 1.49 (1.35 to 1.64) for all-cause mortality and 1.60 (1.24 to 2.05) for CVD mortality. In general, higher all-cause mortality risks were seen with older age, underweight (body mass index <20 kg/m²), reduced renal function, and cardiovascular/liver disease, and lower risks were seen with being female or overweight. In the DKD cohort, higher risks of ESRD were seen with reduced renal function at baseline, high material deprivation, cancer and non-insulin glucose-lowering drugs, and a lower risk was seen with overweight (≥25 kg/m²).

CONCLUSIONS

Annually, one death will occur among every 20 people with type 2 diabetes and DKD. The identified risk factors in this study will help identify people with type 2 diabetes at most risk of death and progression of kidney disease, and help to direct effective management strategies.

Impact of educational level on incident chronic kidney disease during 13 years of follow-up: a prospective cohort study

OBJECTIVES

To examine the association between educational level and chronic kidney disease (CKD) among the Iranian population.

STUDY DESIGN

This is a prospective cohort study conducted in the framework of the Tehran Lipid and Glucose Study.

METHODS

A total of 8173 Iranians (men = 3659) aged ≥20 years were included in the study. CKD was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m². The association between educational status and CKD was explored using multivariate Cox proportional regression analyses, adjusted for age, gender, current smoking, marital status, body mass index, waist circumference, baseline eGFR, diabetes, hypertension, physical activity, history of cardiovascular diseases and dyslipidaemia.

RESULTS

During a median follow-up of 13.14 years, 2609 cases of incident CKD were identified; the corresponding incidence rate was 26.35 (range 25.39-27.34) per 1000 person-years. Compared to low educational level, middle and high educational levels showed lower risks for incident CKD in the crude model [hazard ratio (HR) 0.37 (95% confidence interval {CI} 0.34-0.40) and HR 0.40 (95% CI 0.35-0.45), respectively]; however, these HRs changed direction after further adjustment for age and gender [HR 1.26 (95% CI 1.14-1.39) and HR 1.40 (95% CI 1.22-1.61), respectively]. The increased risk of incident CKD for those at higher educational levels remained significant in the fully adjusted model. In addition, results from the gender stratified analyses were in the same direction as those found among the whole study population (P-value for interaction of gender and education >0.8).

CONCLUSIONS

Higher educational levels were associated with incident CKD during more than a decade of follow-up; this finding may be attributed to unhealthy lifestyle behaviours among this population group.

Area Deprivation and Risk of Death and CKD Progression: Long-Term Cohort Study in Patients under Unrestricted Nephrology Care

BACKGROUND

Area deprivation index (ADI) associates with prognosis in non-dialysis CKD. However, no study has evaluated this association in CKD patients under unrestricted nephrology care.

METHODS

We performed a long-term prospective study to assess the role of deprivation in CKD progression and mortality in stage 1-4 CKD patients under regular nephrology care, living in Naples (Italy). We used ADI calculated at census block levels, standardized to mean values of whole population in Naples, and linked to patients by georeference method. After 12 months of "goal-oriented" nephrology treatment, we compared the risk of death or composite renal outcomes (end-stage kidney disease or doubling of serum creatinine) in the tertiles of standardized ADI. Estimated glomerular filtration rate (eGFR) decline was evaluated by mixed effects model for repeated eGFR measurements.

RESULTS

We enrolled 715 consecutive patients (age: 64 ± 15 years; 59.1% males; eGFR: 49 ± 22 mL/min/1.73 m2). Most (75.2%) were at the lowest national ADI quintile. At referral, demographic, clinical, and therapeutic features were similar across ADI tertiles; after 12 months, treatment intensification allowed better control of hypertension, proteinuria, hypercholesterolaemia, and anaemia with no difference across ADI tertiles. During the subsequent long-term follow-up (10.5 years [interquartile range 8.2-12.6]), 166 renal events and 249 deaths were registered. ADI independently associated with all-cause death (p for trend = 0.020) and non-cardiovascular (CV) mortality (p for trend = 0.045), while CV mortality did not differ (p for trend = 0.252). Risk of composite renal outcomes was similar across ADI tertiles (p for trend = 0.467). The same held true for eGFR decline (p for trend = 0.675).

CONCLUSIONS

In CKD patients under regular nephrology care, ADI is not associated with CKD progression, while it is associated with all-cause death due to an excess of non-CV mortality.

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.

Social Determinants of CKD Hotspots

Chronic kidney disease (CKD) hotspots are defined as countries, regions, communities, or ethnicities with a higher than average incidence of CKD when compared with the worldwide, country, or regional rates. Here, we describe what is known about socially determined CKD hotspots, that is, the burden of CKD among socially defined communities that often collocate geographically. We focus on the poor, the homeless, and the food insecure, and their intersection with other social determinants of health, including race/ethnicity. In addition to discussing the burden of CKD in these communities, we describe some efforts to mitigate this burden and identify gaps in current knowledge.

Socioeconomic disadvantage and the risk of advanced chronic kidney disease: results from a cohort study with 1.4 million participants

Background

Several studies have investigated the effect of socioeconomic deprivation on cardiovascular disease (CVD) and diabetes; less is known about its effect on chronic kidney disease (CKD). We aimed to measure the association between deprivation, CKD Stages 4–5 and end-stage renal disease (ESRD) in a general population sample.

Methods

This observational study examined 1 405 016 participants from the English Clinical Practice Research Datalink (2000–14), linked to hospital discharge data and death certification. Deprivation was assessed according to the participant’s postcode. Cox models were used to estimate hazard ratios (HRs) for CKD Stages 4–5 and ESRD, adjusting for age and sex, and additionally for smoking status, body mass index, diabetes, systolic blood pressure, prior CVD and estimated glomerular filtration rate (eGFR) at baseline.

Results

During 7.5 years of median follow-up, 11 490 individuals developed CKD Stages 4–5 and 1068 initiated ESRD. After adjustment for age and sex, the HRs and confidence interval (CI) comparing those in the 20% most deprived of the population to the 20% least deprived were 1.76 (95% CI 1.68–1.84) and 1.82 (95% CI 1.56–2.12) for CKD Stages 4–5 and ESRD, respectively. Further adjustment for known risk factors and eGFR substantially attenuated these HRs. Adding our results to all known cohort studies produced a pooled relative risk of 1.61 (95% CI 1.42–1.83) for ESRD, for comparisons between highest to lowest categories of deprivation.

Conclusion

Socioeconomic deprivation is independently associated with an increased hazard of CKD Stages 4–5 and ESRD, but in large part may be mediated by known risk factors.

Associations between socioeconomic status and chronic kidney disease: a meta-analysis

BACKGROUND

Socioeconomic status (SES) has long been conjectured to be associated with the incidence and progression of chronic kidney disease (CKD), but few studies have examined this quantitatively. This meta-analysis aims to fill this gap.

METHODS

A systematic literature review was performed using Medline and EMBASE to identify observational studies on associations between SES and incidence and progression of CKD, published between 1974 and March 2017. Individual results were meta-analysed using a random effects model, in line with Meta-analysis of Observational Studies in Epidemiology guidelines.

RESULTS

In total, 43 articles met our inclusion criteria. CKD prevalence was associated with several indicators of SES, particularly lower income (OR 1.34, 95% CI (1.18 to 1.53), P<0.001; I²=73.0%, P=0.05); lower education (OR 1.21, 95% CI (1.11 to 1.32), P<0.001; I²=45.20%, P=0.034); and lower combined SES (OR 2.18, 95% CI (1.64 to 2.89), P<0.001; I²=0.0%, P=0.326). Lower levels of income, occupation and combined SES were also significantly associated with progression to end-stage renal disease (risk ratio (RR) 1.24, 95% CI (1.12 to 1.37), P<0.001; I²=66.6%, P=0.006; RR 1.05, 95% CI (1.01 to 1.09), P=0.012; I²=0.0%, P=0.796; and RR 1.39, 95% CI (1.09 to 1.79), P=0.009; I²=74.2%, P=0.009). Subgroup analyses generally confirmed these results, except in a few cases, such as an inverse association related to particular socioeconomic backgrounds and where results were adjusted by more disease-related risk factors.

CONCLUSION

Lower income was most closely associated with prevalence and progression of CKD, and lower education was significantly associated with its prevalence. Evidence for other indicators was inconclusive.