Social Determinants of Racial Disparities in CKD

The Association Between Social Determinants of Health, Risk Factors, Job Performance, and Health Care Costs in an Employed Population

OBJECTIVE

The aim of the study is to compare employees of a US school district based on their social determinants of health (SDoH). Methods: Employees ( N = 5006) were categorized into low-, medium-, or high-need SDoH tiers. Of them, n = 2469 also participated in a health risk appraisal in 2019. Subjects' average health care costs, health risk factors, and self-rated job performance were compared by SDoH tier and race. Results: Significant differences were observed among the SDoH comparison groups regarding age, gender, race, and marital status. SDoH was associated with health care costs, number of health risk factors, and self-rated job performance differently for Black and White employees. Conclusions: SDoH are complex and multifaceted. Black employees in the high-need SDoH group had higher average health care costs, lower self-rated job performance, and more average health risk factors than subjects in the lower need tiers.

Comparison of Glomerular Filtration Rate Equations in a Rural New Mexico Cohort: Results from the COMPASS Study

Rationale and Objective

The NKF-ASN Task Force recommends accurate kidney function estimation avoiding biases through racial adjustments. We explored the use of multiple kidney function biomarkers and hence estimated glomerular filtration rate (eGFR) equations to improve kidney function calculations in an ethnically diverse patient population.

Study design

Prospective community cohort study.

Setting and Participants

rural New Mexico clinic with patients > 18 yo.

Methods

Markers of kidney function, IDMS-Creatinine (SCr), chemiluminescence Beta-2 Microglobulin (B2M), Nephelometry-calibrated ELISA Cystatin C (CysC), inflammation, glucose tolerance, demographics, BUN/UACR from the baseline visit of the COMPASS cohort, were analyzed by Kernel-based Virtual Machine learning methods.

Results

Among 205 participants, the mean age was 50.1, 62% were female, 54.1% Hispanic American and 30.2% Native American. Average kidney function biomarkers were: SCr 0.9 mg/dl, B2M 1.8 mg/L, and CysC 0.7 mg/dl. The highest agreement was observed between SCr and B2M-based eGFR equations [mean difference in eGFRs: (4.48 ml/min/1.73m2], and the lowest agreement between B2M and CysC-based eGFR equations (-24.75 ml/min/1.73m2). There was no pattern of association between the differences in eGFR measures and gender. In the continuous analyses, the absolute eGFR value (p<2 x 10-16) and serum albumin (p =6.4 x 10-5) predicted the difference between B2M- and SCr-based e-GFR. The absolute eGFR value (p<2 x 10-16) and age (p =7.6 x 10-5) predicted the difference between CysC- and SCr-based e-GFR.

Limitations

Relatively small sample size, elevated inflammatory state in majority of study participants and no inulin excretion rate measurements.

Conclusion

B2M should be strongly considered as a kidney function biomarker fulfilling the criteria for the NKF-ASN. B2M's eGFR equation does not need adjustment for gender or race and showed the highest agreement with SCr-based eGFR equations.

Toward Equitable Kidney Function Estimation in Critical Care Practice: Guidance From the Society of Critical Care Medicine's Diversity, Equity, and Inclusion in Renal Clinical Practice Task Force

OBJECTIVES

Accurate glomerular filtration rate (GFR) assessment is essential in critically ill patients. GFR is often estimated using creatinine-based equations, which require surrogates for muscle mass such as age and sex. Race has also been included in GFR equations, based on the assumption that Black individuals have genetically determined higher muscle mass. However, race-based GFR estimation has been questioned with the recognition that race is a poor surrogate for genetic ancestry, and racial health disparities are driven largely by socioeconomic factors. The American Society of Nephrology and the National Kidney Foundation (ASN/NKF) recommend widespread adoption of new "race-free" creatinine equations, and increased use of cystatin C as a race-agnostic GFR biomarker.

DATA SOURCES

Literature review and expert consensus.

STUDY SELECTION

English language publications evaluating GFR assessment and racial disparities.

DATA EXTRACTION

We provide an overview of the ASN/NKF recommendations. We then apply an Implementation science methodology to identify facilitators and barriers to implementation of the ASN/NKF recommendations into critical care settings and identify evidence-based implementation strategies. Last, we highlight research priorities for advancing GFR estimation in critically ill patients.

DATA SYNTHESIS

Implementation of the new creatinine-based GFR equation is facilitated by low cost and relative ease of incorporation into electronic health records. The key barrier to implementation is a lack of direct evidence in critically ill patients. Additional barriers to implementing cystatin C-based GFR estimation include higher cost and lack of test availability in most laboratories. Further, cystatin C concentrations are influenced by inflammation, which complicates interpretation.

CONCLUSIONS

The lack of direct evidence in critically ill patients is a key barrier to broad implementation of newly developed "race-free" GFR equations. Additional research evaluating GFR equations in critically ill patients and novel approaches to dynamic kidney function estimation is required to advance equitable GFR assessment in this vulnerable population.

Chronic Kidney Disease Risk Awareness, Dietary Intake, and Food Security Among Black Male College Students

OBJECTIVES

Nutrition, lifestyle factors, and awareness of chronic kidney disease (CKD) risk are vital tools for preventing or delaying its development and progression in Black American (BA) males. Few published studies assess awareness of CKD risk in BA male college students despite being at high risk. This study aimed to 1) assess the awareness of CKD risk among BA male college students and 2) identify dietary and lifestyle habits related to CKD risk.

METHODS

This was a cross-sectional online survey utilizing a network sampling technique. Inclusion criteria were self-identification as a BA male and current enrollment in a university. Participants were recruited through publicly available social media sites and emails. The online questionnaire contained demographic, health status, and food security items. Pearson's correlations explored associations between continuous variables; independent samples t-tests compared mean scores of responses between perceived risk of disease groups.

RESULTS

Sixty-seven participants completed the survey. Only 22.4% perceived they were at increased risk for kidney disease, while 49.3% felt at increased risk for developing hypertension (HTN). More respondents (32.8%) also felt at increased risk for developing diabetes than kidney disease. Dietary sodium restriction was reported by 34.3%, while only 14.9% had been advised to do so by a health-care provider. Half of the respondents were deemed food insecure, and 17.86% were categorized as experiencing very low food security.

CONCLUSION

Awareness of CKD risk is low for BA male college students and lags behind awareness of HTN and diabetes risk. There may be a lack of knowledge regarding CKD as a long-term complication of HTN and diabetes. Dietary sodium restriction is marginal, and food security is a significant challenge in this high-risk group. Educational initiatives are needed to increase awareness of CKD risk among BA male college students.

Associations of social determinants of health and childhood obesity: a cross-sectional analysis of the 2021 National Survey of Children's Health

CONTEXT

Childhood obesity is a growing health problem in the United States, with those affected having an increased likelihood of developing chronic diseases at a younger age. Social determinants of health (SDOH) are known to influence overall health. Families who are of low socioeconomic status (SES) have also been shown to be more likely to experience food insecurity.

OBJECTIVES

Our primary objective was to utilize the National Survey of Children's Health (NSCH) 2021 data to determine the current associations between childhood obesity and SDOH. Secondarily, we estimated the prevalence of select SDOH among children with obesity.

METHODS

We conducted a cross-sectional analysis of 2021 NSCH to extract data related to the SDOH domains. We extracted sociodemographic variables to utilize as controls and constructed logistic regression models to determine associations, via odds ratios, between SDOH and childhood obesity.

RESULTS

Within the binary regression models, children with obesity (≥95th percentile) were more likely than children without obesity to experience SDOH in all domains. After controlling for sociodemographic variables, children with obesity were significantly more likely to experience food insecurity when compared to children without obesity (adjusted odds ratio [AOR]=1.39; 95 % confidence interval [CI]: 1.13-1.17).

CONCLUSIONS

In line with the current American Academy of Pediatrics (AAP) Clinical Practice Guidelines (CPG), improving policies for nutrition programs and addressing the lack of access to nutritious foods may alleviate some food insecurity. Ensuring that children have access to sufficient nutritious foods is critical in addressing childhood obesity and thus decreasing risk of chronic disease.

Predictors of chronic kidney disease survival in type 2 diabetes: a 12-year retrospective cohort study utilizing estimated glomerular filtration rate

Predicting the course of kidney disease in individuals with both type 1 and type 2 diabetes mellitus (DM) is a significant clinical and policy challenge. In several regions, DM is now the leading cause of end-stage renal disease. The aim of this study to identify both modifiable and non-modifiable risk factors, along with clinical markers and coexisting conditions, that increase the likelihood of stage 3-5 chronic kidney disease (CKD) development in individuals with type 2 DM in the United Arab Emirates (UAE). This was a single-center retrospective cohort study based on data derived from electronic medical records of UAE patients with DM who were registered at outpatient clinics at Tawam Hospital in Al Ain, UAE, between January 2011 and December 2021. Type 2 DM patients aged ≥ 18 years who had serum HbA1c levels ≥ 6.5% were included in the study. Patients with type 1 DM, who had undergone permanent renal replacement therapy, who had under 1 year of follow-up, or who had missing or incomplete data were excluded from the study. Factors associated with diabetic patients developing stage 3-5 CKD were identified through Cox regression analysis and a fine and gray competing risk model to account for competing events that could potentially hinder the development of CKD. A total of 1003 patients were recruited for the study. The mean age of the study cohort at baseline was 70.6 ± 28.2 years. Several factors were found to increase the risk of developing stage 3-5 CKD: advancing age (HR 1.005, 95% CI 1.002-1.009, p = 0.026), a history of hypertension (HR 1.69, 95% CI 1.032-2.8, p = 0.037), a history of heart disease (HR 1.49, 95% CI 1.16-1.92, p = 0.002), elevated levels of serum creatinine (HR 1.006, 95% CI 1.002-1.010, p = 0.003), decreased levels of estimated glomerular filtration rate (eGFR) (HR 0.943, 95% CI, 0.938-0.947; p < 0.001), and the use of beta-blockers (HR 139, 95% CI 112-173, p = 0.003). Implementing preventative measures, initiating early interventions, and developing personalized care plans tailored to address specific risk factors are imperative for reducing the impact of CKD. Additionally, the unforeseen findings related to eGFR highlight the ongoing need for research to deepen our understanding of the complexities of kidney disease.

Higher potassium intake is associated with a lower risk of chronic kidney disease: population-based prospective study

BACKGROUND

High-potassium intake is associated with a lower risk of cardiovascular disease. However, the association between potassium intake and the development of chronic kidney disease (CKD) remains unclear.

OBJECTIVE

The objective of this study was to investigate whether potassium intake is associated with outcomes of incident CKD.

METHODS

This is a population-based prospective observational cohort study from the UK Biobank cohort between 2006 and 2010. We included 317,162 participants without CKD from the UK Biobank cohort. The main predictor was spot urine potassium-to-creatinine ratio (KCR). The primary outcome was incident CKD, which was defined by the International Classification of Disease 10 codes or Operating Procedure Codes Supplement 4 codes.

RESULTS

At baseline, individuals with higher KCR had lower blood pressure, body mass index, and inflammation, and were less likely to have diabetes and hypertension. During a median follow-up of 11.9 y, primary outcome events occurred in 15,246 (4.8%) participants. In the cause-specific model, the adjusted hazard ratio (aHR) per 1-standard deviation increase in KCR for incident CKD was 0.90 [95% confidence interval (CI): 0.89, 0.92]. Compared with quartile 1 of KCR, the aHRs (95% CIs) for quartiles 2-4 were 0.98 (0.94, 1.02), 0.90 (0.86, 0.95), and 0.80 (0.76, 0.84), respectively. In sensitivity analysis with different definitions of CKD, the results were similar. In addition, further analysis with dietary potassium intake also showed a negatively graded association with the primary outcome.

CONCLUSIONS

Higher urinary potassium excretion and intake were associated with a lower risk of incident CKD.

Racialized and Immigrant Status and the Pursuit of Living Donor Kidney Transplant - a Canadian Cohort Study

Introduction

Both immigrant and racialized status may be associated with the pursuit of living donor kidney transplant (LDKT).

Methods

This study was a secondary analysis of a convenience cross-sectional sample of patients with kidney failure in Toronto, obtained from our "Comprehensive Psychosocial Research Data System" research database. The exposures included racialized, immigrant, and combined immigrant and racialized status (White nonimmigrant, racialized nonimmigrant, White immigrant and racialized immigrant). Outcomes include the following: (i) having spoken about LDKT with others, (ii) having a potential living donor (LD) identified, (iii) having allowed others to share the need for LDKT, (iv) having directly asked a potential donor to be tested, and (v) accept a hypothetical LDKT offer. We assessed the association between exposure and outcomes using univariable, and multivariable binary or multinominal logistic regression (reference: White or White nonimmigrant participants).

Results

Of the 498 participants, 281 (56%) were immigrants; 142 (28%) were African, Caribbean, and Black (ACB); 123 (25%) were Asian; and 233 (47%) were White. Compared to White nonimmigrants, racialized immigrants (relative risk ratio [RRR]: 2.98; 95% confidence interval [CI]: 1.76-5.03) and racialized nonimmigrants (RRR: 2.84; 95% CI: 1.22-6.65) were more likely not to have spoken about LDKT with others (vs. having spoken or planning to do so). Both racialized immigrant (odds ratio [OR]: 4.07; 95% CI: 2.50-6.34), racialized nonimmigrants (OR: 2.68; 95% CI: 1.31-5.51) and White immigrants (OR: 2.68; 95% CI: 1.43-5.05) were more likely not to have a potential LD identified.

Conclusion

Both racialized and immigrant status are associated with less readiness to pursue LDKT. Supporting patients to communicate their need for LDKT may improve equitable access to LDKT.

Age- and Race-Specific Changes in ESKD Incidence over Four Decades

SIGNIFICANCE STATEMENT

ESKD incidence has changed substantially in the past four decades, but differences by age and race have been unexplored. Using data from the United States Renal Data System, we found that ESKD incidence rose for Black and White teenagers, adults, and older adults for two decades beginning in 1980. Growth in incidence slowed for most groups by 1993, and by 2006, the annual percent change (APC) in ESKD incidence had declined for all groups, except White adults, for whom rates continued to rise. By 2019, ESKD incidence among Black and White adolescents nearly returned to 1980 levels, but no other group achieved that degree of improvement. Nonetheless, the ESKD incidence rate among Black American patients exceeds that of White patients in every age group. Distinct patterns in ESKD incidence among patients of different age, sex, and racial groups are shown. These findings could reflect changes in dialysis acceptance rates, access to preventive health care, incidence of diabetes mellitus, implementation of evidence-based guidelines for treatment of CKD, or other unrecognized factors. There may be population-specific opportunities to change the growth of the US ESKD population and address current racial disparities.

BACKGROUND

Substantial changes in ESKD incidence over four decades among Black and White Americans of different ages have been incompletely explored.

METHODS

We analyzed United States Renal Data System data from 1980 to 2019 to determine ESKD incidence trends among Black and White adolescent (13-17 years), adult (18-64 years), and older adult (≥65) populations. We used the National Cancer Institute Joinpoint Regression Program to estimate annual percent change (APC) in ESKD incidence and to define points in time where a statistically significant change in APC slope occurred for each group.

RESULTS

ESKD incidence rose after 1980 for all groups, although the trends differed ( P < 0.001). Growth in incidence slowed for most by 1993, and by 2006, the APC in ESKD incidence had declined for all groups, except White adults, for whom rates continued to rise ( P < 0.05). By 2019, ESKD incidence among Black and White adolescents nearly returned to 1980 levels, but no other group achieved that degree of improvement. Nonetheless, the ESKD incidence among Black American patients exceeds that of White patients in every age group.

CONCLUSIONS

Distinct patterns in ESKD incidence among patients of different age, sex, and racial groups are shown. These findings could reflect changes in dialysis acceptance rates, access to preventive health care, incidence of diabetes mellitus, implementation of evidence-based guidelines for treatment of CKD, or other unrecognized factors.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2024_03_13_ASN0000000000000310.mp3.

Social determinants of health and dialysis modality selection in patients with advanced chronic kidney disease: A retrospective cohort study

BACKGROUND

Social determinants of health are non-medical factors that impact health. For patients with chronic kidney disease (CKD) progressing to kidney failure, the influence of social determinants of health on dialysis modality selection (haemodialysis vs. peritoneal dialysis (PD)) is incompletely understood.

METHODS

Retrospective cohort study of 981 consecutive patients with advanced CKD referred to the Ottawa Hospital Multi-Care Kidney Clinic (Canada) who progressed to dialysis from 2010 to 2021. Multivariable logistic regression was used to measure odds ratios (OR) for the associations between social determinants of health (education, employment, marital status and residence) and modality of dialysis initiation.

RESULTS

The mean age and estimated glomerular filtration rate were 64 and 18 mL/min/1.73 m2, respectively. Not having a high school degree was associated with lower odds of initiating dialysis via PD compared to having a college degree (29% vs. 48%, OR 0.55 (95% confidence interval (CI) 0.34-0.88)). Unemployment was associated with lower odds of initiating dialysis via PD compared to active employment (38% vs. 62%, OR 0.40 (95% CI 0.27-0.60)). Being single was associated with lower odds of initiating dialysis via PD compared to being married (35% vs. 48%, adjusted OR 0.52 (95% CI 0.39-0.70)). Living alone at home was associated with lower odds of initiating dialysis via PD compared to living at home with family (33% vs. 47%, adjusted OR 0.55 (95% CI 0.39-0.78)).

CONCLUSIONS

Social determinants of health including education, employment, marital status and residence are associated with dialysis modality selection. Addressing these 'upstream' social factors may allow for more equitable outcomes during the transition from advanced CKD to kidney failure.

Bias and Accuracy of Glomerular Filtration Rate Estimating Equations in the US: A Systematic Review and Meta-Analysis

Importance

There is increasing concern that continued use of a glomerular filtration rate (GFR) estimating equation adjusted for a single racial group could exacerbate chronic kidney disease-related disparities and inequalities.

Objective

To assess the performance of GFR estimating equations across varied patient populations.

Data Sources

PubMed, Embase, Web of Science, ClinicalTrials.gov, and Scopus databases were systematically searched from January 2012 to February 2023.

Study Selection

Inclusion criteria were studies that compared measured GFR with estimated GFR in adults using established reference standards and methods. A total of 6663 studies were initially identified for screening and review.

Data Extraction and Synthesis

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 authors independently extracted data on studies that examined the bias and accuracy of GFR estimating equations. For each outcome, a random-effects model was used to calculate pooled estimates. Data analysis was conducted from March to December 2023.

Main Outcomes and Measures

The primary outcomes were bias and accuracy of estimated GFRs in Black vs non-Black patients, as well as in individuals with chronic conditions. Bias was defined as the median difference between the measured GFR and the estimated GFR. Accuracy was assessed with P30 (the proportion of persons in a data set whose estimated GFR values were within 30% of measured GFR values) and measures of heterogeneity.

Results

A total of 12 studies with a combined 44 721 patients were included. Significant heterogeneity was found in the bias of various GFR estimation equations. Race-corrected equations and creatinine-based equations tended to overestimate GFR in Black populations and showed mixed results in non-Black populations. For creatinine-based equations, the mean bias in subgroup analysis was 2.1 mL/min/1.73 m2 (95% CI, -0.2 mL/min/1.73 m2 to 4.4 mL/min/1.73 m2) in Black persons and 1.3 mL/min/1.73 m2 (95% CI, 0.0 mL/min/1.73 m2 to 2.5 mL/min/1.73 m2) in non-Black persons. Equations using only cystatin C had small biases. Regarding accuracy, heterogeneity was high in both groups. The overall P30 was 84.5% in Black persons and 87.8% in non-Black persons. Creatinine-based equations were more accurate in non-Black persons than in Black persons. For creatinine-cystatin C equations, the P30 was higher in non-Black persons. There was no significant P30 difference in cystatin C-only equations between the 2 groups. In patients with chronic conditions, P30 values were generally less than 85%, and the biases varied widely.

Conclusions and Relevance

This systematic review and meta-analysis of GFR estimating equations suggests that there is bias in race-based GFR estimating equations, which exacerbates kidney disease disparities. Development of a GFR equation independent of race is a crucial starting point, but not the sole solution. Addressing the disproportionate burden of kidney failure on Black individuals in the US requires an enduring, multifaceted approach that should include improving diagnostics, tackling social determinants of health, confronting systemic racism, and using effective disease prevention and management strategies.

Clearing the air: a review of the effects of air pollution on dialysis outcomes

PURPOSE OF REVIEW

An evolving body of literature indicates exposure to air pollutants is associated with adverse health outcomes in dialysis patients. As the prevalence of kidney disease increases, understanding the role of environmental agents on the health of dialysis patients is critical to reducing global morbidity and mortality.

RECENT FINDINGS

We identified 16 publications that investigated associations between pollutants including particulate matter (PM 2.5 and PM 10 ), carbon monoxide (CO), nitrogen dioxide (NO 2 ), sulfur dioxide (SO 2 ), and ozone (O 3 ) and health outcomes among dialysis patients. Eight studies examined the effects of particulate matter (PM) and four studies examined the effects CO exposure on dialysis patients. Exposure to PM was consistently associated with outcomes including all-cause mortality and a smaller body of literature suggested relationships with subclinical outcomes. Exposure to CO was associated with all-cause mortality, generalized inflammation, and uremic pruritus. An additional four studies examined multiple pollutant exposures including NO 2 , SO 2 , and O 3 and reported associations with all-cause mortality in dialysis patients.

SUMMARY

This review emphasized the nascent literature that demonstrates consistent relationships between air pollutant exposure and adverse outcomes among dialysis patients. Further research is needed to assess the impact of air pollutants, including how co-exposures will impact dialysis patient health.

Assessing knowledge of end-stage kidney disease and treatment options in hospitalized African American patients undergoing hemodialysis

OBJECTIVE

African Americans are more likely to develop end-stage kidney disease (ESKD) than whites and face multiple inequities regarding ESKD treatment, renal replacement therapy (RRT), and overall care. This study focused on determining gaps in participants' knowledge of their chronic kidney disease and barriers to RRT selection in an effort to identify how we can improve health care interventions and health outcomes among this population.

METHODS

African American participants undergoing hemodialysis were recruited from an ongoing research study of hospitalized patients at an urban Midwest academic medical center. Thirty-three patients were interviewed, and the transcribed interviews were entered into a software program. The qualitative data were coded using template analysis to analyze text and determine key themes. Medical records were used to obtain demographic and additional medical information.

RESULTS

Three major themes emerged from the analysis: patients have limited information on ESKD causes and treatments, patients did not feel they played an active role in selecting their initial dialysis unit, and interpersonal interactions with the dialysis staff play a large role in overall unit satisfaction.

DISCUSSION

Although more research is needed, this study provides information and suggestions to improve future interventions and care quality, specifically for this population.

Role of Age and Competing Risk of Death in the Racial Disparity of Kidney Failure Incidence after Onset of CKD

SIGNIFICANCE STATEMENT

Black adults in the United States have 2-4 times higher incidence of kidney failure than White adults. Yet, the reasons underlying this disparity remain poorly understood. Among 547,188 US veterans with new-onset CKD, according to a new race-free GFR equation, Black veterans had a 2.5-fold higher cumulative incidence of kidney failure, compared with White veterans, in any follow-up period from CKD onset. This disparity resulted from a combination of higher hazards of progression to kidney failure and lower hazards of competing-risk death in Black veterans. Both, in turn, were largely explained by the younger age at CKD onset in Black veterans, underscoring an urgent need to prevent early onset and slow progression of CKD in younger Black adults.

BACKGROUND

The Black adult population is well known to have higher incidence of kidney failure than their White counterpart in the United States, but the reasons underlying this disparity are unclear. We assessed the racial differences in kidney failure and death from onset of CKD on the basis of the race-free 2021 CKD Epidemiology Collaboration equation and examined the extent to which these differences could be explained by factors at the time of CKD onset.

METHODS

We analyzed a national cohort consisting of 547,188 US veterans (103,821 non-Hispanic Black and 443,367 non-Hispanic White), aged 18-85 years, with new-onset CKD between 2005 and 2016 who were followed through 10 years or May 2018 for incident kidney failure with replacement therapy (KFRT) and pre-KFRT death.

RESULTS

At CKD onset, Black veterans were, on average, 7.8 years younger than White veterans. In any time period from CKD onset, the cumulative incidence of KFRT was 2.5-fold higher for Black versus White veterans. Meanwhile, Black veterans had persistently >2-fold higher hazards of KFRT throughout follow-up (overall hazard ratio [95% confidence interval], 2.38 [2.31 to 2.45]) and conversely had 17%-48% decreased hazards of pre-KFRT death. These differences were reduced after accounting for the racial difference in age at CKD onset.

CONCLUSIONS

The 2.5-fold higher cumulative incidence of kidney failure in Black adults resulted from a combination of higher hazards of progression to kidney failure and lower hazards of the competing risk of death, both of which can be largely explained by the younger age at CKD onset in Black compared with White adults.

Exploring Patient Needs and Preferences in CKD Education: A Cross-Sectional Survey Study

Key Points

This largest to date patient survey study explores what patients with kidney disease want to know about treatments, such as dialysis or conservative management. A surprising number of patients want extensive doctor-like education, but are willing to spend only several hours on education. Patients are notably open to online and digital educational modalities—technology may allow for individualized and ongoing patient education.

Background

Despite efforts to educate individuals with CKD and thereby improve outcomes, studies have shown that a significant number of patients still report poor CKD knowledge. Thus, understanding patient needs and preferences is crucial for the development and implementation of an effective CKD educational program.

Methods

A paper survey was distributed to patients with CKD 21 years and older at a tertiary care hospital's outpatient nephrology clinic in Rochester, NY. Data on patient demographics; print and technological literacies; and preferences regarding topics, instructors, class formats, session frequency, duration, and peer support were gathered.

Results

The mean age of 337 patients was 65 years (±12.33 years), and the self-identified races were American Indian or Alaska Native (<1%), Asian (3%), Black (12.17%), Native Hawaiian or other Pacific Islander (<1%), White (83%), and Other (2%). Most of the patients (69%) never needed help with health instructions, and 68% of patients used a smartphone or computer every day. Key topics identified by patients included the definitions of CKD, creatinine, and GFR and information on kidney diet. Seventy-three percent of patients desired more than basic CKD information, with one in five even wanting to know everything a doctor knows. Forty-six percent were willing to attend classes, and 33% preferred using digital (video, computer, or smartphone) modalities. Patients were willing to attend an average of 3.6 classes, and most preferred hour-long classes. Most of the patients (46%) preferred a doctor as the educator, and 53% expressed interest in connecting with fellow patients for peer support.

Conclusions

Most patients with CKD are interested in comprehensive education about their disease. This research may offer insights into the optimal content and delivery of CKD educational programs by elaborating on patients' needs and the integration of online modalities to deliver content. Future person-centered educational programs for people with CKD are needed.

COVSIM: A stochastic agent-based COVID-19 SIMulation model for North Carolina

We document the evolution and use of the stochastic agent-based COVID-19 simulation model (COVSIM) to study the impact of population behaviors and public health policy on disease spread within age, race/ethnicity, and urbanicity subpopulations in North Carolina. We detail the methodologies used to model the complexities of COVID-19, including multiple agent attributes (i.e., age, race/ethnicity, high-risk medical status), census tract-level interaction network, disease state network, agent behavior (i.e., masking, pharmaceutical intervention (PI) uptake, quarantine, mobility), and variants. We describe its uses outside of the COVID-19 Scenario Modeling Hub (CSMH), which has focused on the interplay of nonpharmaceutical and pharmaceutical interventions, equitability of vaccine distribution, and supporting local county decision-makers in North Carolina. This work has led to multiple publications and meetings with a variety of local stakeholders. When COVSIM joined the CSMH in January 2022, we found it was a sustainable way to support new COVID-19 challenges and allowed the group to focus on broader scientific questions. The CSMH has informed adaptions to our modeling approach, including redesigning our high-performance computing implementation.

Enhancing Quality of Life in African American Patients with Chronic Kidney Disease: An Evidence-Based Intervention

This study aimed to assess the effectiveness of achronic kidney disease (CKD) peer coach's educational intervention on the quality of life of African-American individuals with CKD. This study employed an experimental research design to assess a peer coaching educational intervention for African-American individuals with CKD. The theoretical underpinning was grounded in social learning theory, emphasizing observational learning, imitation, and modeling. 165 patients were randomly assigned to either the intervention group (n = 81) or the control group (n = 84). Pre- and post-intervention analyses showed no significant differences in most health measures between the two groups. However, the intervention group demonstrated significant improvement in the energy/fatigue subscale, witha16-point difference supporting the intervention group (p = .003). Additionally, the intervention group showed increased scores in the pain subscale (p = .015), while the control group did not. The CKD educational intervention highlighted cultural considerations and provided cost-effective strategies for social workers. It emphasizes the importance of targeted educational interventions and calls for further research and interventions to address the comprehensive needs of CKD patients and improve their quality of life.

Progress made toward equitable transplantation in children and young adults with kidney disease

Racial disparities in pediatric kidney transplantation have been well described over the last two decades and include disparities in preemptive transplantation, waitlisting, time from activation to transplantation, living donation, and graft outcomes. Changes to the organ allocation system including the institution of Share 35 in 2005 and the Kidney Allocation System (KAS) of 2014 have resulted in resolution of some, but not all racial-ethnic disparities. Despite overall improvements in time from waitlist activation to transplant, disparities remain in preemptive transplantation, time to waitlisting, and living donor transplantation. Although improving under the KAS, racial disparities remain in graft survival as well. Racial disparity in kidney transplant access and graft survival is an international problem within pediatric nephrology. Although the racial group affected may differ, various minoritized pediatric groups across the world are affected by transplant disparities. Social determinants of health including financial access, language barriers, and the presence of a healthy living donor play a role in mediating these disparities. Further investigation is needed to better understand and intervene upon modifiable social, biological, and cultural factors driving the remaining disparity in transplant outcomes.

Relative predictive value of sociodemographic factors for chronic diseases among All of Us participants: a descriptive analysis

BACKGROUND

Although sociodemographic characteristics are associated with health disparities, the relative predictive value of different social and demographic factors remains largely unknown. This study aimed to describe the sociodemographic characteristics of All of Us participants and evaluate the predictive value of each factor for chronic diseases associated with high morbidity and mortality.

METHODS

We performed a cross-sectional analysis using de-identified survey data from the All of Us Research Program, which has collected social, demographic, and health information from adults living in the United States since May 2018. Sociodemographic data included self-reported age, sex, gender, sexual orientation, race/ethnicity, income, education, health insurance, primary care provider (PCP) status, and health literacy scores. We analyzed the self-reported prevalence of hypertension, coronary artery disease, any cancer, skin cancer, lung disease, diabetes, obesity, and chronic kidney disease. Finally, we assessed the relative importance of each sociodemographic factor for predicting each chronic disease using the adequacy index for each predictor from logistic regression.

RESULTS

Among the 372,050 participants in this analysis, the median age was 53 years, 59.8% reported female sex, and the most common racial/ethnic categories were White (54.0%), Black (19.9%), and Hispanic/Latino (16.7%). Participants who identified as Asian, Middle Eastern/North African, and White were the most likely to report annual incomes greater than $200,000, advanced degrees, and employer or union insurance, while participants who identified as Black, Hispanic, and Native Hawaiian/Pacific Islander were the most likely to report annual incomes less than $10,000, less than a high school education, and Medicaid insurance. We found that age was most predictive of hypertension, coronary artery disease, any cancer, skin cancer, diabetes, obesity, and chronic kidney disease. Insurance type was most predictive of lung disease. Notably, no two health conditions had the same order of importance for sociodemographic factors.

CONCLUSIONS

Age was the best predictor for the assessed chronic diseases, but the relative predictive value of income, education, health insurance, PCP status, race/ethnicity, and sexual orientation was highly variable across health conditions. Identifying the sociodemographic groups with the largest disparities in a specific disease can guide future interventions to promote health equity.

Factors Associated With Non-vaccination for Influenza Among Patients With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

RATIONALE & OBJECTIVE

Vaccination for influenza is strongly recommended for people with chronic kidney disease (CKD) due to their immunocompromised state. Identifying risk factors for not receiving an influenza vaccine (non-vaccination) could inform strategies for improving vaccine uptake in this high-risk population.

STUDY DESIGN

Longitudinal observational study.

SETTING & PARTICIPANTS

3,692 Chronic Renal Insufficiency Cohort Study (CRIC) participants.

EXPOSURE

Demographic factors, social determinants of health, clinical conditions, and health behaviors.

OUTCOME

Influenza non-vaccination, which was assessed based on a receipt of influenza vaccine ascertained during annual clinic visits in a subset of participants who were under nephrology care.

ANALYTICAL APPROACH

Mixed-effects Poisson models to estimate adjusted prevalence ratios (APRs).

RESULTS

Between 2009 and 2020, the pooled mean vaccine uptake was 72% (mean age, 66 years; 44% female; 44% Black race). In multivariable models, factors significantly associated with influenza non-vaccination were younger age (APR, 2.16 [95% CI, 1.85-2.52] for<50 vs≥75 years), Black race (APR, 1.58 [95% CI, 1.43-1.75] vs White race), lower education (APR, 1.20 [95% CI, 1.04-1.39 for less than high school vs college graduate]), lower annual household income (APR, 1.26 [95% CI, 1.06-1.49] for <$20,000 vs >$100,000), formerly married status (APR, 1.22 [95% CI, 1.09-1.35] vs currently married), and nonemployed status (APR, 1.13 [95% CI, 1.02-1.24] vs employed). In contrast, participants with diabetes (APR, 0.80 [95% CI, 0.73-0.87] vs no diabetes), chronic obstructive pulmonary disease (COPD) (APR, 0.80 [95% CI, 0.70-0.92] vs no COPD), end-stage kidney disease (APR, 0.64 [0.56 to 0.76] vs estimated glomerular filtration rate≥60mL/min/1.73m2), frailty (APR, 0.86 [95% CI, 0.74-0.99] vs no frailty), and ideal physical activity (APR, 0.90 [95% CI, 0.82-0.99] vs. physically inactive) were less likely to have non-vaccination status.

LIMITATIONS

Possible residual confounding.

CONCLUSIONS

Among adults with CKD receiving nephrology care, younger adults, Black individuals, and those with adverse social determinants of health were more likely to have the influenza non-vaccination status. Strategies are needed to address these disparities and reduce barriers to vaccination.

PLAIN-LANGUAGE SUMMARY

Identifying risk factors for not receiving an influenza vaccine ("non-vaccination") in people living with kidney disease, who are at risk of influenza and its complications, could inform strategies for improving vaccine uptake. In this study, we examined whether demographic factors, social determinants of health, and clinical conditions were linked to the status of not receiving an influenza vaccine among people living with kidney disease and receiving nephrology care. We found that younger adults, Black individuals, and those with adverse social determinants of health were more likely to not receive the influenza vaccine. These findings suggest the need for strategies to address these disparities and reduce barriers to vaccination in people living with kidney disease.

The Awareness, Prevalence, and Risk Factors of Chronic Kidney Disease Among Diabetes Mellitus and Hypertensive Patients in the Aseer Region, Saudi Arabia

Background and objective Given its ever-increasing burden, chronic kidney disease (CKD) represents a significant public health threat. CKD is characterized by a gradual alteration in the kidney's normal glomerular filtration rate, which results in the progressive loss of kidney function over a period of time ranging from a few months to years. Diabetes mellitus (DM) and hypertension (HTN) are well-known risk factors for developing CKD and end-stage renal failure. In light of this, this study aimed to assess the awareness, prevalence, and risk factors of CKD in patients with diabetes and those with HTN in the Aseer region, the Kingdom of Saudi Arabia. Methods A correlational cross-sectional study was conducted among a sample of people across Saudi Arabia. The data collection was conducted via an online questionnaire circulated on social media platforms. The study questionnaire included socioeconomic and demographic information and medical history of DM, HTN, and CKD. Also, patients' awareness of and attitude towards CKD were assessed. Results A total of 301 diabetic or hypertensive patients fulfilling the inclusion criteria completed the study questionnaire. Of them, 174 (57.8%) were aged less than 55 years, while 127 (42.2%) were aged more than 55 years; 200 (66.4%) patients were males. A total of 94 (31.2%) study patients were diabetic, 64 (21.3%) were hypertensive, and 143 (47.5%) were both diabetic and hypertensive; 226 (75.1%) study patients had an overall good awareness of CKD while only 75 (24.9%) showed a poor awareness level. Higher awareness was associated with patients' age, education, and having CKD, DM, or HTN (p<0.05). Conclusion Our findings revealed that CKD was not common among study patients, and its prevalence was found to be less than estimated based on many studies in the literature. Also, diabetic and hypertensive patients showed a higher than satisfactory level of awareness of CKD, especially young patients with high levels of education.

Incidence and predictors of chronic kidney disease among patients with diabetes treated at governmental hospitals of Harari Region, eastern Ethiopia, 2022

Background

Chronic kidney disease (CKD) is the leading cause of morbidity and mortality in diabetic patients. However, limited evidence is available about its incidence and predictors in Ethiopia, specifically in the Harari region.

Methods

A retrospective follow-up study was conducted among 520 diabetes patients who followed their treatment at governmental hospitals in the Harari region between 1 September 2012, and 30 May 2022. The risk of developing CKD was calculated with a 95% CI, and the risk was stratified by type of diabetes mellitus. Predictors of CKD were determined using the Gompertz regression model with the baseline Cox model.

Results

Data from 494 patients were included in the final analysis with 26 (5%) excluded. A total of 51 patients (10.32%) developed CKD over the 10-year follow-up period with an incidence rate of 2.16 cases (95% CI 1.64-2.84) per 100 person-years of observation. The risk of CKD was increased by three times (AHR: 3.09, 45 95% CI: 1.56, 6.14) among patients older than 60 years and by more than three times (AHR: 3.53, 95% CI: 1.43, 8.71) among patients with diabetes mellitus for longer than 5 years of stay with the diabetes mellitus. Moreover, the risk of CKD was increased four-fold among patients with high-density lipoprotein cholesterol (HDL-C) levels <40 mg/dL (AHR: 3.84, 95% CI, 1.80-8.18) and those with positive baseline proteinuria (AHR: 3.77, 95% CI: 1.43-8.71).

Conclusion

We found that one in ten diabetic patients had developed CKD within 10 years of the diabetes mellitus diagnosis. Advanced age, longer duration of diabetes, lower baseline HDL-C level, and proteinuria had increased the hazards of developing CKD. We recommend a more focused follow-up of older adult patients with advanced disease status at baseline for optimal control of diabetes mellitus that prevents its furthering to CKD.

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.

Knowledge About Renal Transplantation Among African, Caribbean, and Black Canadian Patients With Advanced Kidney Failure

Introduction

Variable transplant-related knowledge may contribute to inequitable access to living donor kidney transplant (LDKT). We compared transplant-related knowledge between African, Caribbean, and Black (ACB) versus White Canadian patients with kidney failure using the Knowledge Assessment of Renal Transplantation (KART) questionnaire.

Methods

This was a cross-sectional cohort study. Data were collected from a cross-sectional convenience sample of adults with kidney failure in Toronto. Participants also answered an exploratory question about their distrust in the kidney allocation system. Clinical characteristics were abstracted from medical records. The potential contribution of distrust to differences in transplant knowledge was assessed in mediation analysis.

Results

Among 577 participants (mean [SD] age 57 [14] years, 63% male), 25% were ACB, and 43% were White Canadians. 45% of ACB versus 26% of White participants scored in the lowest tertile of the KART score. The relative risk ratio to be in the lowest tertile for ACB compared to White participants was 2.22 (95% confidence interval [CI]: 1.11, 4.43) after multivariable adjustment. About half of the difference in the knowledge score between ACB versus White patients was mediated by distrust in the kidney allocation system.

Conclusion

Participants with kidney failure from ACB communities have less transplant-related knowledge compared to White participants. Distrust is potentially contributing to this difference.

Community-Engaged Research (CEnR) to Address Gaps in Chronic Kidney Disease Education among Underserved Latines-The CARE Study

Ensuring equitable chronic kidney disease (CKD) education for Latine patients with low health literacy and low English proficiency stands as a critical challenge, and the "Caridad Awareness and Education" (CARE) initiative represents our ongoing effort to address this imperative issue. In collaboration with twenty-three patients living with CKD, diabetes and/or hypertension and twelve trained Community Health Workers (CHWs) from diverse Latine subgroups, we conducted a research initiative funded by the National Kidney Foundation. Our primary objective was to co-design and test culturally tailored patient education materials (PEMs) for underserved Latine adults at risk for or diagnosed with CKD. We effectively integrated Community-Engaged Research (CEnR) principles with a Human-Centered Design (HCD) approach to create a range of CKD-PEM prototypes in Spanish. Patient preferences for printed educational materials were clear. They favored printed materials that incorporated visual content with concise text over digital, email, texts, or online resources and personalized phone outreach and the involvement of CHWs. Additionally, patients identified their unwavering commitment to their families as a forceful motivator for caring for their kidney health. Currently, a culturally and linguistically tailored CKD flipchart for one-on-one education, led by CHWs, is undergoing a pilot testing phase involving a sample of one hundred Latine patients at risk for or diagnosed with CKD. This innovative approach signifies a commitment to amplifying the insights and expertise of the Latine community afflicted by kidney health disparities, effectively embracing a CEnR to forge meaningful and impactful CKD-PEMs.

Inequities in kidney health and kidney care

Health inequity refers to the existence of unnecessary and unfair differences in the ability of an individual or community to achieve optimal health and access appropriate care. Kidney diseases, including acute kidney injury and chronic kidney disease, are the epitome of health inequity. Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of disease. Insufficient investment across the spectrum of kidney health and kidney care is a fundamental source of inequity. In addition, social and structural inequities, including inequities in access to primary health care, education and preventative strategies, are major risk factors for, and contribute to, poorer outcomes for individuals living with kidney diseases. Access to affordable kidney care is also highly inequitable, resulting in financial hardship and catastrophic health expenditure for the most vulnerable. Solutions to these injustices require leadership and political will. The nephrology community has an important role in advocacy and in identifying and implementing solutions to dismantle inequities that affect kidney health.

Structural and Psychosocial Challenges Among Underserved Patients Receiving Hemodialysis During and Beyond the COVID-19 Pandemic: A Qualitative Study

Rationale & Objective

Racial and ethnic minority groups in the United States are disproportionately affected by chronic kidney disease and progressive kidney failure and face significantly more socioeconomic and psychosocial challenges. However, how such patients' social environment and stigmatization shape their illness experiences and abilities to cope before and during the coronavirus disease 2019 (COVID-19) pandemic has not been well documented, even as social scientific research predicts these groups' exponential vulnerability.

Study Design

Qualitative study using semistructured interviews to elicit individual patient narratives about their personal illness experiences before and during the COVID-19 pandemic, any challenges they faced, and their sources of support.

Setting & Participants

Using purposive sampling, we recruited 20 adult patients receiving maintenance hemodialysis from centers affiliated with a safety-net hospital in Boston, Massachusetts.

Analytical Approach

Interviews were audiotaped, transcribed, and analyzed using thematic content analysis to identify patients' challenges and supports before and during the pandemic.

Results

Of the 20 patients in the study, 9 were women, and 18 self-identified as Black or African American. Three main themes emerged, whereby most patients described: (1) stigma and stigmatization as a central element of their life experience; (2) the pandemic as a difficult experience but not a complete rupture from their prepandemic life; and (3) social networks, particularly family, friends, and religious communities, as sources of support crucial to coping with their debilitating illness.

Limitations

Whether the findings apply to other settings is unknown, as participants were recruited from centers in a single safety-net urban hospital setting.

Conclusions

Psychosocial and environmental factors, including institutional racism and stigmatization, play significant roles in amplifying the burdens shouldered by racial and ethnic minority individuals with kidney disease who now also face the COVID-19 pandemic that has since turned endemic. The results of this study can inform the development of policy interventions aimed at alleviating tensions and structural conditions that impinge on kidney disease patients' wellbeing and health outcomes.

Plain-Language Summary

Members of racial and ethnic minority groups in the United States experience the highest rates of progressive kidney failure and face significantly more socioeconomic and psychosocial challenges. We interviewed 20 patients who receive maintenance hemodialysis treatment from centers affiliated with a safety-net hospital. Patients described stigmatization as a central element of their life experience and the pandemic as a difficult challenge (but not a complete rupture) that added to their struggles with illness-related, race-related, and class-related stigmas. Social networks, particularly family, friends, and religious communities, are key sources of support crucial to coping with illness. Findings from this study can inform health care providers and community workers and guide the development of policy interventions to provide better support for these patients.

Factors associated with chronic kidney disease in patients with diabetes in French Guiana

Introduction

With over half of the population living under the poverty threshold, the social and health context in French Guiana is more difficult than in mainland France. The prevalence of diabetes is twice as great and end-stage renal failure is 45% higher than in mainland France.

Objective

Our objective was to describe the profile of diabetic patients with chronic kidney disease in French Guiana and search for possible risk factors.

Method

We conducted a multicenter cross-sectional observational study based on the CODIAM cohort (Cohort of Diabetes in French Amazonia). We analyzed 1,287 patients followed up between May 2019 and June 2021 at Cayenne Hospital, Saint Laurent Hospital, and delocalized health centers.

Results

In our cohort, chronic kidney disease was present after an average of 12 years of diabetes. Compared with the French population, 41% of diabetic patients had chronic kidney disease (i.e., 12% more), and had an average age of 56 years (i.e., 10 years younger). Forty-eight per cent of these patients were obese (i.e., 7% more). Seventy-four per cent of patients were precarious and 45% were foreigners but neither was associated with chronic kidney disease, contrary to countries where the health system is not universal.

Conclusion

Screening of patients with chronic kidney disease among diabetics in French Guiana remains a real challenge. Patients were younger and more obese than in other French territories. In this cohort, precariousness and immigration were not associated with the presence of chronic kidney disease. However, particular attention should be paid to hypertensive patients and those over 65 years of age, which are, with diabetes itself, the two most obvious risk factors for developing chronic kidney disease among diabetic patients in our territory.

POINT: Pipeline for Offline Conversion and Integration of Geocodes and Neighborhood Data

OBJECTIVES

Geocoding, the process of converting addresses into precise geographic coordinates, allows researchers and health systems to obtain neighborhood-level estimates of social determinants of health. This information supports opportunities to personalize care and interventions for individual patients based on the environments where they live. We developed an integrated offline geocoding pipeline to streamline the process of obtaining address-based variables, which can be integrated into existing data processing pipelines.

METHODS

POINT is a web-based, containerized, application for geocoding addresses that can be deployed offline and made available to multiple users across an organization. Our application supports use through both a graphical user interface and application programming interface to query geographic variables, by census tract, without exposing sensitive patient data. We evaluated our application's performance using two datasets: one consisting of 1 million nationally representative addresses sampled from Open Addresses, and the other consisting of 3,096 previously geocoded patient addresses.

RESULTS

A total of 99.4 and 99.8% of addresses in the Open Addresses and patient addresses datasets, respectively, were geocoded successfully. Census tract assignment was concordant with reference in greater than 90% of addresses for both datasets. Among successful geocodes, median (interquartile range) distances from reference coordinates were 52.5 (26.5-119.4) and 14.5 (10.9-24.6) m for the two datasets.

CONCLUSION

POINT successfully geocodes more addresses and yields similar accuracy to existing solutions, including the U.S. Census Bureau's official geocoder. Addresses are considered protected health information and cannot be shared with common online geocoding services. POINT is an offline solution that enables scalability to multiple users and integrates downstream mapping to neighborhood-level variables with a pipeline that allows users to incorporate additional datasets as they become available. As health systems and researchers continue to explore and improve health equity, it is essential to quickly and accurately obtain neighborhood variables in a Health Insurance Portability and Accountability Act (HIPAA)-compliant way.

The impact of neighborhood social disadvantage on presentation and management of first-time hemodialysis access surgery patients

OBJECTIVES

The impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) arteriovenous (AV) access creation have not been well-characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members living within a community. Our goal was to examine the effect of ADI on health outcomes for first-time AV access patients.

METHODS

We identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between July 2011 to May 2022. Patient zip codes were correlated with an ADI quintile, defined as quintile 1 (Q1) to quintile 5 (Q5) from least to most disadvantaged. Patients without ADI were excluded. Preoperative, perioperative, and postoperative outcomes considering ADI were analyzed.

RESULTS

There were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 34% were of Black race, 10% were of Hispanic ethnicity, and 85% received autogenous AV access. Patient distribution by ADI quintile was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with lower rates of autogenous AV access creation (OR, 0.82; 95% confidence interval [CI], 0.74-0.90; P < .001), preoperative vein mapping (OR, 0.57; 95% CI, 0.45-0.71; P < .001), access maturation (OR, 0.82; 95% CI, 0.71-0.95; P = .007), and 1-year survival (OR, 0.81; 95% CI, 0.71-0.91; P = .001) compared with Q1. Q5 was associated with higher 1-year intervention rates than Q1 on univariable analysis, but not on multivariable analysis.

CONCLUSIONS

The patients undergoing AV access creation who were most socially disadvantaged (Q5) were more likely to experience lower rates of autogenous access creation, obtaining vein mapping, access maturation, and 1-year survival compared with the most socially advantaged (Q1). Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population.

The impact of mobile health applications on the outcomes of patients with chronic kidney disease: a systematic review and meta-analysis

Chronic kidney disease is one of the main causes of mortality worldwide. It affects more than 800 million patients globally, accounting for approximately 10% of the general population. The significant burden of the disease prompts healthcare systems to implement adequate preventive and therapeutic measures. This systematic review and meta-analysis aimed to provide a concise summary of the findings published in the existing body of research about the influence that mobile health technology has on the outcomes of patients with the disease. A comprehensive systematic literature review was conducted from inception until March 1st, 2023. This systematic review and meta-analysis included all clinical trials that compared the efficacy of mobile app-based educational programs to that of more conventional educational treatment for the patients. Eleven papers were included in the current analysis, representing 759 CKD patients. 381 patients were randomly assigned to use the mobile apps, while 378 individuals were assigned to the control group. The mean systolic blood pressure was considerably lower in the mobile app group (MD -4.86; 95%-9.60, -0.13; p=0.04). Meanwhile, the mean level of satisfaction among patients who used the mobile app was considerably greater (MD 0.75; 95% CI 0.03, 1.46; p=0.04). Additionally, the mean self-management scores in the mobile app groups were significantly higher (SMD 0.534; 95% CI 0.201, 0.867; p=0.002). Mobile health applications are potentially valuable interventions for patients. This technology improved the self-management of the disease, reducing the mean levels of systolic blood pressure with a high degree of patient satisfaction.

Retaining Race in Chronic Kidney Disease Diagnosis and Treatment

The best overall measure of kidney function is glomerular filtration rate (GFR) as commonly estimated from serum creatinine concentrations (eGFRcr) using formulas that correct for the higher average creatinine concentrations in Blacks. After two decades of use, these formulas have come under scrutiny for estimating GFR differently in Blacks and non-Blacks. Discussions of whether to include race (Black vs. non-Black) in the calculation of eGFRcr fail to acknowledge that the original race-based eGFRcr provided the same CKD treatment recommendations for Blacks and non-Blacks based on directly (exogenously) measured GFR. Nevertheless, the National Kidney Foundation and the American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease removed race in CKD treatment guidelines and pushed for the immediate adoption of a race-free eGFRcr formula by physicians and clinical laboratories. This formula is projected to negate CKD in 5.51 million White and other non-Black adults and reclassify CKD to less severe stages in another 4.59 million non-Blacks, in order to expand treatment eligibility to 434,000 Blacks not previously diagnosed and to 584,000 Blacks previously diagnosed with less severe CKD. This review examines: 1) the validity of the arguments for removing the original race correction, and 2) the performance of the proposed replacement formula. Excluding race in the derivation of eGFRcr changed the statistical bias from +3.7 to -3.6 ml/min/1.73m2 in Blacks and from +0.5 to +3.9 in non-Blacks, i.e., promoting CKD diagnosis in Blacks at the cost of restricting diagnosis in non-Blacks. By doing so, the revised eGFRcr greatly exaggerates the purported racial disparity in CKD burden. Claims that the revised formulas identify heretofore undiagnosed CKD in Blacks are not supported when studies that used kidney failure replacement therapy and mortality are interpreted as proxies for baseline CKD. Alternatively, a race-stratified eGFRcr (i.e., separate equations for Blacks and non-Blacks) would provide the least biased eGFRcr for both Blacks and non-Blacks and the best medical treatment for all patients.

Age-Based Versus Young-Adult Thresholds for Nephrosclerosis on Kidney Biopsy and Prognostic Implications for CKD

SIGNIFICANCE STATEMENT

Nephrosclerosis (glomerulosclerosis, interstitial fibrosis, and tubular atrophy) is the defining pathology of both kidney aging and CKD. Optimal thresholds for nephrosclerosis that identify persons with a progressive disease are unknown. This study determined a young-age threshold (18-29 years) and age-based 95th percentile thresholds for nephrosclerosis on the basis of morphometry of kidney biopsy sections from normotensive living kidney donors. These thresholds were 7.1-fold to 36-fold higher in older (70 years or older) versus younger (aged 18-29 years) normotensive donors. Age-based thresholds, but not young-age threshold, were prognostic for determining risk of progressive CKD among patients who underwent a radical nephrectomy or a for-cause native kidney biopsy, suggesting that age-based thresholds are more useful than a single young-age threshold for identifying CKD on biopsy.

BACKGROUND

Nephrosclerosis, defined by globally sclerotic glomeruli (GSG) and interstitial fibrosis and tubular atrophy (IFTA), is a pathology of both kidney aging and CKD. A comparison of risk of progressive CKD using aged-based thresholds for nephrosclerosis versus a single young-adult threshold is needed.

METHODS

We conducted morphometric analyses of kidney biopsy images for %GSG, %IFTA, and IFTA foci density among 3020 living kidney donors, 1363 patients with kidney tumor, and 314 patients with native kidney disease. Using normotensive donors, we defined young-age thresholds (18-29 years) and age-based (roughly by decade) 95th percentile thresholds. We compared age-adjusted risk of progressive CKD (kidney failure or 40% decline in eGFR) between nephrosclerosis that was "normal compared with young," "normal for age but abnormal compared with young," and "abnormal for age" in patients with tumor and patients with kidney disease.

RESULTS

The 95th percentiles in the youngest group (18-29 years) to the oldest group (70 years or older) ranged from 1.7% to 16% for %GSG, 0.18% to 6.5% for %IFTA, and 8.2 to 59.3 per cm 2 for IFTA foci density. Risk of progressive CKD did not differ between persons with nephrosclerosis "normal compared with young" versus "normal for age but abnormal compared with young." Risk of progressive CKD was significantly higher with %GSG, %IFTA, or IFTA foci density that was abnormal versus normal for age in both cohorts.

CONCLUSIONS

Given that increased risk of progressive CKD occurs only when nephrosclerosis is abnormal for age, age-based thresholds for nephrosclerosis seem to be better than a single young-age threshold for identifying clinically relevant CKD.

Racial Differences and Contributory Cardiovascular and Non-Cardiovascular Risk Factors Towards Chronic Kidney Disease Progression

Background

The prevalence of advanced chronic kidney disease (CKD) is higher in Black than in White Americans. We evaluated CKD progression in Black and White participants and the contribution of biological risk factors. We included the study of lung function (measured by forced vital capacity [FVC]), which is part of the emerging notion of interorgan cross-talk with the kidneys to racial differences in CKD progression.

Methods

This longitudinal study included 2175 Black and 2207 White adult Coronary Artery Risk Development in Young Adults (CARDIA) participants. Estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) were measured at study year 10 (age 27-41y) and every five years for 20 years. The outcome was CKD progression through no CKD, low, moderate, high, or very high-risk categories based on eGFR and UACR in combination. The association between race and CKD progression as well as the contribution of risk factors to racial differences were assessed in multivariable-adjusted Cox models.

Results

Black participants had higher CKD transition probabilities than White participants and more prevalent risk factors during the 20-year period studied. Hazard ratios for CKD transition for Black (vs White participants) were 1.38 from No CKD into ≥ low risk, 2.25 from ≤ low risk into ≥ moderate risk, and 4.49 from ≤ moderate risk into ≥ high risk. Racial differences in CKD progression from No CKD into ≥ low risk were primarily explained by FVC (54.8%), hypertension (30.9%), and obesity (20.8%). In contrast, racial differences were less explained in more severe transitions.

Conclusion

Black participants had a higher risk of CKD progression, and this discrepancy may be partly explained by FVC and conventional risk factors.

Diagnosis of Chronic Kidney Disease and Assessing Glomerular Filtration Rate

Chronic kidney disease (CKD) is a silent progressive disease. It is diagnosed by assessing filtration and markers of kidney damage such as albuminuria. The diagnosis of CKD should include not only assessing the glomerular filtration rate (GFR) and albuminuria but also the cause. The CKD care plan should include documentation of the trajectory and prognosis. The use of a combination of serum cystatin C and creatinine concentration offers a more accurate estimation of GFR. Social determinants of health are important to address as part of the diagnosis because they contribute to CKD disparities.

Social determinants of health and the transition from advanced chronic kidney disease to kidney failure

BACKGROUND

The transition from chronic kidney disease (CKD) to kidney failure is a vulnerable time for patients, with suboptimal transitions associated with increased morbidity and mortality. Whether social determinants of health are associated with suboptimal transitions is not well understood.

METHODS

This retrospective cohort study included 1070 patients with advanced CKD who were referred to the Ottawa Hospital Multi-Care Kidney Clinic and developed kidney failure (dialysis or kidney transplantation) between 2010 and 2021. Social determinant information, including education level, employment status and marital status, was collected under routine clinic protocol. Outcomes surrounding suboptimal transition included inpatient (versus outpatient) dialysis starts, pre-emptive (versus delayed) access creation and pre-emptive kidney transplantation. We examined the association between social determinants of health and suboptimal transition outcomes using multivariable logistic regression.

RESULTS

The mean age and estimated glomerular filtration rate were 63 years and 18 ml/min/1.73 m2, respectively. Not having a high school degree was associated with higher odds for an inpatient dialysis start compared with having a college degree {odds ratio [OR] 1.71 [95% confidence interval (CI) 1.09-2.69]}. Unemployment was associated with higher odds for an inpatient dialysis start [OR 1.85 (95% CI 1.18-2.92)], lower odds for pre-emptive access creation [OR 0.53 (95% CI 0.34-0.82)] and lower odds for pre-emptive kidney transplantation [OR 0.48 (95% CI 0.24-0.96)] compared with active employment. Being single was associated with higher odds for an inpatient dialysis start [OR 1.44 (95% CI 1.07-1.93)] and lower odds for pre-emptive access creation [OR 0.67 (95% CI 0.50-0.89)] compared with being married.

CONCLUSIONS

Social determinants of health, including education, employment and marital status, are associated with suboptimal transitions from CKD to kidney failure.

Racial and Ethnic Disparities and Prevalence in Prescription Drug Misuse, Illicit Drug Use, and Combination of Both Behaviors in the United States

This study examines racial and ethnic disparities and prevalence in prescription drug misuse, illicit drug use, and the combination of both behaviors in the United States. Using five waves of the National Survey on Drug Use and Health (NSDUH, 2015-2019; n = 276,884), a multinomial logistic regression model estimated the outcomes of prescription drug misuse, illicit drug use, and the combination of both behaviors. Participants' age was considered as an interaction effect. Approximately 5.4%, 2.9%, and 2.5% misused prescription drug, used illicit drug, or had both behaviors, respectively. Compared with White participants, Black (AOR = 0.69, 99.9 CI: 0.61, 0.79) and Asian (AOR = 0.60, 99.9% CI: 0.42, 0.87) participants had significantly lower odds of reporting prescription drug misuse. Individuals who were classified as others had higher odds of reporting illicit drug use (AOR = 1.31; 99.9% CI: 1.05, 1.64), compared with White participants. Black (AOR = 0.40, 99.9% CI: 0.29, 0.56) and Hispanic (AOR = 0.71, 99.9% CI: 0.55, 0.91) participants were significantly less likely to have both prescription drug misuse and illicit drug use behaviors. Interaction analysis showed that Black participants between 18 and 49 years old were less likely to participate in prescription drug misuse. However, Black participants who were 50 years of age or above were more likely to engage in illicit drug use and the combination of both prescription drug misuse and illicit drug use (all p < 0.001). Hispanic adult participants between 18 and 49 years old were more likely to engage in illicit drug use. Successful intervention and cessation programs may consider the cultural and age disparities among different racial and ethnic groups.

Flattening the Playing Field for Treatment of Diabetic Kidney Disease

Diabetic kidney disease (DKD) remains a major health care issue and is beset with significant racial and ethnic disparities in regard to its incidence, progression, and complication rate. An individual's health is influenced strongly by an array of societal-level factors commonly called the social determinants of health. Among these, DKD is influenced highly by structured resources and opportunities, as well as an individual's socioeconomic status, health insurance status, access to care, education, health literacy, nutrition, green space exposure, level of trust in the medical community, and more. Health equity is considered a state in which everyone has a fair and just opportunity to attain his or her highest level of health. Conversely, health inequities are a consequence of a structured discriminatory system of inequitable allocation of social determinants of health. When this discriminatory system is race-based it is referred to as structural racism, which eventually leads to racial and ethnic health disparities. The further downstream sequela of structural racism, consciously or unconsciously, impacts health systems, providers, and patients, and can lead to disparities in DKD development, progression, and complications. In this article, we explore potential interventions at the societal, health system, and provider levels that can help flatten the playing field and reduce racial and ethnic disparities in DKD.

Mitigating the health effects of systemic racism: Evaluation of the Race-Based Stress and Trauma Empowerment intervention

BACKGROUND

Disparities in physical and mental health among Black, Indigenous, and People of Color (BIPOC) are well-documented and mirrored in the Veteran population. Chronic stress due to racism and discrimination is one possible mechanism driving these negative health outcomes. The Race-Based Stress and Trauma Empowerment (RBSTE) group is a novel, manualized, health promotion intervention designed to address the direct and indirect impacts of racism among Veterans of Color. This paper describes the protocol of the first pilot randomized controlled trial (RCT) of RBSTE. This study will examine the feasibility, acceptability, and appropriateness of RBSTE compared to an active control (an adaptation of Present-Centered Therapy; PCT) in a Veterans Affairs (VA) healthcare setting. A secondary aim is to identify and optimize strategies for holistic evaluation.

METHODS

Veterans of Color (N = 48) endorsing perceived discrimination and stress will be randomized to RBSTE or PCT; both groups will be delivered in 8 weekly, 90-min virtual group sessions. Outcomes will include measures of psychological distress, discrimination and ethnoracial identity, holistic wellness, and allostatic load. Measures will be administered at baseline and post-intervention.

CONCLUSION

This study will inform future interventions targeting identity-based stressors and represents an important step in advancing equity for BIPOC in medicine and research.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05422638.

A "Rich People's Disease": Migrant Workers and Structural Disability in China

Drawing on fieldwork in southwest China, I examine how structural marginalization shapes therapeutic choices and healing experiences of chronic illness. I explore why Chinese rural migrant workers avoid chronic care in biomedicine to grapple with their chronic kidney disease. I show that migrant workers, who live precarious labor lives, experience chronic kidney disease as both a chronic, disabling experience and an acute crisis. I call for broader awareness of structural disability and argue that chronic disease care necessitates not only treating the disease but also the provision of equitable social security.

Conflict Nephrology: War and Natural Disasters

Access to care for patients with ESKD is frequently disrupted after natural disasters, public health crises, and human conflict. Emergency preparation can mitigate the risk of harm and improve outcomes. Before Hurricane Katrina in 2005, the United States was unprepared to assist patients facing disaster. We evaluate responses to Hurricane Katrina which caused unprecedented damage to health and property in the Gulf Coast. As a result of the multitude of identified problems with the national, local, and kidney-specific responses to Katrina, new systems were created that mitigated loss after Hurricane Sandy in 2012. The improved disaster response system was no match for the coronavirus disease 2019 pandemic; real-time changes worsened the effect on highly vulnerable populations, including patients with ESKD. Similarly, preparation can only mitigate the difficulties faced by patients with ESKD living in a war zone. Government agencies need to provide tools and dialysis centers need to educate patients. Beginning with steps implemented in the aftermath of Hurricane Katrina and augmented after Hurricane Sandy, every patient with ESKD and those who care for them must begin emergency preparations before the need arises. Recognizing that it is not possible to prepare for every possible emergency, our health care systems must be ready to adapt to our ever-changing world. After reviewing the responses to previous events, we suggest steps that should be considered to improve preparations for our uncertain future.

Racial/ethnic differences in social determinants of health and health outcomes among adolescents and youth ages 10-24 years old: a scoping review

INTRODUCTION

With the recent emergence of the Healthy People 2030 goals there is a need to understand the role of SDOH on health inequalities from an upstream perspective. This review summarizes the recent body of evidence on the impact of SDOH across adolescence and youth health outcomes by race/ethnicity using the Health People 2030 Framework.

METHODS

A systematic, reproducible search was performed using PubMed, Academic Search Premier, PsychInfo, and ERIC. A total of 2078 articles were screened for inclusion. A total of 263 articles met inclusion criteria, resulting in 29 articles included for final synthesis.

RESULTS

Across the 29 articles, 11 were cross-sectional, 16 were cohort, and 2 were experimental. Across SDOH categories (economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context), 1 study examined self-efficacy, 6 educational attainment, 10 behavior, 5 smoking, 11 alcohol use, 10 substance use, and 1 quality of life. The majority of outcomes represented in this search included health behaviors such as health risk behavior, smoking, alcohol use, and substance use. Across the 29 articles identified, significant differences existed across outcomes by race/ethnicity across SDOH factors, however magnitude of differences varied by SDOH category.

DISCUSSION

SDOH differentially affect adolescents and youth across race/ethnicity. The lived adverse experiences, along with structural racism, increase the likelihood of adolescents and youth engaging in risky health behaviors and negatively influencing health outcomes during adolescence and youth. Research, public health initiatives, and policies integrating SDOH into interventions at early stage of life are needed to effectively reduce social and health inequalities at a population level.

Racial and ethnic disparities in major adverse limb events persist for chronic limb threatening ischemia despite presenting limb threat severity after peripheral vascular intervention

OBJECTIVE

Racial and ethnic disparities have been well-documented in the outcomes for chronic limb threatening ischemia (CLTI). One purported explanation has been the disease severity at presentation. We hypothesized that the disparities in major adverse limb events (MALE) after peripheral vascular intervention (PVI) for CLTI would persist despite controlling for disease severity at presentation using the WIfI (Wound, Ischemia, foot Infection) stage.

METHODS

The Vascular Quality Initiative PVI dataset (2016-2021) was queried for CLTI. Patients were excluded if they were missing the WIfI stage. The primary end point was the incidence of 1-year MALE, defined as major amputation (through the tibia or fibula or more proximally) or reintervention (endovascular or surgical) of the initial treatment limb. A multivariate hierarchical Fine-Gray analysis was performed, controlling for hospital variation, competing risk of death, and presenting WIfI stage, to assess the independent association of Black/African American race and Latinx/Hispanic ethnicity with MALE. A Cox proportional hazard regression model was used for the 1-year survival analysis.

RESULTS

Overall, 47,830 patients (60%) had had WIfI scores reported (73% White, 20% Black, and 7% Latinx). The 1-year unadjusted cumulative incidence of MALE was 13.1% (95% confidence interval [CI], 12.6%-13.5%) for White, 14.3% (95% CI, 13.5%-15.3%) for Black, and 17.0% (95% CI, 15.3%-18.9%) for Latinx patients. On bivariate analysis, the occurrence of MALE was significantly associated with younger age, Black race, Latinx ethnicity, coronary artery disease, cerebrovascular disease, congestive heart failure, hypertension, diabetes, dialysis, intervention level, any prior minor or major amputation, and WIfI stage (P < .001). The cumulative incidence of 1-year MALE increased by increasing WIfI stage: stage 1, 11.7% (95% CI, 10.9%-12.4%); stage 2, 12.4% (95% CI, 11.8%-13.0%); stage 3, 14.8% (95% CI, 13.8%-15.8%); and stage 4, 15.4% (95% CI, 14.3%-16.6%). The cumulative incidence also increased by intervention level: inflow, 10.7% (95% CI, 9.8%-11.7%), femoropopliteal, 12.3% (95% CI, 11.7%-12.9%); and infrapopliteal, 14.1% (95% CI, 13.5%-14.8%). After adjustment for WIfI stage only, Black race (subdistribution hazard ratio [SHR], 1.30; 95% CI, 1.17-1.44; P < .001) and Latinx ethnicity (SHR, 1.58; 95% CI, 1.37-1.81; P < .001) were associated with an increased 1-year hazard of MALE compared with White race. On adjusted multivariable analysis, MALE disparities persisted for Black/African American race (SHR, 1.12; 95% CI, 1.01-1.25; P = .028) and Latinx/Hispanic ethnicity (SHR, 1.34; 95% CI, 1.16-1.54; P < .001) compared with White race.

CONCLUSIONS

Black/African American and Latinx/Hispanic patients had a higher associated hazard of MALE after PVI for CLTI compared with White patients despite an adjustment for WIfI stage at presentation. These results suggest that disease severity at presentation does not account for disparities in outcomes. Further work should focus on better understanding the underlying mechanisms for disparities in historically marginalized racial and ethnic groups presenting with CLTI.

Use of Race in Kidney Function Estimation: Lessons Learned and the Path Toward Health Justice

In 2020, the nephrology community formally interrogated long-standing race-based clinical algorithms used in the field, including the kidney function estimation equations. A comprehensive understanding of the history of kidney function estimation and racial essentialism is necessary to understand underpinnings of the incorporation of a Black race coefficient into prior equations. We provide a review of this history, as well as the considerations used to develop race-free equations that are a guidepost for a more equity-oriented, scientifically rigorous future for kidney function estimation and other clinical algorithms and processes in which race may be embedded as a variable.

Psychosocial Distress in Patients With Advanced CKD by Racial Group and Immigrant Status: A Canadian Cross-sectional Study

RATIONALE & OBJECTIVE

Patients with advanced chronic kidney disease (CKD) have been reported to experience profound psychosocial distress. Other work has established that patients with CKD from marginalized populations (including individuals who on the basis of race often face racism and related discrimination, termed "racialization") experience health care inequities. Given limited information on the intersection of these 2 phenomena, we assessed the association of psychosocial distress with racialized status and immigrant status in Canadians with advanced CKD.

STUDY DESIGN

Secondary analysis of cross-sectional data.

SETTING & PARTICIPANTS

536 patients with advanced CKD (estimated glomerular filtration rate<30mL/min/1.73m², with or without kidney replacement therapy) from multiple clinical centers in Toronto.

EXPOSURE

Racialized status (individuals who identify as Asian or as African, Caribbean, or Black Canadian), immigrant status, and combined immigrant-racialized status.

OUTCOME

Psychosocial distress, defined as the presence of depression, anxiety, or social difficulties (ie, a score of≥10 points on the Patient Health Questionnaire 9, Generalized Anxiety Disorder 7, or Social Distress 16 scales, respectively).

ANALYTICAL APPROACH

The independent associations of racialized status and immigrant status with psychosocial distress, depression, anxiety, and social difficulties were examined using univariable- and multivariable-adjusted logistic regression.

RESULTS

Mean age of the 536 participants was 57±16 (SD) years, 62% were male, and 45% were immigrants. Of the sample, 58% were White, 22% were African, Caribbean, or Black Canadian, and 20% were Asian. Psychosocial distress was present in 36% of participants (depression in 19%, anxiety in 12%, and social difficulties in 31%). To assess the combined impact of racialized and immigrant status, we created a variable with mutually exclusive categories: White nonimmigrant, racialized nonimmigrant, White immigrant, and racialized immigrant participants. In our final multivariable-adjusted model, compared with White nonimmigrant participants, racialized immigrant participants were more likely to have psychosocial distress (OR, 2.96 [95% CI, 1.81-4.81]), depression (OR, 1.87 [95% CI, 1.05-3.34]), and social difficulties (OR, 3.36 [95% CI, 2.03-5.57]). Overall similar associations were seen for racialized nonimmigrants and for White immigrants.

LIMITATIONS

Convenience sample; small subgroups; combined exposure variable grouping Asian and African, Caribbean, and Black participants together; lack of data about mechanisms.

CONCLUSIONS

Both racialized and immigrant status based on self-report of demographic characteristics were associated with psychosocial distress among patients with advanced CKD. These patients may benefit from culturally competent psychosocial support.

PLAIN-LANGUAGE SUMMARY

Psychosocial distress is frequent in patients with advanced chronic kidney disease and impacts quality of life and clinical outcomes. Psychosocial distress may be especially scarring in people who are racialized (marginalized on account of their membership in a particular racial group) and/or who are immigrants. We assessed the association of psychosocial distress with racialized and immigrant status in Canadians with advanced chronic kidney disease. Among 536 participants from multiple medical centers in Toronto, we found that racialized and immigrant participants were more likely to have psychosocial distress, depression, and social difficulties compared with White nonimmigrant participants. This is likely related to the multiple intersectional challenges, including experience with racism and discrimination that racialized immigrant patients may face. Further studies are needed to elucidate the specific factors that contribute to more distress. The potential impact of culturally competent and safe support for these patients will also need to be studied.

Self-Perceived Barriers and Facilitators to Dietary Approaches to Stop Hypertension Diet Adherence Among Black Americans With Chronic Kidney Disease: A Qualitative Study

OBJECTIVE

The Dietary Approaches to Stop Hypertension (DASH) eating plan improves hypertension in Black individuals and is associated with favorable chronic kidney disease (CKD) outcomes. Yet, adherence to DASH is low among US adults in general, particularly among Black Americans. We assessed perceptions about DASH, its cultural compatibility, and barriers and facilitators to DASH adherence in Black adults with CKD.

DESIGN AND METHODS

We conducted focus groups and semistructured individual interviews involving 22 Black men and women with CKD Stages 3-4 from outpatient clinics at a US academic medical center. Transcripts of audio-recorded interviews were analyzed using thematic analysis.

RESULTS

Among participants (2 focus groups [N = 8 and 5] and 9 individual interviews), 13 (59%) had CKD Stage 3, 13 (59%) were female, the median age was 61 years, and 19 (90%) had hypertension. After receiving information about DASH, participants perceived it as culturally compatible based on 3 emergent themes: (1) Black individuals already eat DASH-recommended foods ("Blacks eat pretty much like this"), (2) traditional recipes (e.g., southern or soul food) can be modified into healthy versions ("you can come up with decent substitutes to make it just as good"), and ( 3) diet is not uniform among Black individuals ("I can't say that I eat traditional"). Perceived barriers to DASH adherence included unfamiliarity with serving sizes, poor cooking skills, unsupportive household members, and high cost of healthy food. Eleven (52%) reported after paying monthly bills that they "rarely" or "never" had leftover money to purchase healthy food. Perceived facilitators included having local access to healthy food, living alone or with supportive household members, and having willpower and internal/external motivation for change.

CONCLUSIONS

Black adults with CKD viewed DASH as a healthy, culturally compatible diet. Recognizing that diet in Black adults is not uniform, interventions should emphasize person-centered, rather than stereotypically culture-centered, approaches to DASH adherence.