1
|
Goldstein BA, Mohottige D, Bessias S, Cary MP. Enhancing Clinical Decision Support in Nephrology: Addressing Algorithmic Bias Through Artificial Intelligence Governance. Am J Kidney Dis 2024:S0272-6386(24)00791-1. [PMID: 38851444 DOI: 10.1053/j.ajkd.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 04/01/2024] [Accepted: 04/06/2024] [Indexed: 06/10/2024]
Abstract
There has been a steady rise in the use of clinical decision support (CDS) tools to guide Nephrology, as well as general clinical care. Through guidance set by federal agencies and concerns raised by clinical investigators, there has been an equal rise in understanding whether such tools exhibit algorithmic bias leading to unfairness. This has spurred the more fundamental question of whether sensitive variables such as race should be included in CDS tools. In order to properly answer this question, it is necessary to understand how algorithmic bias arises. We break down three sources of bias encountered when using electronic health record data to develop CDS tools: (1) use of proxy variables, (2) observability concerns and (3) underlying heterogeneity. We discuss how answering the question of whether to include sensitive variables like race often hinges more on qualitative considerations than on quantitative analysis, dependent on the function that the sensitive variable serves. Based on our experience with our own institution's CDS governance group, we show how health system-based governance committees play a central role in guiding these difficult and important considerations. Ultimately, our goal is to foster a community practice of model development and governance teams that emphasizes consciousness about sensitive variables and prioritizes equity.
Collapse
Affiliation(s)
- Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, School of Medicine, Duke University, Durham NC; AI Health, School of Medicine, Duke University, Durham NC.
| | - Dinushika Mohottige
- Institute for Health Equity Research, Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, NY; Barbara T. Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sophia Bessias
- AI Health, School of Medicine, Duke University, Durham NC
| | - Michael P Cary
- AI Health, School of Medicine, Duke University, Durham NC; School of Nursing, Duke University, Durham NC
| |
Collapse
|
2
|
Chu CD, McCulloch CE, Hsu RK, Powe NR, Bieber B, Robinson BM, Raina R, Pecoits-Filho R, Tuot DS. Utility of the Kidney Failure Risk Equation and Estimated GFR for Estimating Time to Kidney Failure in Advanced CKD. Am J Kidney Dis 2023; 82:386-394.e1. [PMID: 37301501 PMCID: PMC10588536 DOI: 10.1053/j.ajkd.2023.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/12/2023] [Indexed: 06/12/2023]
Abstract
RATIONALE & OBJECTIVE The Kidney Failure Risk Equation (KFRE) predicts the 2-year risk of kidney failure for patients with chronic kidney disease (CKD). Translating KFRE-predicted risk or estimated glomerular filtration rate (eGFR) into time to kidney failure could inform decision making for patients approaching kidney failure. STUDY DESIGN Retrospective cohort. SETTING & PARTICIPANTS CKD Outcomes and Practice Patterns Study (CKDOPPS) cohort of patients with an eGFR<60mL/min/1.73m2 from 34 US nephrology practices (2013-2021). EXPOSURE 2-year KFRE risk or eGFR. OUTCOME Kidney failure defined as initiation of dialysis or kidney transplantation. ANALYTICAL APPROACH Accelerated failure time (Weibull) models used to estimate the median, 25th, and 75th percentile times to kidney failure starting from KFRE values of 20%, 40%, and 50%, and from eGFR values of 20, 15, and 10mL/min/1.73m2. We examined variability in time to kidney failure by age, sex, race, diabetes status, albuminuria, and blood pressure. RESULTS Overall, 1,641 participants were included (mean age 69±13 years; median eGFR of 28mL/min/1.73m2 [IQR 20-37mL/min/1.73 m2]). Over a median follow-up period of 19 months (IQR, 12-30 months), 268 participants developed kidney failure, and 180 died before reaching kidney failure. The median estimated time to kidney failure was widely variable across patient characteristics from an eGFR of 20mL/min/1.73m2 and was shorter for younger age, male sex, Black (versus non-Black), diabetes (vs no diabetes), higher albuminuria, and higher blood pressure. Estimated times to kidney failure were comparably less variable across these characteristics for KFRE thresholds and eGFR of 15 or 10mL/min/1.73m2. LIMITATIONS Inability to account for competing risks when estimating time to kidney failure. CONCLUSIONS Among those with eGFR<15mL/min/1.73m2 or KFRE risk>40%), both KFRE risk and eGFR showed similar relationships with time to kidney failure. Our results demonstrate that estimating time to kidney failure in advanced CKD can inform clinical decisions and patient counseling on prognosis, regardless of whether estimates are based on eGFR or the KFRE. PLAIN-LANGUAGE SUMMARY Clinicians often talk to patients with advanced chronic kidney disease about the level of kidney function expressed as the estimated glomerular filtration rate (eGFR) and about the risk of developing kidney failure, which can be estimated using the Kidney Failure Risk Equation (KFRE). In a cohort of patients with advanced chronic kidney disease, we examined how eGFR and KFRE risk predictions corresponded to the time patients had until reaching kidney failure. Among those with eGFR<15mL/min/1.73m2 or KFRE risk > 40%), both KFRE risk and eGFR showed similar relationships with time to kidney failure. Estimating time to kidney failure in advanced CKD using either eGFR or KFRE can inform clinical decisions and patient counseling on prognosis.
Collapse
Affiliation(s)
- Chi D Chu
- Department of Medicine, University of California-San Francisco, San Francisco, California.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California
| | - Raymond K Hsu
- Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Neil R Powe
- Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Rupesh Raina
- Department of Pediatric Nephrology, Akron Children's Hospital, Akron, Ohio; Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | | | - Delphine S Tuot
- Department of Medicine, University of California-San Francisco, San Francisco, California
| |
Collapse
|
3
|
Williams P. Retaining Race in Chronic Kidney Disease Diagnosis and Treatment. Cureus 2023; 15:e45054. [PMID: 37701164 PMCID: PMC10495104 DOI: 10.7759/cureus.45054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/14/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Paul Williams
- Life Sciences, Lawrence Berkeley National Laboratory, Berkeley, USA
| |
Collapse
|
4
|
Gluba-Sagr A, Franczyk B, Rysz-Górzyńska M, Ławiński J, Rysz J. The Role of miRNA in Renal Fibrosis Leading to Chronic Kidney Disease. Biomedicines 2023; 11:2358. [PMID: 37760798 PMCID: PMC10525803 DOI: 10.3390/biomedicines11092358] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 09/29/2023] Open
Abstract
Chronic kidney disease (CKD) is an important health concern that is expected to be the fifth most widespread cause of death worldwide by 2040. The presence of chronic inflammation, oxidative stress, ischemia, etc., stimulates the development and progression of CKD. Tubulointerstitial fibrosis is a common pathomechanism of renal dysfunction, irrespective of the primary origin of renal injury. With time, fibrosis leads to end-stage renal disease (ESRD). Many studies have demonstrated that microRNAs (miRNAs, miRs) are involved in the onset and development of fibrosis and CKD. miRNAs are vital regulators of some pathophysiological processes; therefore, their utility as therapeutic agents in various diseases has been suggested. Several miRNAs were demonstrated to participate in the development and progression of kidney disease. Since renal fibrosis is an important problem in chronic kidney disease, many scientists have focused on the determination of miRNAs associated with kidney fibrosis. In this review, we present the role of several miRNAs in renal fibrosis and the potential pathways involved. However, as well as those mentioned above, other miRs have also been suggested to play a role in this process in CKD. The reports concerning the impact of some miRNAs on fibrosis are conflicting, probably because the expression and regulation of miRNAs occur in a tissue- and even cell-dependent manner. Moreover, different assessment modes and populations have been used. There is a need for large studies and clinical trials to confirm the role of miRs in a clinical setting. miRNAs have great potential; thus, their analysis may improve diagnostic and therapeutic strategies.
Collapse
Affiliation(s)
- Anna Gluba-Sagr
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland
| | - Magdalena Rysz-Górzyńska
- Department of Ophthalmology and Visual Rehabilitation, Medical University of Lodz, 90-549 Lodz, Poland
| | - Janusz Ławiński
- Department of Urology, Institute of Medical Sciences, College of Medical Sciences, University of Rzeszow, 35-055 Rzeszow, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland
| |
Collapse
|
5
|
Randhawa A, Randhawa KS, Tseng CC, Fang CH, Baredes S, Eloy JA. Racial Disparities in Charges, Length of Stay, and Complications Following Adult Inpatient Epistaxis Treatment. Am J Rhinol Allergy 2022; 37:51-57. [PMID: 36221850 DOI: 10.1177/19458924221130880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although recent studies have identified an association between race and adverse outcomes in head and neck surgeries, there are limited data examining the impact of racial disparities on adult inpatient outcomes following epistaxis management procedures. OBJECTIVE To analyze the association between race and adverse outcomes in hospitalized patients undergoing epistaxis treatment. METHODS This retrospective cohort analysis utilized the 2003 to 2014 National Inpatient Sample. International Classification of Diseases, Ninth Revision codes were used to identify cases with a primary diagnosis of epistaxis that underwent a procedure for epistaxis control. Cases with missing data were excluded. Higher total charges and prolonged length of stay (LOS) were indicated by values greater than the 75th percentile. Demographics, hospital characteristics, Elixhauser comorbidity score, and complications were compared among race cohorts using univariate chi-square analysis and one-way analysis of variance (ANOVA). The independent effect of race on adverse outcomes was analyzed using multivariate binary logistic regression while adjusting for the aforementioned variables. RESULTS Of the 83 356 cases of epistaxis included, 80.3% were White, 12.5% Black, and 7.2% Hispanic. Black patients had increased odds of urinary/renal complications (odds ratio [OR] 2.148, 95% confidence interval [CI] 1.797-2.569, P < .001) compared to White patients. Additionally, Black patients experienced higher odds of prolonged LOS (OR 1.227, 95% CI 1.101-1.367, P < .001) and higher total charges (OR 1.257, 95% CI 1.109-1.426, P < .001) compared to White patients. Similarly, Hispanic patients were more likely to experience urinary/renal complications (OR 1.605, 95% CI 1.244-2.071, P < .001), higher total charges (OR 1.519, 95% CI 1.302-1.772, P < .001), and prolonged LOS (OR 1.157, 95% CI 1.007-1.331, P = .040) compared to White patients. CONCLUSION Race is an important factor associated with an increased incidence of complications in hospitalized patients treated for epistaxis.
Collapse
Affiliation(s)
- Avneet Randhawa
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey
| | - Karandeep S Randhawa
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey
| | - Christopher C Tseng
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey
| | - Christina H Fang
- Department of Otorhinolaryngology - Head and Neck Surgery, 2013Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine, Bronx, New York
| | - Soly Baredes
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, 12286Rutgers New Jersey Medical School, Newark, New Jersey
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Department of Neurological Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Department of Ophthalmology and Visual Science, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Department of Otolaryngology and Facial Plastic Surgery, Saint Barnabas Medical Center - RWJBarnabas Health, Livingston, New Jersey
| |
Collapse
|
6
|
Novick TK, Crews DC. Centering Black Men With Kidney Disease. JAMA Netw Open 2022; 5:e2211903. [PMID: 35552730 DOI: 10.1001/jamanetworkopen.2022.11903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tessa K Novick
- Division of Nephrology, Dell Medical School, University of Texas at Austin, Austin
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, Maryland
| |
Collapse
|
7
|
Sahu RK, Xavier S, Chauss D, Wang L, Chew C, Taylor RP, Stallcup WB, Ma JZ, Kazemian M, Afzali B, Köhl J, Portilla D. Folic acid-mediated fibrosis is driven by C5a receptor 1-mediated activation of kidney myeloid cells. Am J Physiol Renal Physiol 2022; 322:F597-F610. [PMID: 35379003 DOI: 10.1152/ajprenal.00404.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We previously reported that increased expression and activation of kidney cell complement components play an important role in the pathogenesis of renal scarring. Here we used floxed green fluorescent protein (GFP)-C5a receptor 1 (C5aR1) knock-in mice (GFP-C5ar1fl/fl) and the model of Folic acid-induced kidney injury to define the cell types and potential mechanisms by which increased C5aR1 activation leads to fibrosis. Using flow cytometry and confocal microscopy we identified macrophages as the major interstitial cell type showing increased expression of C5aR1 in FA-treated mice. C5ar1fl/fl.Lyz2Cre+/- mice, in which C5aR1 has been specifically deleted in lysozyme M (LysM)-expressing myeloid cells, experienced reduced fibrosis when compared to control C5ar1fl/fl mice. Examination of C5aR1-expressing macrophage transcriptomes by gene set enrichment analysis (GSEA) demonstrated that these cells were enriched in pathways corresponding to the complement cascade, collagen formation and the NABA matrisome, strongly pointing to their critical roles in tissue repair/scarring. Since C5aR1 was also detected in a small population of PDGFBR+ GFP+ cells we develop C5ar1fl/fl.Foxd1Cre+/- mice, in which C5aR1 is deleted specifically in pericytes, and found reduced FA-induced fibrosis. Primary cell cultures of platelet-derived growth factor receptor beta (PDGFRβ)+ pericytes isolated from FA-treated C5ar1fl/fl.Foxd1Cre+/- mice showed reduced secretion of several cytokines, including IL-6, and macrophage inflammatory proteins (MIP) 2, when compared to pericytes isolated from FA-treated control GFP-C5ar1fl/fl mice. Collectively, these data imply that the C5a/C5aR1 axis activation primarily in interstitial cells contributes to the development of renal fibrosis.
Collapse
Affiliation(s)
- Ranjit K Sahu
- PO Box 800133, grid.27755.32University of Virginia, Charlottesville, VA, United States
| | - Sandhya Xavier
- Department of Medicine, grid.27755.32University of Virginia, Charlottesville, VA, United States
| | - Daniel Chauss
- Immunoregulation Section, Kidney Diseases Branch, grid.419635.cNational Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, United States
| | - Luopin Wang
- Department of Computer Science, grid.169077.ePurdue University West Lafayette, West Lafayette, IN, United States
| | - Claude Chew
- Flow Cytometry Core, grid.27755.32University of Virginia, Charlottesville, VA, United States
| | | | - William B Stallcup
- Tumor Metastasis and Caner Immunology Program, grid.479509.6Sanford Burnham Prebys Medical Discovery Institute
| | - Jennie Z Ma
- Public Health Sciences, grid.27755.32University of Virginia, Charlottesville, VA, United States
| | - Majid Kazemian
- Departments of Biochemistry and Computer Science, grid.169077.ePurdue University West Lafayette, IN, United States
| | - Behdad Afzali
- Immunoregulation Section, Kidney Diseases Branch, grid.419635.cNational Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, United States
| | - Jörg Köhl
- Division of Immunobiology, Institute for Systemic Inflammation Research
| | - Didier Portilla
- Medicine/Nephrology, grid.27755.32University of Virginia, Charlottesville, United States
| |
Collapse
|
8
|
Racial and Socioeconomic Disparities in CKD in the Context of Universal Health Care Provided by the Military Health System. Kidney Med 2022; 4:100381. [PMID: 35072045 PMCID: PMC8767122 DOI: 10.1016/j.xkme.2021.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Rationale & Objective Health-impeding social determinants of health—including reduced access to care—contribute to racial and socioeconomic disparities in chronic kidney disease (CKD). The Military Health System (MHS) provides an opportunity to assess a large, diverse population for CKD disparities in the context of universal health care. Study Design Cross-sectional study. Setting & Participants MHS beneficiaries aged 18 to 64 years receiving care between October 1, 2015, and September 30, 2018. Predictors Race, sponsor’s rank (a proxy for socioeconomic status and social class), median household income by sponsor’s zip code, and marital status. Outcome CKD prevalence, defined by International Classification of Diseases, Tenth Revision codes and/or a validated, laboratory value-based electronic phenotype. Analytical Approach Multivariable logistic regression compared CKD prevalence by predictors, controlling separately for confounders (age, sex, active-duty status, sponsor’s service branch, and depression) and mediators (hypertension, diabetes, HIV, and body mass index). Results Of 3,330,893 beneficiaries, 105,504 (3.2%) had CKD. In confounder-adjusted models, the CKD prevalence was higher in Black versus White beneficiaries (OR, 1.67; 95% CI, 1.64-1.70), but lower in single versus married beneficiaries (OR, 0.77; 95% CI, 0.76-0.79). The prevalence of CKD was increased among those with a lower military rank and among those with a lower median household income in a nearly dose-response fashion (P < 0.0001). Associations were attenuated when further adjusting for suspected mediators. Limitations The cross-sectional design prevents causal inferences. We may have underestimated the CKD prevalence, given a lack of data for laboratory tests conducted outside the MHS and the use of a specific CKD definition. The transient nature of the MHS population may limit the accuracy of zip code–level median household income data. Conclusions Racial and socioeconomic CKD disparities exist in the MHS despite universal health care coverage. The existence of CKD disparities by rank and median household income suggests that social risks may contribute to both racial and socioeconomic disparities despite access to universal health care coverage.
Collapse
|
9
|
Iorember FM, Bamgbola OF. Structural Inequities and Barriers to Accessing Kidney Healthcare Services in the United States: A Focus on Uninsured and Undocumented Children and Young Adults. Front Pediatr 2022; 10:833611. [PMID: 35450110 PMCID: PMC9016185 DOI: 10.3389/fped.2022.833611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
The population of children living in poverty and lacking healthcare insurance has increased in the United States of America in the last decade. Several factors have been responsible for this trend including illegal immigration, socioeconomic deprivation, young age, racial segregation, environmental degradation, and discriminatory housing policies. These systemic barriers have contributed to the exclusion of families from essential healthcare services. They are also contributory to the development of chronic illnesses (such as dialysis-dependent kidney disease) that are debilitating and frequently require considerable therapeutic resources. This unfortunate scenario creates a never-ending vicious cycle of poverty and diseases in a segment of society. For pediatric nephrologists, the challenges of caring for uninsured children with chronic kidney disease are all too familiar. Federally funded healthcare programs do not cover this patient population, leaving them the option of seeking care in emergency healthcare settings. Presentation with a critical illness often necessitates urgent placement of vascular catheters and the choice of acute hemodialysis. Adverse social environment influences the need for protracted chronic hemodialysis and a delay in kidney transplantation. Consequently, there is greater comorbidity, recurrent hospitalization, and a higher mortality rate. New policies should address the deficit in health insurance coverage while promoting social programs that will remove structural barriers to health care resources for undocumented children and young adults.
Collapse
Affiliation(s)
- Franca M Iorember
- Division of Pediatric Nephrology, Baylor College of Medicine, Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Oluwatoyin F Bamgbola
- Division of Pediatric Nephrology, SUNY Downstate Medical Center, Brooklyn, NY, United States
| |
Collapse
|
10
|
Diamantidis CJ, Zepel L, Wang V, Smith VA, Hudson Scholle S, Tamayo L, Maciejewski ML. Disparities in Chronic Kidney Disease Progression by Medicare Advantage Enrollees. Am J Nephrol 2021; 52:949-957. [PMID: 34875668 DOI: 10.1159/000519758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The prevalence of chronic kidney disease (CKD) in Medicare beneficiaries has quadrupled in the past 2 decades, but little is known about risk factors affecting the progression of CKD. This study aims to understand the progression in Medicare Advantage enrollees and whether it differs by provider recognition of CKD, race and ethnicity, or geographic location. In a large cohort of Medicare Advantage (MA) enrollees, we examined whether CKD progression, up to 5 years after study entry, differed by demographic and clinical factors and identified additional risk factors of CKD progression. METHODS In a cohort of 1,002,388 MA enrollees with CKD stages 1-4 based on 2013-2018 labs, progression was estimated using a mixed-effects model that adjusted for demographics, geographic location, comorbidity, urine albumin-to-creatinine ratio, clinical recognition via diagnosed CKD, and time-fixed effects. Race and ethnicity, geographic location, and clinical recognition of CKD were interacted with time in 3 separate regression models. RESULTS Mean (median) follow-up was 3.1 (3.0) years. Black and Hispanic MA enrollees had greater kidney function at study entry than other beneficiaries, but their kidney function declined faster. MA enrollees with clinically recognized CKD had estimated glomerular filtration rate levels that were 18.6 units (95% confidence interval [CI]: 18.5-18.7) lower than levels of unrecognized patients, but kidney function declined more slowly in enrollees with clinical recognition. There were no differences in CKD progression by geography. After removal of the race coefficient from the eGFR equation in a sensitivity analysis, kidney function was much lower in all years among Black MA enrollees, but patterns of progression remained the same. DISCUSSION/CONCLUSIONS These results suggest that patients with clinically recognized CKD and racial and ethnic minorities merit closer surveillance and management to reduce their risk of faster progression.
Collapse
Affiliation(s)
- Clarissa Jonas Diamantidis
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lindsay Zepel
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- OptumLabs Visiting Fellow, Cambridge, Massachusetts, USA
| | - Virginia Wang
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Valerie A Smith
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | | | - Loida Tamayo
- Centers for Medicare & Medicaid Services, Baltimore, Maryland, USA
| | - Matthew L Maciejewski
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| |
Collapse
|
11
|
Norris K. Can Understanding Outcomes for Medicare Advantage Enrollees Reduce Racial and Ethnic Disparities in Kidney Disease? Am J Nephrol 2021; 52:958-960. [PMID: 34875651 PMCID: PMC8758522 DOI: 10.1159/000519759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Keith Norris
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California
| |
Collapse
|
12
|
Conner CK, Jain B, Khan A, Laragh ML, Lowery S, Nichols N, Steffan J, Weber JK, White S. A Step Toward Health Equity for Veterans: Evidence Supports Removing Race From Kidney Function Calculations. Fed Pract 2021; 38:368-373. [PMID: 34733089 DOI: 10.12788/fp.0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The practice of race-based medicine fails to recognize that race cannot be used as a proxy for genetic ancestry and that racial and ethnic categories are complex sociopolitical constructs without biological basis. Clinical algorithms and equations that incorporate race modifiers and are currently considered standard for diagnosis and management of disease are appropriately being scrutinized for lack of biological plausibility and their role in exacerbating health inequities. In this paper, we review the history, evidence, and implications of using a Black race coefficient when calculating estimated glomerular filtration rate (eGFR) in the diagnosis and management of kidney disease. Observations Currently, the US Department of Veterans Affairs (VA) uses the Modification of Diet in Renal Disease (MDRD) equation for eGFR. This equation includes a Black race coefficient that results in an eGFR that is 21% higher for a Black patient when compared with a patient of any other race. The rationale for the inclusion of this coefficient is based on racist science that incorrectly assumes race as a proxy for genetic ancestry. Multiple studies across diverse Black populations demonstrate that the application of a race coefficient in kidney function estimation equations is inferior when compared with the race-neutral option. Furthermore, the most utilized eGFR equations are biased and imprecise. Because eGFR is the primary diagnostic method for detecting and managing kidney disease, preventing its progression, planning for dialysis, and evaluating for transplantation, it is vital that eGFR be as accurate, precise, and equitable as possible. Conclusions The incorporation of a race coefficient in kidney estimation equations lacks biological plausibility and its use exacerbates kidney health disparities. Until a better method to estimate kidney function becomes available, a race-neutral option for current estimation equations should be applied for all patients.
Collapse
Affiliation(s)
| | - Cheryl K Conner
- and are Attending Physicians; is the Section Chief for Hospital Medicine; is an Inpatient Pharmacy Clinical Pharmacy Specialist; is a Nurse Practitioner Section of Palliative Care; and is Facility Transplant Coordinator; all at the Jesse Brown Veterans Affairs Medical Center in Chicago, Illinois. is an Internal Medicine Resident; and Bijal Jain and Natasha Nichols are Assistant Professors, Department of Medicine; and all at Northwestern University Feinberg School of Medicine. Marci Laragh, Cheryl Conner and Ambareen Khan are Clinical Assistant Professors of Medicine, and Sheryl Lowery is Adjunct Clinical Assistant Professor School of Pharmacy; all at the University of Illinois at Chicago
| | - Bijal Jain
- and are Attending Physicians; is the Section Chief for Hospital Medicine; is an Inpatient Pharmacy Clinical Pharmacy Specialist; is a Nurse Practitioner Section of Palliative Care; and is Facility Transplant Coordinator; all at the Jesse Brown Veterans Affairs Medical Center in Chicago, Illinois. is an Internal Medicine Resident; and Bijal Jain and Natasha Nichols are Assistant Professors, Department of Medicine; and all at Northwestern University Feinberg School of Medicine. Marci Laragh, Cheryl Conner and Ambareen Khan are Clinical Assistant Professors of Medicine, and Sheryl Lowery is Adjunct Clinical Assistant Professor School of Pharmacy; all at the University of Illinois at Chicago
| | - Ambareen Khan
- and are Attending Physicians; is the Section Chief for Hospital Medicine; is an Inpatient Pharmacy Clinical Pharmacy Specialist; is a Nurse Practitioner Section of Palliative Care; and is Facility Transplant Coordinator; all at the Jesse Brown Veterans Affairs Medical Center in Chicago, Illinois. is an Internal Medicine Resident; and Bijal Jain and Natasha Nichols are Assistant Professors, Department of Medicine; and all at Northwestern University Feinberg School of Medicine. Marci Laragh, Cheryl Conner and Ambareen Khan are Clinical Assistant Professors of Medicine, and Sheryl Lowery is Adjunct Clinical Assistant Professor School of Pharmacy; all at the University of Illinois at Chicago
| | - Marci L Laragh
- and are Attending Physicians; is the Section Chief for Hospital Medicine; is an Inpatient Pharmacy Clinical Pharmacy Specialist; is a Nurse Practitioner Section of Palliative Care; and is Facility Transplant Coordinator; all at the Jesse Brown Veterans Affairs Medical Center in Chicago, Illinois. is an Internal Medicine Resident; and Bijal Jain and Natasha Nichols are Assistant Professors, Department of Medicine; and all at Northwestern University Feinberg School of Medicine. Marci Laragh, Cheryl Conner and Ambareen Khan are Clinical Assistant Professors of Medicine, and Sheryl Lowery is Adjunct Clinical Assistant Professor School of Pharmacy; all at the University of Illinois at Chicago
| | - Sheryl Lowery
- and are Attending Physicians; is the Section Chief for Hospital Medicine; is an Inpatient Pharmacy Clinical Pharmacy Specialist; is a Nurse Practitioner Section of Palliative Care; and is Facility Transplant Coordinator; all at the Jesse Brown Veterans Affairs Medical Center in Chicago, Illinois. is an Internal Medicine Resident; and Bijal Jain and Natasha Nichols are Assistant Professors, Department of Medicine; and all at Northwestern University Feinberg School of Medicine. Marci Laragh, Cheryl Conner and Ambareen Khan are Clinical Assistant Professors of Medicine, and Sheryl Lowery is Adjunct Clinical Assistant Professor School of Pharmacy; all at the University of Illinois at Chicago
| | - Natasha Nichols
- and are Attending Physicians; is the Section Chief for Hospital Medicine; is an Inpatient Pharmacy Clinical Pharmacy Specialist; is a Nurse Practitioner Section of Palliative Care; and is Facility Transplant Coordinator; all at the Jesse Brown Veterans Affairs Medical Center in Chicago, Illinois. is an Internal Medicine Resident; and Bijal Jain and Natasha Nichols are Assistant Professors, Department of Medicine; and all at Northwestern University Feinberg School of Medicine. Marci Laragh, Cheryl Conner and Ambareen Khan are Clinical Assistant Professors of Medicine, and Sheryl Lowery is Adjunct Clinical Assistant Professor School of Pharmacy; all at the University of Illinois at Chicago
| | - Janine Steffan
- and are Attending Physicians; is the Section Chief for Hospital Medicine; is an Inpatient Pharmacy Clinical Pharmacy Specialist; is a Nurse Practitioner Section of Palliative Care; and is Facility Transplant Coordinator; all at the Jesse Brown Veterans Affairs Medical Center in Chicago, Illinois. is an Internal Medicine Resident; and Bijal Jain and Natasha Nichols are Assistant Professors, Department of Medicine; and all at Northwestern University Feinberg School of Medicine. Marci Laragh, Cheryl Conner and Ambareen Khan are Clinical Assistant Professors of Medicine, and Sheryl Lowery is Adjunct Clinical Assistant Professor School of Pharmacy; all at the University of Illinois at Chicago
| | - Jane K Weber
- and are Attending Physicians; is the Section Chief for Hospital Medicine; is an Inpatient Pharmacy Clinical Pharmacy Specialist; is a Nurse Practitioner Section of Palliative Care; and is Facility Transplant Coordinator; all at the Jesse Brown Veterans Affairs Medical Center in Chicago, Illinois. is an Internal Medicine Resident; and Bijal Jain and Natasha Nichols are Assistant Professors, Department of Medicine; and all at Northwestern University Feinberg School of Medicine. Marci Laragh, Cheryl Conner and Ambareen Khan are Clinical Assistant Professors of Medicine, and Sheryl Lowery is Adjunct Clinical Assistant Professor School of Pharmacy; all at the University of Illinois at Chicago
| | - Samantha White
- and are Attending Physicians; is the Section Chief for Hospital Medicine; is an Inpatient Pharmacy Clinical Pharmacy Specialist; is a Nurse Practitioner Section of Palliative Care; and is Facility Transplant Coordinator; all at the Jesse Brown Veterans Affairs Medical Center in Chicago, Illinois. is an Internal Medicine Resident; and Bijal Jain and Natasha Nichols are Assistant Professors, Department of Medicine; and all at Northwestern University Feinberg School of Medicine. Marci Laragh, Cheryl Conner and Ambareen Khan are Clinical Assistant Professors of Medicine, and Sheryl Lowery is Adjunct Clinical Assistant Professor School of Pharmacy; all at the University of Illinois at Chicago
| |
Collapse
|
13
|
Chu CD, Powe NR, Crews DC, Tuot DS. CKD Progression From the Time of Estimated GFR-Based Waitlist Eligibility and Racial Disparities in Transplant Access. Am J Kidney Dis 2021; 79:841-848.e1. [PMID: 34543686 PMCID: PMC10404025 DOI: 10.1053/j.ajkd.2021.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/30/2021] [Indexed: 12/31/2022]
Abstract
RATIONALE & OBJECTIVE eGFR equations that incorporate a term for race assign a higher value to Black individuals compared to non-Black individuals not attributable to sex, age, or serum creatinine. This difference may contribute to racial disparities in kidney transplant access. We sought to 1) compare time from meeting a transplant eligibility threshold of eGFR ≤20 ml/min/1.73M2 to kidney failure with replacement therapy (KFRT) among Black, Hispanic, and White patients, and 2) assess the impact of incorporation of race into eGFR expressions on establishment of waitlist eligibility and time from eligibility to KFRT. STUDY DESIGN Retrospective cohort. SETTING & PARTICIPANTS Using the OptumLabs® Data Warehouse, we assembled a cohort of 40,042 White, 8,519 Black, and 3,569 Hispanic patients having at least one eGFR value between 20 and 60 mL/min/1.73m2 within the preceding two years and an incident outpatient eGFR of ≤20 ml/min/1.73m2 between 2008-2018, using the CKD-EPI equation that includes a term for race coded as Black or non-Black. We then re-assembled a Black patient cohort based on incident eGFR ≤20 ml/min/1.73m2 (n=11,269) estimated using the same CKD-EPI equation for Black patients but coding patients as non-Black. EXPOSURE Race/ethnicity. OUTCOME Time to KFRT. ANALYTICAL APPROACH Unadjusted and adjusted Fine-Gray models; linear regression to compute eGFR slopes. RESULTS By 3 years, the cumulative incidence of KFRT was 20.5% among White patients, 40.9% among Hispanic patients, and 36% among Black patients whose eGFR was estimated using a race term coded as Black and 28.7% among Black patients whose eGFR was estimated using a race term coded as non-Black. In fully adjusted analyses including 11,269 Black patients with an eGFR <20 ml/min/1.73m2 based on coding them as non-Black, KFRT risk remained greater among Black (HR 1.28; 95% CI, 1.15-1.43) and Hispanic (HR 1.66; 95% CI 1.18-2.31) than among White patients. Based on slopes of eGFR decline, coding Black patients as non-Black would allow earlier waitlist activation by an estimated median of 0.5 years [IQR 0.27-1.23]. LIMITATIONS Inability to exclude individuals who would not be kidney transplant candidates if comprehensively evaluated. CONCLUSIONS A uniform eGFR threshold provides less opportunity for being placed on the transplant waitlist among Black and Hispanic patients. For many Black patients, estimation of GFR as if their race category were non-Black would allow substantially earlier waitlisting but would not eliminate their shorter time to KFRT and reduced opportunity for preemptive transplantation compared to White patients.
Collapse
Affiliation(s)
- Chi D Chu
- Department of Medicine, University of California, San Francisco, San Francisco, CA; OptumLabs Visiting Fellow, OptumLabs, Eden Prairie, MN.
| | - Neil R Powe
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA
| | - Deidra C Crews
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Center for Health Equity, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Delphine S Tuot
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA
| |
Collapse
|
14
|
Chu CD, Powe NR, McCulloch CE, Crews DC, Han Y, Bragg-Gresham JL, Saran R, Koyama A, Burrows NR, Tuot DS. Trends in Chronic Kidney Disease Care in the US by Race and Ethnicity, 2012-2019. JAMA Netw Open 2021; 4:e2127014. [PMID: 34570204 PMCID: PMC8477264 DOI: 10.1001/jamanetworkopen.2021.27014] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/25/2021] [Indexed: 12/13/2022] Open
Abstract
Importance Significant racial and ethnic disparities in chronic kidney disease (CKD) progression and outcomes are well documented, as is low use of guideline-recommended CKD care. Objective To examine guideline-recommended CKD care delivery by race and ethnicity in a large, diverse population. Design, Setting, and Participants In this serial cross-sectional study, adult patients with CKD that did not require dialysis, defined as a persistent estimated glomerular filtration rate less than 60 mL/min/1.73 m2 or a urine albumin-creatinine ratio of 30 mg/g or higher for at least 90 days, were identified in 2-year cross-sections from January 1, 2012, to December 31, 2019. Data from the OptumLabs Data Warehouse, a national data set of administrative and electronic health record data for commercially insured and Medicare Advantage patients, were used. Exposures The independent variables were race and ethnicity, as reported in linked electronic health records. Main Outcomes and Measures On the basis of guideline-recommended CKD care, the study examined care delivery process measures (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker prescription for albuminuria, statin prescription, albuminuria testing, nephrology care for CKD stage 4 or higher, and avoidance of chronic nonsteroidal anti-inflammatory drug prescription) and care delivery outcome measures (blood pressure and diabetes control). Results A total of 452 238 patients met the inclusion criteria (mean [SD] age, 74.0 [10.2] years; 262 089 [58.0%] female; a total of 7573 [1.7%] Asian, 49 970 [11.0%] Black, 15 540 [3.4%] Hispanic, and 379 155 [83.8%] White). Performance on process measures was higher among Asian, Black, and Hispanic patients compared with White patients for angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use (79.8% for Asian patients, 76.7% for Black patients, and 79.9% for Hispanic patients compared with 72.3% for White patients in 2018-2019), statin use (72.6% for Asian patients, 69.1% for Black patients, and 74.1% for Hispanic patients compared with 61.5% for White patients), nephrology care (64.8% for Asian patients, 72.9% for Black patients, and 69.4% for Hispanic patients compared with 58.3% for White patients), and albuminuria testing (53.9% for Asian patients, 41.0% for Black patients, and 52.6% for Hispanic patients compared with 30.7% for White patients). Achievement of blood pressure control to less than 140/90 mm Hg was similar or lower among Asian (71.8%), Black (63.3%), and Hispanic (69.8%) patients compared with White patients (72.9%). Achievement of diabetes control with hemoglobin A1c less than 7.0% was 50.1% in Asian patients, 49.3% in Black patients, and 46.0% in Hispanic patients compared with 50.3% for White patients. Conclusions and Relevance Higher performance on CKD care process measures among Asian, Black, and Hispanic patients suggests that differences in medication prescription and diagnostic testing are unlikely to fully explain known disparities in CKD progression and kidney failure. Improving care delivery processes alone may be inadequate for reducing these disparities.
Collapse
Affiliation(s)
- Chi D. Chu
- Division of Nephrology, University of California, San Francisco
- OptumLabs Visiting Fellow, OptumLabs, Eden Prairie, Minnesota
| | - Neil R. Powe
- Department of Medicine, University of California, San Francisco
- Department of Medicine, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital, San Francisco, California
- Center for Vulnerable Populations, University of California, San Francisco
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Deidra C. Crews
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yun Han
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | | | - Rajiv Saran
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Alain Koyama
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nilka R. Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Delphine S. Tuot
- Division of Nephrology, University of California, San Francisco
- Department of Medicine, University of California, San Francisco
- Department of Medicine, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital, San Francisco, California
- Center for Vulnerable Populations, University of California, San Francisco
| |
Collapse
|
15
|
Cohen JB, Cohen DL, Herman DS, Leppert JT, Byrd JB, Bhalla V. Testing for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans : A Retrospective Cohort Study. Ann Intern Med 2021; 174:289-297. [PMID: 33370170 PMCID: PMC7965294 DOI: 10.7326/m20-4873] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Primary aldosteronism is a common cause of treatment-resistant hypertension. However, evidence from local health systems suggests low rates of testing for primary aldosteronism. OBJECTIVE To evaluate testing rates for primary aldosteronism and evidence-based hypertension management in patients with treatment-resistant hypertension. DESIGN Retrospective cohort study. SETTING U.S. Veterans Health Administration. PARTICIPANTS Veterans with apparent treatment-resistant hypertension (n = 269 010) from 2000 to 2017, defined as either 2 blood pressures (BPs) of at least 140 mm Hg (systolic) or 90 mm Hg (diastolic) at least 1 month apart during use of 3 antihypertensive agents (including a diuretic), or hypertension requiring 4 antihypertensive classes. MEASUREMENTS Rates of primary aldosteronism testing (plasma aldosterone-renin) and the association of testing with evidence-based treatment using a mineralocorticoid receptor antagonist (MRA) and with longitudinal systolic BP. RESULTS 4277 (1.6%) patients who were tested for primary aldosteronism were identified. An index visit with a nephrologist (hazard ratio [HR], 2.05 [95% CI, 1.66 to 2.52]) or an endocrinologist (HR, 2.48 [CI, 1.69 to 3.63]) was associated with a higher likelihood of testing compared with primary care. Testing was associated with a 4-fold higher likelihood of initiating MRA therapy (HR, 4.10 [CI, 3.68 to 4.55]) and with better BP control over time. LIMITATIONS Predominantly male cohort, retrospective design, susceptibility of office BPs to misclassification, and lack of confirmatory testing for primary aldosteronism. CONCLUSION In a nationally distributed cohort of veterans with apparent treatment-resistant hypertension, testing for primary aldosteronism was rare and was associated with higher rates of evidence-based treatment with MRAs and better longitudinal BP control. The findings reinforce prior observations of low adherence to guideline-recommended practices in smaller health systems and underscore the urgent need for improved management of patients with treatment-resistant hypertension. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
Affiliation(s)
- Jordana B Cohen
- Perelman School of Medicine, University of Pennsylvania, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania (J.B.C.)
| | - Debbie L Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (D.L.C., D.S.H.)
| | - Daniel S Herman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (D.L.C., D.S.H.)
| | - John T Leppert
- Stanford University School of Medicine, Stanford, California, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California (J.T.L.)
| | - James Brian Byrd
- University of Michigan Medical School, Ann Arbor, Michigan (J.B.B.)
| | - Vivek Bhalla
- Stanford University School of Medicine, Stanford, California (V.B.)
| |
Collapse
|
16
|
Clark-Cutaia MN, Rivera E, Iroegbu C, Squires A. Disparities in chronic kidney disease-the state of the evidence. Curr Opin Nephrol Hypertens 2021; 30:208-214. [PMID: 33464006 DOI: 10.1097/mnh.0000000000000688] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review was to assess the prevalence of United States chronic kidney disease (CKD) health disparities, focusing on racial/ethnic groups, immigrants and refugees, sex or gender, and older adults. RECENT FINDINGS There are major racial/ethnic disparities in CKD, with possible contributions from the social determinants of health, socioeconomics, and racial discrimination. Racial/ethnic minority patients experience faster progression to end-stage kidney disease (ESKD) and higher mortality predialysis, however, once on dialysis, appear to live longer. Similarly, men are quicker to progress to ESKD than women, with potential biological, behavioral, and measurement error factors. There is a lack of substantial evidence for intersex, nonbinary, or transgender patients. There are also strikingly few studies about US immigrants or older adults with CKD despite the fact that they are at high risk for CKD due to a variety of factors. SUMMARY As providers and scientists, we must combat both conscious and unconscious biases, advocate for minority patient populations, and be inclusive and diverse in our treatment regimens and provision of care. We need to acknowledge that sufficient evidence exists to change treatment guidelines, and that more is required to support the diversity of our patient population.
Collapse
Affiliation(s)
| | - Eleanor Rivera
- Assistant Professor, University of Illinois Chicago College of Nursing, Chicago, Illinois
| | - Christin Iroegbu
- Doctoral Student, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Allison Squires
- Associate Professor, NYU Meyers College of Nursing, New York, New York, USA
| |
Collapse
|
17
|
Reese PP, Mohan S, King KL, Williams WW, Potluri VS, Harhay MN, Eneanya ND. Racial disparities in preemptive waitlisting and deceased donor kidney transplantation: Ethics and solutions. Am J Transplant 2021; 21:958-967. [PMID: 33151614 DOI: 10.1111/ajt.16392] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/04/2020] [Accepted: 10/27/2020] [Indexed: 01/25/2023]
Abstract
Kidney transplantation prior to dialysis, known as "preemptive transplant," enables patients to live longer and avoid the substantial quality of life burdens due to chronic dialysis. Deceased donor kidneys are a public resource that ought to provide health benefits equitably. Unfortunately, White, better educated, and privately insured patients enjoy disproportionate access to preemptive transplantation using deceased donor kidneys. This problem has persisted for decades and is exacerbated by the first-come, first-served approach to kidney allocation for predialysis patients. In this Personal Viewpoint, we describe the diverse barriers to preemptive waitlisting and kidney transplant. The analysis focuses on healthcare system features that particularly disadvantage Black patients, such as the waitlisting eligibility criterion of a single glomerular filtration rate or creatinine clearance ≤20 ml/min, and neglect of wide variation in the rate of progression to end-stage kidney disease (ESKD) in allocating preemptive transplants. We propose initiatives to improve equity including: (1) standardization of waitlisting eligibility criteria related to kidney function; (2) aggressive education for clinicians about early transplant referral; (3) innovations in electronic medical record capabilities; and (4) rapid status 7 listing by centers. If those initiatives fail, the transplant field should consider eliminating preemptive waitlisting and transplantation with deceased donor kidneys.
Collapse
Affiliation(s)
- Peter P Reese
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, New York
| | - Winfred W Williams
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Vishnu S Potluri
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Meera N Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania.,Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania.,Tower Health Transplant Institute, Tower Health System, West Reading, Pennsylvania
| | - Nwamaka D Eneanya
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
18
|
Harhay MN, Mark PB. Will Universal Access to Health Care Mean Equitable Access to Kidney Transplantation? Clin J Am Soc Nephrol 2020; 15:752-754. [PMID: 32467308 PMCID: PMC7274288 DOI: 10.2215/cjn.03000320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Meera N Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania .,Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania.,Tower Health Transplant Institute, Tower Health System, West Reading, Pennsylvania
| | - Patrick B Mark
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, United Kingdom.,Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| |
Collapse
|
19
|
Crews DC, Novick TK. Achieving equity in dialysis care and outcomes: The role of policies. Semin Dial 2020; 33:43-51. [PMID: 31899828 DOI: 10.1111/sdi.12847] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis care and outcomes, how current ESKD and other public policies may influence or exacerbate these inequities, and gaps in the literature needed to inform future policies toward achieving equity in ESKD. We give special attention to the 2019 Advancing American Kidney Health Executive Order, which has high potential to radically transform dialysis care.
Collapse
Affiliation(s)
- Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Tessa K Novick
- Division of Nephrology, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| |
Collapse
|
20
|
King KL, Husain SA, Jin Z, Brennan C, Mohan S. Trends in Disparities in Preemptive Kidney Transplantation in the United States. Clin J Am Soc Nephrol 2019; 14:1500-1511. [PMID: 31413065 PMCID: PMC6777592 DOI: 10.2215/cjn.03140319] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/02/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Long wait times for deceased donor kidneys and low rates of preemptive wait-listing have limited preemptive transplantation in the United States. We aimed to assess trends in preemptive deceased donor transplantation with the introduction of the new Kidney Allocation System (KAS) in 2014 and identify whether key disparities in preemptive transplantation have changed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We identified adult deceased donor kidney transplant recipients in the United States from 2000 to 2018 using the Scientific Registry of Transplant Recipients. Preemptive transplantation was defined as no dialysis before transplant. Associations between recipient, donor, transplant, and policy era characteristics and preemptive transplantation were calculated using logistic regression. To test for modification by KAS policy era, an interaction term between policy era and each characteristic of interest was introduced in bivariate and adjusted models. RESULTS The proportion of preemptive transplants increased after implementation of KAS from 9.0% to 9.8%, with 1.10 (95% confidence interval [95% CI], 1.06 to 1.14) times higher odds of preemptive transplantation post-KAS compared with pre-KAS. Preemptive recipients were more likely to be white, older, female, more educated, hold private insurance, and have ESKD cause other than diabetes or hypertension. Policy era significantly modified the association between preemptive transplantation and race, age, insurance status, and Human Leukocyte Antigen zero-mismatch (interaction P<0.05). Medicare patients had a significantly lower odds of preemptive transplantation relative to private insurance holders (pre-KAS adjusted OR, [aOR] 0.26; [95% CI, 0.25 to 0.27], to 0.20 [95% CI, 0.18 to 0.22] post-KAS). Black and Hispanic patients experienced a similar phenomenon (aOR 0.48 [95% CI, 0.45 to 0.51] to 0.41 [95% CI, 0.37 to 0.45] and 0.43 [95% CI, 0.40 to 0.47] to 0.40 [95% CI, 0.36 to 0.46] respectively) compared with white patients. CONCLUSIONS Although the proportion of deceased donor kidney transplants performed preemptively increased slightly after KAS, disparities in preemptive kidney transplantation persisted after the 2014 KAS policy changes and were exacerbated for racial minorities and Medicare patients.
Collapse
Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | | | - Corey Brennan
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York; .,The Columbia University Renal Epidemiology (CURE) Group, New York, New York.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| |
Collapse
|