Social environmental stressors, psychological factors, and kidney disease

Mental health and social-emotional functioning in children and adolescents with chronic kidney disease

For children and young adults, living with chronic kidney disease (CKD) poses physical, mental, and social challenges. The mental health functioning of children and adolescents with CKD plays an important role in the medical, educational, vocational, and quality of life outcomes, yet receives little systematic attention in the busy pediatric nephrology clinic. This article will provide an overview of the prevalence of mental illness and symptoms in children and young adults with CKD, strategies to assess for dysfunction, and the long-term outcomes associated with impaired functioning. While there is a relative dearth of literature regarding evidence-based interventions in this population to improve mental health functioning, we provide "best practice" strategies based on the available literature to address emotional and/or behavioral challenges once they are identified. More research is needed to define appropriate interventions to alleviate mental health issues and social-emotional distress, and this review of the literature will serve to provide directions for future research.

Loneliness, social isolation and incident chronic kidney disease among patients with diabetes

Background

Individuals with diabetes have a significantly higher risk of developing chronic kidney disease (CKD) and higher levels of social isolation and loneliness compared with those without diabetes. Recently, the American Heart Association highlighted the importance of considering social determinants of health (SDOH) in conjunction with traditional risk factors in patients with diabetes.

Aims

To investigate the associations of loneliness and social isolation with incident CKD risk in patients with diabetes in the UK Biobank.

Methods

A total of 18 972 patients with diabetes were included in this prospective study. Loneliness and Social Isolation Scales were created based on self-reported factors. An adjusted Cox proportional hazard model was used to investigate the associations of loneliness and social isolation with CKD risk among patients with diabetes. The relative importance in predicting CKD was also calculated alongside traditional risk factors.

Results

During a median follow-up of 10.8 years, 1127 incident CKD cases were reported. A higher loneliness scale, but not social isolation, was significantly associated with a 25% higher risk of CKD, independent of traditional risk factors, among patients with diabetes. Among the individual loneliness factors, the sense of feeling lonely emerged as the primary contributing factor to the elevated risk of CKD. Compared with individuals not experiencing feelings of loneliness, those who felt lonely exhibited a 22% increased likelihood of developing CKD. In addition, feeling lonely demonstrated greater relative importance of predicting CKD compared with traditional risk factors such as body mass index, smoking, physical activity and diet.

Conclusions

This study indicates the significant relationship between loneliness and CKD risk among patients with diabetes, highlighting the need to address SDOH in preventing CKD in this population.

Financial Toxicity in Renal Patients (FINTORE) Study: A Cross-Sectional Italian Study on Financial Burden in Kidney Disease-A Project Protocol

Financial toxicity (FT) refers to the negative impact of health-care costs on clinical conditions. In general, social determinants of health, especially poverty, socioenvironmental stressors, and psychological factors, are increasingly recognized as important determinants of non-communicable diseases, such as chronic kidney disease (CKD), and their consequences. We aim to investigate the prevalence of FT in patients at different stages of CKD treated in our universal health-care system and from pediatric nephrology, hemodialysis, peritoneal dialysis and renal transplantation clinics. FT will be assessed with the Patient-Reported Outcome for Fighting Financial Toxicity (PROFFIT) score, which was first developed by Italian oncologists. Our local ethics committee has approved the study. Our population sample will answer the sixteen questions of the PROFFIT questionnaire, seven of which are related to the outcome and nine the determinants of FT. Data will be analyzed in the pediatric and adult populations and by group stratification. We are confident that this study will raise awareness among health-care professionals of the high risk of adverse health outcomes in patients who have both kidney disease and high levels of FT. Strategies to reduce FT should be implemented to improve the standard of care for people with kidney disease and lead to truly patient-centered care.

Harnessing the Full Potential of Multi-Omic Analyses to Advance the Study and Treatment of Chronic Kidney Disease

Chronic kidney disease (CKD) was the 12th leading cause of death globally in 2017 with the prevalence of CKD estimated at ~9%. Early detection and intervention for CKD may improve patient outcomes, but standard testing approaches even in developed countries do not facilitate identification of patients at high risk of developing CKD, nor those progressing to end-stage kidney disease (ESKD). Recent advances in CKD research are moving towards a more personalised approach for CKD. Heritability for CKD ranges from 30% to 75%, yet identified genetic risk factors account for only a small proportion of the inherited contribution to CKD. More in depth analysis of genomic sequencing data in large cohorts is revealing new genetic risk factors for common diagnoses of CKD and providing novel diagnoses for rare forms of CKD. Multi-omic approaches are now being harnessed to improve our understanding of CKD and explain some of the so-called 'missing heritability'. The most common omic analyses employed for CKD are genomics, epigenomics, transcriptomics, metabolomics, proteomics and phenomics. While each of these omics have been reviewed individually, considering integrated multi-omic analysis offers considerable scope to improve our understanding and treatment of CKD. This narrative review summarises current understanding of multi-omic research alongside recent experimental and analytical approaches, discusses current challenges and future perspectives, and offers new insights for CKD.

Understanding Structural Racism as a Barrier to Living Donor Kidney Transplantation and Transplant Care

Recent Findings

Black and Hispanic patients carry higher burden of kidney disease, yet have lower access to LDKT. Until recently, these differences were thought to be due to medical co-morbidities and variation in transplant center practices. However, recent studies have shown that systemic and structural inequities related to race may be one of the major drivers.

Purpose of Review

In this paper, we examine the definition of race and systemic racism, then describe patient-, transplant center–, and society-level barriers to LDKT. We identify how social determinants, cultural biases and mistrust in medical system, influence behaviors, and provider racial profiling affects all phases of transplant evaluation. Finally, we discuss initiatives to overcome some of these barriers, starting from federal government, national organizations, transplant centers, and community partners.

Summary

Examining structural biases in transplant practices is an important step to developing solutions to address disparities in health care access and outcomes for patients who need and receive transplants.

Health inequities and the inappropriate use of race in nephrology

Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race - a socio-political construct that mediates the effect of structural racism - as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.

Historical Redlining and Resident Exposure to COVID-19: A Study of New York City

The Coronavirus Disease 2019 (COVID-19) has been reported to disproportionately impact racial/ethnic minorities in the USA, both in terms of infections and deaths. This racial disparity in the COVID-19 outcomes may result from the segregation of minorities in neighborhoods with health-compromising conditions. We, thus, anticipate that neighborhoods would be especially vulnerable to COVID-19 if they are of present-day economic and racial disadvantage and were redlined historically. To test this expectation, we examined the change of both confirmed COVID-19 cases and deaths from April to July, 2020, in zip code tabulation areas (ZCTAs) in the New York City using multilevel regression analysis. The results indicate that ZCTAs with a higher proportion of black and Hispanic populations are associated with a higher percentage of COVID-19 infection. Historically low-graded neighborhoods show a higher risk for COVID-19 infection, even for ZCTAs with present-day economic and racial privilege. These associations change over time as the pandemic unfolds. Racial/ethnic minorities are bearing the brunt of the COVID-19 pandemic's health impact. The current evidence shows that the pre-existing social structure in the form of racial residential segregation could be partially responsible for the disparities observed, highlighting an urgent need to stress historical segregation and to build a less segregated and more equal society.

Religious Service Attendance and Mortality among Adults in the United States with Chronic Kidney Disease

Religion and related institutions have resources to help individuals cope with chronic conditions, such as chronic kidney disease (CKD). The purpose of this investigation is to examine the association between religious service attendance and mortality for adults with CKD. Data were drawn from NHANES III linked to the 2015 public use Mortality File to analyze a sample of adults (n = 3558) who had CKD as defined by a single value of estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and/or albumin-to-creatinine ratio ≥17 mg/g for males or ≥25 for females. All-cause mortality was the primary outcome and religious service attendance was the primary independent variable. Cox proportional hazards models were estimated to determine the association between religious service attendance and mortality. The mortality risks for participants who attended a service at least once per week were 21% lower than their peers with CKD who did not attend a religious service at all (HR 0.79; CI 0.64–0.98). The association between religious service attendance and mortality in adults with CKD suggest that prospective studies are needed to examine the influence of faith-related behaviors on clinical outcomes in patients with CKD.

The Association of Posttraumatic Stress Disorder With Longitudinal Change in Glomerular Filtration Rate in World Trade Center Responders

OBJECTIVE

High levels of psychological distress increase the risk of a wide range of medical diseases. In this study, we investigated the association between posttraumatic stress disorder (PTSD) and kidney disease.

METHODS

World Trade Center (WTC) responders were included if they had two or more measures of estimated glomerular filtration rate (eGFR). The PTSD Checklist (PCL) was used to define no PTSD (PCL < 40), "mild" PTSD (40 ≤ PCL <50), and "severe" PTSD (PCL ≥50). Subtypes of PTSD by symptom clusters were analyzed. Multinomial logistic regression was used to estimate the association of PTSD with two GFR change outcomes (decline or increase) compared with the stable GFR outcome.

RESULTS

In 2266 participants, the mean age was 53.1 years, 8.2% were female, and 89.1% were White. Individuals with PTSD (n = 373; 16.5%) did not differ in mean baseline GFR from individuals without PTSD (89.73 versus 90.56 mL min-1 1.73 m-2; p = .29). During a 2.01-year mean follow-up, a mean GFR decline of -1.51 mL min-1 1.73 m-2 per year was noted. In multivariable-adjusted models, PTSD was associated with GFR decline (adjusted relative risk [aRR] = 1.74 [1.32-2.30], p < .001) compared with stable GFR, with "hyperarousal" symptoms showing the strongest association (aRR =2.11 [1.40-3.19]; p < .001). Dose-response effects were evident when comparing mild with severe PTSD and comparing PTSD with versus without depression. PTSD was also associated with GFR rise (aRR = 1.47 [1.10-1.97], p < .009). The association between PTSD and GFR change was stronger in participants older than 50 years.

CONCLUSIONS

PTSD may be a novel risk factor for exaggerated longitudinal GFR change in young, healthy adults. These findings need to be validated in other cohorts.

A Scoping Review of Life-Course Psychosocial Stress and Kidney Function

Increased exposure to maternal psychosocial stress during gestation and adverse neonatal environments has been linked to alterations in developmental programming and health consequences in offspring. A programmed low nephron endowment, among other altered pathways of susceptibility, likely increases the vulnerability to develop chronic kidney disease in later life. Our aim in this scoping review was to identify gaps in the literature by focusing on understanding the association between life-course exposure to psychosocial stress, and the risk of reduced kidney function. A systematic search in four databases (PubMed, ProQuest, Wed of Science, and Scopus) was performed, yielding 609 articles. Following abstract and full-text review, we identified 19 articles meeting our inclusion criteria, reporting associations between different psychosocial stressors and an increase in the prevalence of kidney disease or decline in kidney function, mainly in adulthood. There are a lack of studies that specifically evaluated the association between gestational exposure to psychosocial stress and measures of kidney function or disease in early life, despite the overall evidence consistent with the independent effects of prenatal stress on other perinatal and postnatal outcomes. Further research will establish epidemiological studies with clear and more comparable psychosocial stressors to solve this critical research gap.

Poverty, Racism, and the Public Health Crisis in America

The purpose of this article is to discuss poverty as a multidimensional factor influencing health. We will also explicate how racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. Poverty is one of the most significant challenges for our society in this millennium. Over 40% of the world lives in poverty. The U.S. has one of the highest rates of poverty in the developed world, despite its collective wealth, and the burden falls disproportionately on communities of color. A common narrative for the relatively high prevalence of poverty among marginalized minority communities is predicated on racist notions of racial inferiority and frequent denial of the structural forms of racism and classism that have contributed to public health crises in the United States and across the globe. Importantly, poverty is much more than just a low-income household. It reflects economic well-being, the ability to negotiate society relative to education of an individual, socioeconomic or health status, as well as social exclusion based on institutional policies, practices, and behaviors. Until structural racism and economic injustice can be resolved, the use of evidence-based prevention and early intervention initiatives to mitigate untoward effects of socioeconomic deprivation in communities of color such as the use of social media/culturally concordant health education, social support, such as social networks, primary intervention strategies, and more will be critical to address the persistent racial/ethnic disparities in chronic diseases.

A randomized trial of race-related stress among African Americans with chronic kidney disease

OBJECTIVE

African Americans progress from early to late-stage chronic kidney disease (CKD) at a rate that is three times that of Whites. Given research that implicates social stress in poor kidney outcomes, there is a need to examine whether race-related stress contributes to these disparities. Through experimental manipulation, this study sought to determine whether acute race-related stress was associated with autonomic arousal and an inflammatory marker, which are well-established pathways to poor kidney outcomes. Further we tested the hypothesis that expectations of racism may moderate this relationship.

METHOD

Fifty-two African American patients along the CKD continuum were randomized to recall a general or race-related stressful experience. Before, during, and after the recall, patients' blood pressure and Interleukin-6 (IL-6) were monitored. Prior to the experimental manipulation, participants completed self-reported measures of expectations of racism.

RESULTS

Across both study conditions, change in self-reported distress from baseline to stress was associated with both systolic and diastolic reactivity (both ps <.01), but not change in IL-6 responses (all ps > 0.05). A significant interaction revealed that those who were randomized to recall a race-related stressor demonstrated less diastolic blood pressure reactivity (F=4.80, p<.05) if they scored lower in expectations of racism as compared to those who scored high. Moreover, those who were randomized to the race-related stressor demonstrated greater increase in IL-6 from 45 to 90 min post-recall than those who recalled a general stressor (F=6.35, p<.05).

CONCLUSIONS

Acute race-related stress may be associated with autonomic arousal and inflammatory response among African American patients along the CKD continuum, suggesting the need to further understand its role in racial disparities in CKD progression.

The Voices of Black South African Men on Renal Dialysis at a Tertiary Hospital: A Phenomenological Inquiry

The study explored the psychosocial experiences of rural black South African men undergoing renal dialysis in a tertiary hospital. Twenty men aged between 20 and 59 years (Meanage = 40.65 yrs; SD = 12.52) participated in the study. Participants were recruited purposefully. Data were collected over a period of 4 months through in-depth face-to-face interviews and analyzed using the Interpretative Phenomenological Analytical method. The following three key themes were extracted from the interviews: (a) the emotional pain and fear of death following a diagnosis of ESRD; (b) living on dialysis interferes with the management and handling of "manly" responsibilities and duties and, (c) dialysis as a challenging yet life-saving measure. The findings further suggest that renal dialysis has an impact on men's sense of masculinity and has the potential to complicate the management of renal failure. The paper concludes by recommending that cultural and community factors be taken into account when considering interventions to manage the health of men living with renal conditions.

Avaliação da modulação autonômica da frequência cardíaca de pacientes com doença renal crônica em hemodiálise: estudo preliminar

RESUMO A doença renal crônica (DRC) é definida como dano à função renal. Doentes renais crônicos atingem alta prevalência de morte por eventos cardiovasculares antes dos estágios finais, sendo maior a mortalidade em estágio dialítico, em que é evidenciado um desequilíbrio autonômico. Objetivamos avaliar a modulação simpatovagal de pacientes com DRC em tratamento de hemodiálise ambulatorial. Foram avaliados 23 pacientes, divididos em: Grupo DRC com DRC no estágio 5D (DRC-5D) em tratamento regular de hemodiálise ambulatorial; Grupo-controle com indivíduos saudáveis. A variabilidade da frequência cardíaca (VFC) foi coletada por um cardiofrequencímetro e analisada por índices lineares do domínio do tempo e do domínio da frequência. 14 pacientes no Grupo DRC com média de idade 48±16; e 9 pacientes saudáveis no Grupo-controle com média de idade 64±5. Nos resultados pelo domínio de tempo, o Grupo DRC mostrou valores significativamente maiores da frequência cardíaca (FC) comparado ao Grupo-controle (83,49±13,09 bpm vs. 67,88±9,43 bpm). Todavia, os índices média dos intervalos R-R (735,82±121,54 ms vs. 898,94±123,58 ms), RMSSD (11,75±11,86 ms vs. 20,03±6,80 ms), SDNN (17,06±9,81ms vs. 28,42±7,62 ms) do Grupo DRC mostraram valores significativamente menores comparados aos do Grupo-controle, respectivamente. Nos resultados pelo domínio da frequência, o Grupo DRC mostrou valores significativamente menores em comparação ao Grupo-controle nos índices BFab (129,7±184,3 ms vs. 262,31±168,15 ms) e AFab (82,70±227,66 ms vs. 180,77±119,85 ms). Pacientes com DRC em hemodiálise apresentaram redução da modulação parassimpática quando comparados com indivíduos saudáveis, sugerindo prejuízo do balanço simpatovagal e, consequente, disfunção autonômica cardíaca.

Analysis of chronic kidney disease among national hospitalization data with 14 million children

BACKGROUND

The main purpose was to determine basic epidemiological data on CKD among hospitalized pediatric patients in China.

METHODS

Data from pediatric inpatients with CKD hospitalized from June 1, 2013 to May 31, 2017 were extracted from the electronic records of HQMS database, which includes over 14 million inpatients. Codes from the 10th revision of the International Classification of Diseases (ICD-10) were used to search the database.

RESULTS

A total of 524 primary diseases of CKD were included in this study. In all, there were 278 231 pediatric inpatients with CKD, which accounted for 1.95 % of the 14 250 594 pediatric inpatients registered in the HQMS database. The number of pediatric inpatients with CKD was 67 498 in 2013, 76 810 in 2014, 81 665 in 2015 and 82 649 in 2016, which accounted for 1.93 %, 1.93 %, 1.99 and 2.09 %, respectively, of the total population of pediatric inpatients. The etiology of CKD was secondary nephrosis in 37.95 % of cases, which ranked first and followed by CAKUT with a percentage of 24.61 %. Glomerular diseases and cystic kidney disease accounted for 21.18 and 5.07 %, respectively. Among all 278 231 patients, 6 581 (2.37 %) had a primary discharge diagnosis of CKD. The renal pathology findings of CKD showed that IgA accounted for 51.17 %.

CONCLUSIONS

This study provides a descriptive analysis of the hospitalized population of pediatric CKD patients. Our study provides important, fundamental data for policy making and legislation, registry implementation and the diagnosis, treatment and prevention of CKD in China.

Association of Noise Annoyance with Measured Renal Hemodynamic Changes

BACKGROUND

Chronic mental stress is recognized as a modifiable risk factor for cardiovascular disease. The aim of this study was to demonstrate that noise annoyance-induced stress is associated with changes in renal hemodynamics.

METHODS

Renal hemodynamic parameters were measured using steady-state input clearance with infusion of para-aminohippuric acid and inulin in individuals with normal, high normal, and elevated blood pressure. All individuals ranked subjective annoyance due to noise in everyday life on a 7-grade Likert scale. The median of all rankings was used as a cutoff point to divide the group into noise-annoyed and non-noise-annoyed individuals. Different renal hemodynamic parameters were calculated based on the Gomez equation.

RESULTS

Noise-annoyed individuals (n = 58) showed lower renal plasma flow (599 ± 106 vs. 663 ± 124 mL/min, p = 0.009), lower renal blood flow (1,068 ± 203 vs. 1,172 ± 225 mL/min, p = 0.047), higher filtration fraction (22.7 ± 3.3 vs. 21.3 ± 3.0, p = 0.012), higher renal vascular resistance (88.9 ± 25.6 vs. 75.8 ± 22.9 mm Hg/[mL/min], p = 0.002), and higher resistance of afferent arteriole (2,439.5 ± 1,253.4 vs. 1,849.9 ± 1,242.0 dyn s-1 cm-5, p = 0.001) compared to non-noise-annoyed individuals (n = 55). There was no difference in measured glomerular filtration rate (133 ± 11.8 vs. 138 ± 15 mL/min, p = 0.181), resistance of efferent arteriole (2,419.4 ± 472.2 vs. 2,245.8 ± 370.3 dyn s-1 cm-5, p = 0.060), and intraglomerular pressure (64.0 ± 3.1 vs. 64.6 ± 3.5 mm Hg, p = 0.298) between the groups. After adjusting for age, renal plasma flow, renal blood flow, and renal vascular resistance remained significantly different between the groups, with a trend in increased afferent arteriolar resistance and filtration fraction.

CONCLUSION

In this study, noise annoyance was associated with reduced renal perfusion attributed to increased renal vascular resistance predominantly at the afferent site. Long-term consequences of this renal hemodynamic pattern due to noise annoyance need to be investigated.

Understanding the heart-brain axis response in COVID-19 patients: A suggestive perspective for therapeutic development

In-depth characterization of heart-brain communication in critically ill patients with severe acute respiratory failure is attracting significant interest in the COronaVIrus Disease 19 (COVID-19) pandemic era during intensive care unit (ICU) stay and after ICU or hospital discharge. Emerging research has provided new insights into pathogenic role of the deregulation of the heart-brain axis (HBA), a bidirectional flow of information, in leading to severe multiorgan disease syndrome (MODS) in patients with confirmed infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Noteworthy, HBA dysfunction may worsen the outcome of the COVID-19 patients. In this review, we discuss the critical role HBA plays in both promoting and limiting MODS in COVID-19. We also highlight the role of HBA as new target for novel therapeutic strategies in COVID-19 in order to open new translational frontiers of care. This is a translational perspective from the Italian Society of Cardiovascular Researches.

Stress Related Disorders and the Risk of Kidney Disease

INTRODUCTION

Stress related disorders (SRDs, i.e., psychiatric disorders induced by significant life stressors) increase vulnerability to health problems. Whether SRDs associate with risk of acute kidney injury (AKI) and chronic kidney disease (CKD) is unknown.

METHODS

A population-matched cohort study in Sweden included 30,998 patients receiving a SRDs diagnosis and 116,677 unexposed patients matched by age, sex and estimated glomerular filtration rates (eGFR). The primary outcome was CKD progression, defined as a sustained relative decline in eGFR of more than 40% or commencement of kidney replacement therapy. The secondary outcome was AKI, defined by death or hospitalization attributed to AKI or rapid creatinine changes (increase ≥ 0.3 mg/d over 48 hours or 1.5x over 7 days). Cox models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

During a medium follow-up of 3.2 years, compared to the unexposed, patients with SRDs (median age 45 years, 71% women), were at increased risk of CKD progression (HR 1.23, 95% CI 1.10-1.37) and AKI (HR 1.22, 95% CI 1.04-1.42). While the HR of CKD progression remained similarly elevated during the entire follow-up period, the association with AKI was only observed during the first year after SRDs diagnosis. Results were consistent in stratified analyses, when only considering AKI-hospitalizations/death, and when disregarding eGFR measurements close to index date.

CONCLUSIONS

A diagnosis of SRDs is associated with subsequent risk of AKI and CKD progression. While studies should confirm this observation and characterize underlying mechanisms, close monitoring of kidney function following SRDs diagnosis may be indicated.

Association between goal-striving stress and rapid kidney function decline among African Americans: the Jackson Heart Study

African Americans (AAs) are disproportionately affected by kidney disease and also report higher psychosocial stressors than other racial groups. Goal-striving stress (GSS) is an understudied psychosocial stressor related to attempting to accomplish one's life goals. Given the numerous social determinants that contribute to health inequities among AAs, stress from goal striving may also disproportionately affect the health of AAs and in particular kidney disease outcomes. The objective of this study was to explore the association between GSS and rapid kidney function decline (RKFD) in an AA cohort. Using examination 1 (2000-2004) and examination 3 (2009-2013) data from the Jackson Heart Study (n=2630), we examined associations of baseline levels of GSS with RKFD among AAs using multivariable Poisson regression models, adjusting for sociodemographics, health behaviors, chronic disease and discrimination. We also explored baseline cortisol as a mediator. The incidence of RKFD in this sample was 7.34% (mean years of follow-up: 8.06±0.84 years). The mean GSS score was 3.80 (±4.88) and total GSS score ranged from 0 to 36. Those who reported high (vs low) GSS were 1.60 times more likely to experience RKFD after full adjustment (incidence rate ratio (IRR) 1.60; 95% CI 1.11 to 2.14, p=0.01). After confirming cortisol as a mediator and adding it to the model, those who reported high (vs low) GSS had 1.58 times the rate of RKFD (IRR 1.58; 95% CI 1.09 to 2.30, p=0.0153). Stress related to not achieving goals was associated with a greater risk of RKFD in this sample of AAs.

Understanding the Link between Neighborhoods and Kidney Disease

Neighborhoods are where we live, learn, work, pray, and play. Growing evidence indicates that neighborhoods are an important determinant of health. The built features of our neighborhoods, such as the ways in which the streets are designed and connected and the availability of green spaces and transit stops, as well as the social features, such as the trust among neighbors and the perceptions of safety, may influence health through multiple pathways, such as access to important resources, psychosocial stress, and health behaviors. In particular, the extant literature consistently documents an association between neighborhood features and renal-associated conditions, such as cardiovascular disease, hypertension, diabetes, and obesity. There is also some evidence suggesting an association between neighborhood poverty and ESKD. The link between neighborhood and earlier stages of CKD, however, has been less clear, with most studies documenting no association. It may be that the neighborhood measures used in previous studies do not capture features of the neighborhood important for earlier stages of disease development and progression. It may also be that our current biomarkers (e.g., eGFR) and urine protein are not able to pick up very early forms of renal damage because of the kidney's overall high reserve capacity. This paper critically reviews the state of the literature on neighborhood and renal disease, with recommendations for neighborhood measures in future research. Neighborhoods are designed, built, and informed by policy, and thus, they are amenable to intervention, making them a potentially powerful way to improve renal health and reduce health inequalities at the population level.

Long work hours and decreased glomerular filtration rate in the Korean working population

OBJECTIVES

We studied the association between long working hours and decreased kidney function, which was determined using estimated glomerular filtration rate (eGFR), among the working population in South Korea.

METHODS

We analysed nationally representative cross-sectional data for 20 851 Korean workers ≥20 years of age. A negative binomial regression model was used to test differences in the prevalence of chronic kidney disease (eGFR <60 mL/min/1.73 m²) among workers divided into groups according to weekly working hours (<30, 30-40, 41-51 and ≥52 hours/week). Multivariate linear regression analysis was performed to investigate the association between weekly working hours and eGFR, with adjustments made for age, sex/gender, income, education, shift work, occupation, smoking, alcohol use, hypertension, diabetes mellitus, body mass index, systolic blood pressure, fasting blood glucose and total serum cholesterol.

RESULTS

A 1-hour increase in weekly working hours was associated with 0.057 mL/min/1.73 m² (95% CI 0.005 to 0.109) decrease in eGFR among participants who worked ≥52 hours/week. Among participants without hypertension or diabetes, a 1-hour increase in weekly working hours was significantly associated with 0.248 and 0.209 mL/min/1.73 m² decrease in eGFR among participants who worked 30-40 hours/week and 41-51 hours/week, respectively.

CONCLUSION

Long working hours are associated with decreased kidney function. We expect that our findings could call for more research regarding this association and provide policy-oriented perspectives.

The impact of health literacy environment on patient stress: a systematic review

Background

There exists little literature on situational health literacy - that is, how an individual’s health literacy varies across different health literacy environments. However, one can consider the role of stress when examining the relationship between health situations and decision-making ability, and by proxy health literacy. The aim of this study was to assess the strength of the evidence on the relationship between health situations and patient stress, considered in the context of health professional perception, and determine what health situations act to influence patient stress.

Methods

A systematic review of English articles using PubMed, PsycINFO, CINAHL and Embase databases was conducted. Search terms focused on ‘patient’, ‘stress’, and ‘health care situations’. Only peer-reviewed original research with data on patient stress in the context of a health facility environment was included. Studies were screened and critically appraised by both authors. Study elements for extraction were defined by RO and extracted by JY.

Results

Twenty-four studies were included for narrative synthesis. Patients in Intensive Care Units were more stressed about factors relating to their physical discomfort, with some agreement from health care professionals. Parents of children in Intensive Care Units were more concerned with stressors relating to their child’s appearance and behaviour, and alteration in their parental role. Few studies examined health settings other than Intensive Care Units, and those that did varied greatly in terms of study design and population characteristics, lacking generalisability.

Conclusions

Overall, the findings of what patients find most stressful in Intensive Care Units can guide health care professionals practicing best practice care. However, the evidence on how patient stress is influenced by non-Intensive Care Unit health care settings is weak. Further research is needed to enhance current understanding of the interaction between patient stress and health care environments in both hospital and primary care settings.

Behavioral Changes During Development of Chronic Kidney Disease in Rats

Decreased renal function due to chronic kidney disease (CKD) is associated with anxiety and cognitive decline. Although these mental disorders are often obvious in late stage renal disease patients, they might be unnoticeable or are neglected in early stages of the CKD development. Associations between renal and cognitive dysfunction have been indicated by studies performed mainly in patients undergoing dialysis, which itself represents a stress and decreased quality of life. However, experimental and causal studies are scarce. Our aim was to investigate dynamic changes in behavioral traits during the progression of CKD in an animal model. Thirty 12-week old male rats were used in this experiment. CKD was induced by a subtotal (5/6) nephrectomy. Two, 4, and 6 months after surgical induction of CKD, the open field, the light-dark box and the novel object recognition tests were conducted to assess the locomotor activity, anxiety-like behavior and the memory function of rats. Blood urea nitrogen (BUN), plasma concentration of creatinine (CREAT), albumin to creatinine ratio in urine (ACR) along with the renal histology were assessed to monitor the development and severity of CKD. In comparison to control rats, 5/6 nephrectomized rats had by 46–66% higher concentration of BUN during the whole follow-up period, as well as by 52% and by 167% higher CREAT and ACR, respectively, 6 months after surgery. Although the effect of time was observed in some behavioral parameters, nephrectomy did not significantly influence either locomotor activity, or anxiety-like behavior, or memory function of animals. Two and 4 months after surgery, animals moved shorter distance and spent less time in the center zone. However, the open-field ambulation returned back to the baseline level 6 months after CKD induction. Although nephrectomized rats displayed impaired kidney function as early as 2 months after surgery, no significant differences were found between the CKD and the control rats in any of the observed behaviors. Further studies are needed in order to evaluate whether behavioral abnormalities are related to severity of CKD or might be attributed to psychosocial aspect of end-stage renal disease and decreased quality of life in dialysis patients.

Commonalities and differences in abnormal peripheral metabolites between patients with fibromyalgia and complex regional pain syndrome

Background: Fibromyalgia (FM) and complex regional pain syndrome (CRPS) share many pathological mechanisms related to chronic pain that could contribute to multifactorial pathological mechanisms.Methods: We investigated peripheral metabolites in FM and CRPS patients compared to healthy controls based on cross-sectional study.Results: Mean corpuscular hemoglobin (p < 0.001), mean corpuscular volume (p = 0.014), and total bilirubin levels (p = 0.017) were lower in FM patients than in healthy controls. On the other hand, CRPS patients showed lower levels of total bilirubin than healthy controls (p = 0.037). Creatinine level was lower in FM patients (p = 0.057) compared to healthy controls, particularly when comparing the low-hemoglobin subgroup among FM patients (p = 0.035) with the low-hemoglobin subgroup among healthy controls. Red blood cell count (r = -0.620, p = 0.031), hematocrit (r = -0.593, p = 0.042), and creatinine level (r = -0.598, p = 0.040) showed negative correlations with McGill Pain Questionnaire-Affective (MPQ-A) scores in FM patients. A negative correlation was observed between MCV and McGill Pain Questionnaire-Sensory scores (r = -0.680, p = 0.015) in CRPS patients.Conclusion: We found specific peripheral metabolites that may exhibit different tendency between FM and CRPS patients as well as some common metabolites, which may be associated with peripheral pathology in the patients. Considering this study had a few limitations such as a small sample sizes and using a liberal threshold of significance in the correlation analysis, future studies with larger sample sizes may be needed to generalize these findings.

Cross-sectional study of association between psychosocial stressors with chronic kidney disease among migrant and non-migrant Ghanaians living in Europe and Ghana: the RODAM study

OBJECTIVES

The association between psychosocial stressors (PS) and chronic kidney disease (CKD) among sub-Saharan African (SSA) populations is unknown. We examined the association between PS and CKD prevalence among rural and urban Ghanaians and Ghanaian migrants living in three European cities. We also assessed if the influence of PS on CKD is partially mediated by primary risk factors (hypertension and diabetes) of CKD.

DESIGN

A multi-centred cross sectional data from the Research on Obesity and Diabetes among African Migrants study.

SETTING

Rural and urban Ghana and three European cities (Amsterdam, Berlin and London).

PARTICIPANTS

A random sample of 5659 adults (Europe 3167, rural Ghana 1043 and urban Ghana 1449) aged 25-70 years.

EXPLANATORY MEASURES

PS defined by negative life events, perceived discrimination, perceived stress at work/home and depressive symptoms. Three CKD outcomes were considered using the 2012 Kidney Disease: Improving Global Outcomes severity of CKD classification. Comparisons between PS and CKD outcomes were made using logistic regression analyses across all sites.

RESULTS

We observed higher proportion of negative life events (68.7%) and perceived permanent stress (15.9%) among Ghanaians living in Ghana than Ghanaians living in Europe. Depressive symptoms (7.5%) and perceived discrimination (29.7%) were more common among Ghanaians living in Europe than Ghanaians living in Ghana. No significant association was observed between any of the PS constructs and CKD outcomes across sites except for positive association between stress at work/home and albuminuria (2.81, 95% CI 1.46 to 5.40) and CKD risk (2.78, 95% CI 1.43 to 5.43) among Ghanaians living in Berlin.

CONCLUSION

Our study found a positive association between stress at work/home and albuminuria and CKD risk. There was no convincing evidence of associations between the other PS constructs and the prevalence of CKD risk. Further studies are needed to identify potential factors driving the high prevalence of CKD among these populations.

"I Try Not to Even Think About My Health Going Bad": a Qualitative Study of Chronic Kidney Disease Knowledge and Coping Among a Group of Urban African-American Patients with CKD

CONTEXT

African-Americans with chronic kidney disease (CKD) are more likely to progress to end-stage renal disease (ESRD). However, African-Americans are less likely to receive care to delay progression of their CKD and to prepare for ESRD treatment.

OBJECTIVE

The objectives of the study are to understand knowledge among urban, African-American patients diagnosed with CKD and to discover ways they managed their illness and prepared for kidney disease progression.

DESIGN

A qualitative study was conducted using structured interviews. Thematic analysis was used for data interpretation. All 23 participants identified as African-American and had CKD but had not yet reached ESRD requiring renal replacement therapy (RRT). Over half of the participants were women (57%), and the mean age was 53 years old.

RESULTS

Three themes emerged from the data. African-Americans often did not know the severity of their CKD. They struggled to complete all of the diet, exercise, and medication tasks recommended to manage their health conditions, including CKD. Finally, participants, even those with stage 5 CKD, viewed progression to RRT in the next 12 months as unlikely.

CONCLUSION

African-Americans face many barriers to CKD self-care and preparation for ESRD. Improving outcomes requires clinicians to help patients understand the severity of their CKD, to make informed choices about their care, all the while motivating patients to take actions to prevent CKD progression.

Exercise in Individuals With CKD: A Focus Group Study Exploring Patient Attitudes, Motivations, and Barriers to Exercise

Rationale & Objective

Data suggest that exercise is beneficial for patients with chronic kidney disease (CKD) to reduce cardiovascular disease and the progression of CKD. Despite these benefits, the majority of patients with CKD remain sedentary. The purpose of this study was to identify attitudes, motivators, and barriers to exercise among individuals with CKD.

Study Design

Qualitative study.

Setting & Participants

10 focus groups (41 adult participants with CKD stages 3-4 who were not currently exercising) from the Denver Metro Area.

Analytical Approach

Thematic analysis. Clinics were purposively sampled. Focus groups were recorded and transcribed.

Results

We identified 7 themes reflecting perceptions of exercise of patients with CKD: improvement in health and quality of life; motivation from family, friends, or peers; limitations due to comorbid conditions; challenges due to environmental factors (safety, weather, and cost concerns); lack of time; family as a barrier; and lack of provider counseling on type of exercise and the benefits. Participants recognized the benefits of exercise on health, but exercise was not viewed to have a significant impact on CKD. Having a friend, family member, or group to exercise with was viewed as a significant motivator. However, particularly in Spanish-speaking participants, family was often seen as a barrier if they were not willing to exercise with the patients. Most participants expressed receiving limited information from their kidney provider regarding how exercise affected their kidney health. Spanish-speaking participants in particular expressed frustration with their nephrologist's lack of advice regarding exercise.

Limitations

Potential selection bias and inclusion of only sedentary patients with CKD.

Conclusions

Barriers and motivators to exercise were similar among participating men and women with CKD. Lack of advice from kidney providers regarding exercise was a significant barrier. Exercise interventions in patients with CKD should include not only increased patient self-efficacy and social support, but also counseling and prescribing of exercise by nephrologists.

Sex, Race, Food Security, and Sugar Consumption Change Efficacy Among Low-Income Parents in an Urban Primary Care Setting

The purpose of this study was to examine relationships between food security and parents' self-efficacy to reduce consumption of sugar-sweetened beverages and sugary snacks in a sample of parents in waiting rooms in community-based primary care clinics in West Tennessee. Results from logistic regression models underscore the need for nuanced analysis, as the results from the pooled regression models differ from those stratified by food security status. Self-efficacy is an important factor for behavior change, and our study highlights the need for additional research examining how social, psychological, and behavioral factors have implications for behavior change self-efficacy.

Why are hospitalisations too long? A simple checklist for identifying the main social barriers to hospital discharge from a nephrology ward

The present increase in life span has been accompanied by an even higher increase in the burden of comorbidity. The challenges to healthcare systems are enormous and performance measures have been introduced to make the provision of healthcare more cost-efficient. Performance of hospitalisation is basically defined by the relationship between hospital stay, use of hospital resources, and main diagnosis/diagnoses and complication(s), adjusted for case mix. These factors, combined in different indexes, are compared with the performance of similar hospitals in the same and other countries. The reasons why an approach like this is being employed are clear.Cutting costs cannot be the only criteria, in particular in elderly, high-comorbidity patients: in this population, although social issues are important determinants of hospital stay, they are rarely taken into account or quantified in evaluations. Quantifying the impact of the "social barriers" to care can serve as a marker of the overall quality of treatment a network provides, and point to specific out-of-hospital needs, necessary to improve in-hospital performance. We therefore propose a simple, empiric medico-social checklist that can be used in nephrology wards to assess the presence of social barriers to hospital discharge and quantify their weight.Using the checklist should allow: identifying patients with social frailty that could complicate hospitalisation and/or discharge; evaluating the social needs of patient and entourage at the beginning of hospitalisation, adopting timely procedures, within the partnership with out-of-hospital teams; facilitating prioritization of interventions by social workers.The following ten items were empirically identified: reason for hospitalisation; hospitalisation in relation to the caregiver's problems; recurrent unplanned hospitalisations or early re-hospitalisation; social/family isolation; presence of a dependent relative in the patient's household; lack of housing or unsuitable housing/accommodation; loss of autonomy; lack of economic resources; lack of a safe environment; evidence of physical or psychological abuse.The simple tool here described needs validation; the present proposal is aimed at raising attention on the importance of non-medical issues in medical organisation in our specialty, and is open to discussion, to allow its refinement.

Discrimination and Chronic Kidney Disease among Caribbean Blacks: The Effects of Immigration and Social Status

This study examined the association between discrimination and chronic kidney disease (CKD) among Caribbean blacks and how this association varies by marital status, educational attainment, and length of U.S. residency within the frameworks for the stress buffering hypothesis and stress process model. The analysis was based on the Caribbean black subsample of the National Survey of American Life (N = 1551). Logistic regression models were conducted to test the aims of this study. The findings indicate that the association between discrimination and CKD varied by length of U.S. residency, marital status, and education. Overall, the findings demonstrate the importance of considering immigration and sociodemographic context when investigating the relation between discrimination and CKD in immigrant populations.

Goal-Striving Stress Is Associated with Chronic Kidney Disease Among Participants in the Jackson Heart Study

OBJECTIVE

Research that assesses the relationship between psychosocial factors and chronic kidney disease (CKD) among African Americans (AAs) is limited. Using the Jackson Heart Study (JHS) cohort data, we investigated the association of goal-striving stress (GSS)-the stress experienced from not reaching goals-with prevalent CKD among AAs.

DESIGN

This was a cross-sectional analysis of JHS exam 1 data that assessed the relationship between GSS and CKD.

SETTING AND PARTICIPANTS

We utilized a sample from the JHS (n = 4967), an AA sample of women and men, 35-84 years old from the Jackson, MS metro area.

MAIN OUTCOME MEASURES

The baseline relationship between GSS levels (low, moderate, and high) and CKD (eGFR < 60 mL/min/1.73m²) was evaluated using a logistic regression model to estimate odds ratios (OR) on a 95% confidence interval (CI). The final model was adjusted for sex, age, socioeconomic status, health behaviors, risk factors, and total stress.

RESULTS

After full adjustment, the odds of prevalent CKD increased by 52% (OR 1.52; 95% CI 1.04, 2.24) for those reporting high (versus low) GSS.

CONCLUSIONS

Deficiencies between goal aspiration and achievement were associated with prevalent CKD. Potential interventions might consider the impact GSS contributes to prevalent CKD.

Low Estimated Glomerular Filtration Rate Is Prevalent among North Korean Refugees in South Korea

Background

The number of North Korean refugees entering South Korea is rising. Few studies have investigated the risk of non-communicable disease in North Korean refugees. Moreover, kidney insufficiency, a risk factor for cardiovascular disease, has not been studied in this population. We compared the prevalence of non-communicable disease and kidney function in North Korean refugees and South Koreans.

Methods

Our study was conducted using a case-control design. We enrolled 118 North Korean refugees from the Hana Center and selected 472 randomly sampled South Korean individuals as controls, who were age- and sex-matched with the North Korean refugees in a ratio of 1:4, from the 2014 Korea National Health and Nutrition Examination Survey database.

Results

The prevalence of non-communicable disease did not differ significantly between the groups; however, a low estimated glomerular filtration rate (eGFR; <90 mL/min per 1.73 m²) was more prevalent in the North Korean refugees than in the South Korean population (52.1% vs. 29.9%, P<0.001). After adjusting for covariates and weight gain after escape, the prevalence of a low eGFR was associated with the length of residence in South Korea (odds ratio, 2.84; 95% confidence interval, 1.02–7.89).

Conclusion

The prevalence of non-communicable disease did not differ between North Korean refugees and the South Korean population, while a low eGFR was more prevalent in North Korean refugees than in South Koreans. Moreover, after adjusting for other covariates, the prevalence of a low eGFR in North Korean refugees was associated with the length of residence in South Korea.

Heart Rate Variability and Its Relation to Chronic Kidney Disease: Results From the PREVEND Study

OBJECTIVE

In the general population, reduced heart rate variability (HRV) has been associated with cardiovascular disease. However, its relation to chronic kidney disease (CKD) is debated. We therefore investigated the relation between low HRV and renal outcomes.

METHODS

In the population-based Prevention of REnal and Vascular ENdstage Disease study, renal outcomes (CKD, estimated glomerular filtration rate [eGFR], urinary albumin) were measured at baseline and three consecutive examinations. HRV measures (among which SDNN [standard deviation of normal-to-normal RR intervals]) were calculated from time series of beat-to-beat pulse wave recordings at baseline. The lowest (risk) quartile was compared with the upper three quartiles combined, in multivariable survival and linear mixed-effects analyses.

RESULTS

In 4605 participants (49% males, age range = 33-80, 0.6% blacks), we observed 341 new participants of CKD during a median follow-up duration of 7.4 years. Low SDNN was associated with higher incidence of CKD (crude HR = 1.66, 95% CI = 1.30 to 2.12, p < .001), but this association was no longer significant after adjustment for age, sex, and cardiovascular risk factors (adjusted HR = 1.13, 95% CI = 0.86 to 1.48, p = .40, similar for other HRV measures). No associations between SDNN and eGFR trajectories were found in the total sample. However, in a subgroup of participants with baseline CKD (n = 939), we found a significant association of low SDNN (but not other HRV measures) with lower baseline eGFR, even after multivariable adjustment (adjusted βlevel difference = -3.73 ml/min/1.73 m, 95% CI = -6.70 to -0.75, p = .014), but not with steeper eGFR decline.

CONCLUSIONS

These results suggest that reduced HRV may be a complication of CKD rather than a causal factor.

Nondepressive Psychosocial Factors and CKD Outcomes in Black Americans

BACKGROUND AND OBJECTIVES

Established risk factors for CKD do not fully account for risk of CKD in black Americans. We studied the association of nondepressive psychosocial factors with risk of CKD in the Jackson Heart Study.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used principal component analysis to identify underlying constructs from 12 psychosocial baseline variables (perceived daily, lifetime, and burden of lifetime discrimination; stress; anger in; anger out; hostility; pessimism; John Henryism; spirituality; perceived social status; and social support). Using multivariable models adjusted for demographics and comorbidity, we examined the association of psychosocial variables with baseline CKD prevalence, eGFR decline, and incident CKD during follow-up.

RESULTS

Of 3390 (64%) Jackson Heart Study participants with the required data, 656 (19%) had prevalent CKD. Those with CKD (versus no CKD) had lower perceived daily (mean [SD] score =7.6 [8.5] versus 9.7 [9.0]) and lifetime discrimination (2.5 [2.0] versus 3.1 [2.2]), lower perceived stress (4.2 [4.0] versus 5.2 [4.4]), higher hostility (12.1 [5.2] versus 11.5 [4.8]), higher John Henryism (30.0 [4.8] versus 29.7 [4.4]), and higher pessimism (2.3 [2.2] versus 2.0 [2.1]; all P<0.05). Principal component analysis identified three factors from the 12 psychosocial variables: factor 1, life stressors (perceived discrimination, stress); factor 2, moods (anger, hostility); and, factor 3, coping strategies (John Henryism, spirituality, social status, social support). After adjustments, factor 1 (life stressors) was negatively associated with prevalent CKD at baseline among women only: odds ratio, 0.76 (95% confidence interval, 0.65 to 0.89). After a median follow-up of 8 years, identified psychosocial factors were not significantly associated with eGFR decline (life stressors: β=0.08; 95% confidence interval, -0.02 to 0.17; moods: β=0.03; 95% confidence interval, -0.06 to 0.13; coping: β=-0.02; 95% confidence interval, -0.12 to 0.08) or incident CKD (life stressors: odds ratio, 1.07; 95% confidence interval, 0.88 to 1.29; moods: odds ratio, 1.02; 95% confidence interval, 0.84 to 1.24; coping: odds ratio, 0.91; 95% confidence interval, 0.75 to 1.11).

CONCLUSIONS

Greater life stressors were associated with lower prevalence of CKD at baseline in the Jackson Heart Study. However, psychosocial factors were not associated with risk of CKD over a median follow-up of 8 years.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_01_03_CJASNPodcast_18_2_L.mp3.

Discrimination and Hate Crimes in the Context of Neighborhood Poverty and Stressors Among HIV-Positive African-American Men Who Have Sex with Men

In a sample of HIV-positive African-American men who have sex with men (MSM), we examined neighborhood factors that may contextualize perceived discrimination from three intersecting stigmatized characteristics: race, HIV status, and sexual orientation. HIV-positive African-American MSM (N = 162, mean age = 44, SD = 8) provided information on neighborhood-related stressors and discrimination experiences related to being Black, HIV-positive, or perceived as gay. Residential ZIP codes and US Census data were used to determine neighborhood poverty rates. Regressions, controlling for socio-demographics, indicated that (1) higher neighborhood poverty was significantly related to more frequent experiences with hate crimes (Gay-related: b = 1.15, SE = .43, p < .008); and (2) higher neighborhood-related stressors were significantly related to more frequent discrimination (Black-related: b = .91, SE = .28, p = .001; gay-related: b = .71, SE = .29, p = .01; and HIV-related: b = .65, SE = .28, p = .02) and hate crimes (Gay-related: b = .48, SE = .13, p = .001; and Black-related: b = .28, SE = .14, p = .04). For HIV-positive African-American MSM, higher neighborhood poverty and related stressors are associated with experiencing more discrimination and hate crimes. Interventions for this group should promote individual- and neighborhood-level socioeconomic empowerment and stigma reduction.

Influence of socioeconomic status on the whole blood transcriptome in African Americans

BACKGROUND

The correlation between low socioeconomic status (SES) and poor health outcome or higher risk of disease has been consistently reported by many epidemiological studies across various race/ancestry groups. However, the biological mechanisms linking low SES to disease and/or disease risk factors are not well understood and remain relatively under-studied. The analysis of the blood transcriptome is a promising window for elucidating how social and environmental factors influence the molecular networks governing health and disease. To further define the mechanistic pathways between social determinants and health, this study examined the impact of SES on the blood transcriptome in a sample of African-Americans.

METHODS

An integrative approach leveraging three complementary methods (Weighted Gene Co-expression Network Analysis, Random Forest and Differential Expression) was adopted to identify the most predictive and robust transcriptome pathways associated with SES. We analyzed the expression of 15079 genes (RNA-seq) from whole blood across 36 samples.

RESULTS

The results revealed a cluster of 141 co-expressed genes over-expressed in the low SES group. Three pro-inflammatory pathways (IL-8 Signaling, NF-κB Signaling and Dendritic Cell Maturation) are activated in this module and over-expressed in low SES. Random Forest analysis revealed 55 of the 141 genes that, collectively, predict SES with an area under the curve of 0.85. One third of the 141 genes are significantly over-expressed in the low SES group.

CONCLUSION

Lower SES has consistently been linked to many social and environmental conditions acting as stressors and known to be correlated with vulnerability to chronic illnesses (e.g. asthma, diabetes) associated with a chronic inflammatory state. Our unbiased analysis of the blood transcriptome in African-Americans revealed evidence of a robust molecular signature of increased inflammation associated with low SES. The results provide a plausible link between the social factors and chronic inflammation.

SES, Chronic Kidney Disease, and Race in the U.S.: A Systematic Review and Meta-analysis

CONTEXT

The risk of chronic kidney disease (CKD) in the U.S. is higher in individuals with low SES than in those with high SES. However, differences in these risks between African Americans and whites are unclear.

EVIDENCE ACQUISITION

Studies published through August 30, 2016 in Medline and EMBASE were searched. From the seven studies (1,775,267 participants) that met inclusion criteria, association estimates were pooled by race in meta-analysis. The ratio of association estimates and the corresponding 95% CIs for African Americans and whites were also pooled in meta-analysis. Additionally, meta-regression analysis was used to explore whether race is related to the strength of SES-CKD association. The analysis was conducted in September 2016.

EVIDENCE SYNTHESIS

The risk of CKD in low-SES people was 58% higher in African Americans (relative risk=1.58, 95% CI=1.33, 1.84) and 91% higher in whites (relative risk=1.91, 95% CI=1.47, 2.35) compared with their high-SES counterparts. The relative risk of CKD in low SES (versus high SES) was lower in African Americans than in whites (relative risk ratio=0.71, 95% CI=0.65, 0.77). Results from meta-regression analyses also indicated that race is potentially related to the strength of the association between low SES and CKD (p for difference between whites and African Americans=0.001).

CONCLUSIONS

The risk of CKD in low SES (versus high SES) is higher in whites than in African Americans.

An Age-Period-Cohort Analysis of Religious Involvement and Adult Self-Rated Health: Results from the USA, 1972-2008

This study conducts an age, period, cohort analysis of how religious involvement affects adult health across the life course and over time in the USA. Cross-classified random-effect models are used to examine data drawn from the General Social Survey, 1972-2008. The research shows clear life course patterns, time trends and birth cohort changes in the religious involvement and health relationship with period effects surpassing cohort effects. For the most part, the results show a loss of advantage in health with age for those who are more involved in religion. Period effects are mainly demonstrated by an overall downward trend of self-rated health (SRH) attributable to religious denominational differences and various levels of social integration. Unlike the period effects, the health disparities associated with religious denominational differences fluctuated when cohort progressed. These findings suggest that in general, the positive effect of religious involvement on SRH decreases with age and periods, but its influence on individual SRH fluctuates by cohort. It is expected that a downward trend in SRH attributable to religious involvement will carry on in future.

Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society

End-stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non-Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre-ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.

Psychosocial aspects of children and families treated with hemodialysis

INTRODUCTION

The aim of this study was to analyze the selected psychosocial aspects of chronic kidney disease in children treated with hemodialysis (HD).

METHODS

The study included 25 children treated with HD aged 2 to 18 years and their parents. Data concerning the illness and socio-demographic parameters was collected. We used the Paediatric Quality of Life Inventory (PedsQL) for patients and for their parents the PedsQL-proxy version, General Health Questionnaire (GHQ-12), Berlin Social Support Scales (BSSS), and the Caregivers Burden Scale (CBS) to evaluate health-related quality of life (QoL) of HD children and their primary caregivers.

FINDINGS

In the PedsQL test, the QoL of HD children was lower than in healthy children. Children treated with HD assessed their QoL on the PedsQL questionnaire higher than the primary caregivers, on all subscales as well as an overall health-related QoL. Scoring below 2 on the GHQ-12 test was reported in 56% of mothers, which may indicate that psychological symptoms have intensified. There was no correlation between BSSS, CBS, and GHQ-12.

DISCUSSION

The assessment of QoL in pediatric patients would allow for the earliest possible identification of their nonsomatic problems and irregularities. This could, consequently, contribute to improving QoL in both children with chronic kidney disease and their families.

Accelerated Health Declines among African Americans in the USA

The weathering hypothesis, an explanation for race disparities in the USA, asserts that the health of African Americans begin to deteriorate prematurely compared to whites as a consequence of long-term exposure to social and environmental risk factors. Using data from 2000-2009 National Health Interview Surveys (NHIS), we sought to describe differences in age-related health outcomes in 619,130 African Americans and whites. Outcome measures included hypertension, diabetes, stroke, and cardiovascular disease. Using a mixed models approach to age-period-cohort analysis, we calculated age- and race-specific prevalence rates that accounted for the complex sampling design of NHIS. African Americans exhibited higher prevalence rates of hypertension, diabetes, and stroke than whites across all age groups. Consistent with the weathering hypothesis, African Americans exhibited equivalent prevalence rates for these three conditions 10 years earlier than whites. This suggests that African Americans are acquiring age-related conditions prematurely compared to whites.

Social Determinants of Racial Disparities in CKD

Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups.

Risk of ESRD in the United States

BACKGROUND

Although incidence rates of end-stage renal disease (ESRD) in the United States are reported routinely by the US Renal Data System (USRDS), risks (probabilities) are not reported. Short- and long-term risk estimates need to be updated and expanded to minority populations, including Native Americans, Asian/Pacific Islanders, and Hispanics.

STUDY DESIGN

Risk estimation from surveillance data in large populations using life-table methods. A competing-risks framework was applied by constructing a hypothetical cohort followed from birth to death.

SETTING & PARTICIPANTS

Total US population. Incidence and mortality rates of ESRD were obtained from the USRDS; all-cause mortality rates were obtained from CDC WONDER.

PREDICTORS

Age, sex, race/ethnicity, and year.

OUTCOMES

10-year to lifetime risks (cumulative incidence) of ESRD.

RESULTS

Among males, lifetime risks of ESRD from birth using 2013 data were 3.1% (95% CI, 3.0%-3.1%) for non-Hispanic whites, 8.0% (95% CI, 7.9%-8.2%) for non-Hispanic blacks, 3.8% (95% CI, 3.4%-4.9%) for non-Hispanic Native Americans, 5.1% (95% CI, 4.8%-5.4%) for non-Hispanic Asians/Pacific Islanders, and 6.2% (95% CI, 6.1%-6.4%) for Hispanics. Among females, lifetime risks were 2.0% (95% CI, 2.0%-2.1%) for non-Hispanic whites, 6.8% (95% CI, 6.7%-6.9%) for non-Hispanic blacks, 3.6% (95% CI, 3.3%-4.2%) for non-Hispanic Native Americans, 3.8% (95% CI, 3.6%-4.0%) for non-Hispanic Asian/Pacific Islanders, and 4.3% (95% CI, 4.2%-4.5%) for Hispanics. Lifetime risk of ESRD from birth increased from 3.5% in 2000 to 4.0% in 2013 in males and decreased from 3.0% to 2.8% in females.

LIMITATIONS

Standard life-time assumption of fixed age-specific rates over time and possible ESRD misclassification. To be useful in clinical practice, this application will require additional predictors (eg, comorbid conditions and chronic kidney disease stage).

CONCLUSIONS

ESRD risk in the United States varies more than 2-fold among racial/ethnic groups for both sexes.

Racial Disparities in End-of-Life Communication and Preferences among Chronic Kidney Disease Patients

BACKGROUND

Previous studies on end-of-life (EOL) care among patients with chronic kidney disease (CKD) have been largely limited to White hemodialysis patients. In this study, we sought to explore racial variability in EOL communication, care preferences and advance care planning (ACP) among patients with advanced CKD prior to decisions regarding the initiation of dialysis.

METHODS

We performed a cross-sectional study between 2013 and 2015 of Black and White patients with stage IV or V CKD (per the Modified Diet in Renal Disease estimation of GFR <30 ml/min/1.73 m2) from 2 academic centers in Boston. We assessed experiences with EOL communication, ACP, EOL care preferences, hospice knowledge, spiritual/religious and cultural beliefs, and distrust of providers.

RESULTS

Among 152 participants, 41% were Black. Black patients were younger, had less education, and lower income than White patients (all p < 0.01). Black patients also had less knowledge of hospice compared to White patients (17 vs. 61%, p < 0.01). A small fraction of patients (8%) reported having EOL discussions with their nephrologists and the majority had no advance directives. In multivariable analyses, Blacks were more likely to have not communicated EOL preferences (adjusted OR 2.70, 95% CI 1.08-6.76) and more likely to prefer life-extending treatments (adjusted OR 3.06, 95% CI 1.23-7.60) versus Whites.

CONCLUSIONS

As Black and White patients with advanced CKD differ in areas of EOL communication, preferences, and hospice knowledge, future efforts should aim to improve patient understanding and promote informed decision-making.

Explaining Racial Disparities in Obesity Among Men: Does Place Matter?

National data indicate that Black men have higher rates of obesity than White men. Black men also experience earlier onset of many chronic conditions and premature mortality linked to obesity. Explanations for these disparities have been underexplored, and existing national-level studies may be limited in their ability to explicate these long-standing patterns. National data generally do not account for race differences in risk exposures resulting from racial segregation or the confounding between race and socioeconomic status. Therefore, these differences in obesity may be a function of social environment rather than race. This study examined disparities in obesity among Black and White men living in the same social and environmental conditions, who have similar education levels and incomes using data from the Exploring Health Disparities in Integrated Communities-SWB (EHDIC-SWB) study. The findings were compared with the 2003 National Health Interview Survey (NHIS). Logistic regression was used to examine the association between race and obesity adjusting for demographics, socioeconomic status, and health conditions. In the NHIS, Black men had a higher odds of obesity (odds ratio=1.29, 95% confidence interval=1.12-1.49) than White men. However in the EHDIC-SWB, which accounts for social and environmental conditions of where these men live, Black men had similar odds of obesity (odds ratio=1.06, 95% confidence interval=0.70-1.62) compared with White men. These data highlight the importance of the role that setting plays in understanding race disparities in obesity among men. Social environment may be a key determinant of health when seeking to understand race disparities in obesity among Black and White men.

Psychosocial stress and changes in estimated glomerular filtration rate among adults with diabetes mellitus

BACKGROUND

Psychosocial stress has been hypothesized to impact renal changes, but this hypothesis has not been adequately tested. The aim of this study was to examine the relationship between psychosocial stress and estimated glomerular filtration rate (eGFR) and to examine other predictors of eGFR changes among persons with diabetes mellitus (DM).

METHODS

Data from a survey conducted in 2005 by a major health maintenance organization located in the southeastern part of the United States, linked to patients' clinical and pharmacy records (n=575) from 2005 to 2008, was used. Study participants were working adults aged 25-59 years, diagnosed with DM but without advanced microvascular or macrovascular complications. eGFR was estimated using the Modification of Diet in Renal Disease equation. A latent psychosocial stress variable was created from five psychosocial stress subscales. Using a growth factor model in a structural equation framework, we estimated the association between psychosocial stress and eGFR while controlling for important covariates.

RESULTS

The psychosocial stress variable was not directly associated with eGFR in the final model. Factors found to be associated with changes in eGFR were age, race, insulin use, and mean arterial pressure.

CONCLUSION

Among fairly healthy DM patients, we did not find any evidence of a direct association between psychosocial stress and eGFR changes after controlling for important covariates. Predictors of eGFR change in our population included age, race, insulin use, and mean arterial pressure.

Female family caregivers face a higher risk of hypertension and lowered estimated glomerular filtration rates: a cross-sectional, comparative study

BACKGROUND

Despite societal efforts to alleviate the challenges, caregiving seems to constitute a substantial burden and source of stress for many families of older adults in Japan. However, precise information on the physical health of caregivers, based on objective data, is not available. The purpose of this study was to improve the understanding of the physical health of Japanese family caregivers using objective indicators and a comparative research design.

METHODS

A cross-sectional, comparative study was conducted among family caregivers and their non-caregiver counterparts. Surveyors visited caregivers in their homes to administer a questionnaire survey, measure their blood pressure, and collect blood samples using a kit. Blood samples were tested for LDL-Cholesterol, HDL-Cholesterol, AST, ALT, γ-GTP, uric acid, creatinine and HbA1c. Non-caregiver data were collected at a university-based health checkup center. We compared 149 caregivers with 149 sex- and age-matched non-caregivers using conditional logistic regression analyses to examine the impact of caregiving, adjusting for multiple control variables. Analyses were conducted separately for men and female.

RESULTS

The prevalence of high blood pressure was significantly higher among caregivers than non-caregivers (male: 72.7% among caregivers vs. 40.9% among non-caregivers, female: 57.1% vs. 27.6%, respectively). After adjusting for related sociodemographic and health factors, high blood pressure remained significantly more prevalent among caregivers than non-caregivers, only among female (adjusted OR=2.16, 95% CI [1.14, 4.08]). Female caregivers showed lower eGFR than their non-caregiver counterparts (adjusted OR=6.54, 95% CI [2.38, 17.91]). No significant differences were observed between the two groups on any other indicators.

CONCLUSIONS

Results suggest that female caregivers are at a higher risk of conditions such as cerebral, cardiovascular or kidney diseases than non-caregivers. Steps must be taken to identify caregivers with high blood pressure and lowered eGFR and provide them with the support they need before these risk factors develop into serious diseases.

Apolipoprotein L1, income and early kidney damage

BACKGROUND

The degree to which genetic or environmental factors are associated with early kidney damage among African Americans (AAs) is unknown.

METHODS

Among 462 AAs in the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study, we examined the cross-sectional association between apolipoprotein L1 (APOL1) risk variants and income with: 1) mildly reduced eGFR (<75 mL/min/1.73 m(2), creatinine-cystatin C equation) and 2) elevated urine albumin-to-creatinine ratio (ACR) (≥17 in men and ≥25 mg/g in women). High risk APOL1 status was defined by 2 copies of high-risk variants; low risk if 0 or 1 copy. Income groups were dichotomized as < $14,000/year (lowest income group) or ≥ $14,000/year. Logistic regression models were adjusted for age, sex, and % European ancestry.

RESULTS

Overall, participants' mean age was 47 years and 16% (n = 73) had high risk APOL1 status. Mean eGFR was 99 mL/min/1.73 m(2). Mildly reduced eGFR was prevalent among 11% (n = 51). The lowest income group had higher adjusted odds (aOR) of mildly reduced eGFR than the higher income group (aOR 1.8, 95% CI 1.2-2.7). High-risk APOL1 was not significantly associated with reduced eGFR (aOR 1.5, 95% CI 0.9-2.5). Among 301 participants with ACR data, 7% (n = 21) had elevated ACR. Compared to low-risk, persons with high-risk APOL1 had higher odds of elevated ACR (aOR 3.8, 95% CI 2.0-7.3). Income was not significantly associated with elevated ACR (aOR 1.8, 95% CI 0.7-4.5). There were no significant interactions between APOL1 and income.

CONCLUSIONS

Both genetic and socioeconomic factors may be important determinants of early kidney damage among AAs.