Elsevier

Seminars in Nephrology

Volume 33, Issue 5, September 2013, Pages 409-415
Seminars in Nephrology

Racial Disparities in Kidney Disease Outcomes,☆☆

https://doi.org/10.1016/j.semnephrol.2013.07.002Get rights and content

Summary

Chronic kidney disease (CKD) is a national public health problem. Although the prevalence of early stages of CKD is similar across different racial/ethnic and socioeconomic groups, the prevalence of end-stage renal disease is greater for minorities than their non-Hispanic white peers. Paradoxically, once on dialysis, minorities experience survival rates that exceed their non-Hispanic white peers. Advancing our understanding of the unique interplay of biological, genetic, environmental, sociocultural, and health care system level factors may prompt reorientation of our approach to health promotion and disease prevention. The potential of this new approach is to create previously unimagined gains to improve patient outcomes and reduce health inequities for patients with CKD.

Section snippets

Defining CKD

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines define CKD as the presence of markers of kidney damage such as albuminuria and/or a sustained reduction (≥3 mo) in estimated glomerular filtration rate (eGFR) stratified by five progressive stages of the disease based on decreasing eGFR.12 The guidelines provide specific evaluation and treatment recommendations. The inclusion of the presence of markers of kidney damage such as albuminuria allows for the

Race/Ethnicity and ESRD

Disparities in CKD may be related to many factors such as socioeconomic status, sex, and race/ethnicity among others4, 5, 6 (Fig. 3). Because of the lack of identification of physiologic or biologic differences that confer the notable added risk for CKD and ESRD to minorities, the findings of such tremendous disparities in ESRD incidence and prevalence was surprising. A seminal article by Rostand et al15 noted an average of a four-fold higher race-specific risk for developing ESRD among blacks

Inflammation and ESRD Outcomes

A multitude of factors influence ESRD outcomes in African American patients on dialysis (Fig. 4) and could be targets to explain unexpected differences in survival. In addition to differences in nutritional status,10, 11 racial/ethnic differences in inflammation may be a critical contributor. Noori et al26 reported a strong association of higher levels of C-reactive protein and interleukin-6 (IL-6), but not tumor necrosis factor-α with increased adjusted mortality risks in 799 African American

Access to Care

Overcoming barriers to quality health care is crucial for optimizing health outcomes (Fig. 5).7 A single-payer system has been proposed as a powerful approach to reducing disparities in access to care, delivery of care, and associated health outcomes. Tarver-Carr et al27 reported much lower rates of cardiovascular procedures among women and minorities with CKD not on dialysis when coverage was dispersed among multiple providers. However, after the onset of ESRD and transition to Medicare, a

Health Equity Through Action on the Social Determinants of Health

The persistence of health inequities in the United States is an indictment of the institutionalization of moral apathy and likely contributes to our ranking of last place in preventable deaths among developed nations,33 despite our recognized standing as the world leader in health technology and medical care. Dr. Steven Schroeder, former president of the Robert Wood Johnson Foundation, presented a compelling case for concentrating strategies on actionable determinants of personal health

The Way Forward

At a public health level, continuing efforts to ensure that all Americans have access to and receive quality health care is critical to positively impact the CKD epidemic and particularly the disparities in both CKD and ESRD. Steps to minimize the adverse social determinants of health, to improve provider-patient communication, increase access to evidence-based care and the re-conceptualization of health and health care, including health beliefs and practices and a broader understanding of the

References (39)

  • A.J. Collins et al.

    US Renal Data System 2010 annual data report

    Am J Kidney Dis

    (2011)
  • K. Norris et al.

    Race, gender, and socioeconomic disparities in CKD in the United States

    J Am Soc Nephrol

    (2008)
  • N.R. Powe

    Let's get serious about racial and ethnic disparities

    J Am Soc Nephrol

    (2008)
  • B.I. Freedman et al.

    The apolipoprotein L1 (APOL1) gene and nondiabetic nephropathy in African Americans

    J Am Soc Nephrol

    (2010)
  • G. Genovese et al.

    Association of trypanolytic ApoL1 variants with kidney disease in African Americans

    Science

    (2010)
  • D.C. Crews et al.

    Inflammation and the paradox of racial differences in dialysis survival

    J Am Soc Nephrol

    (2011)
  • K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J...
  • P.A. McCullough et al.

    Cardiovascular disease in chronic kidney disease: data from the Kidney Early Evaluation Program (KEEP)

    Curr Diab Rep

    (2011)
  • S.G. Rostand et al.

    Racial differences in the incidence of treatment for end-stage renal disease

    N Engl J Med

    (1982)
  • Cited by (0)

    Financial support: Supported in part by National Institutes of Health grants U54MD007598 (S.B.N., K.C.N.), UL1TR000124 (K.C.N.), P30AG021684 (K.C.N.), P20-MD000182 (K.C.N.), and K24-DK091419 and R01-DK078106 (K.K.Z.); Burnham and Hubrecht Endowment (S.B.N.).

    ☆☆

    Conflict of interest statement: none.

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