Impact of structural racism, poverty ‘understudied’ in pediatric kidney disease
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Emphasizing that race is not a biological construct, but rather a social construct, a speaker contended that the “multifaceted nature” of disparities impacting outcomes for children with kidney disease must be explored.
“Many studies, primarily in adults, have highlighted the impact of socioeconomic status on chronic kidney disease outcomes,” Keisha L. Gibson, MD, MPH, of the University of North Carolina Kidney Center, said at the National Kidney Foundation’s virtual Kidney and Transplant Symposium. “The real question is, ‘How do we best define this?’”
Gibson explained that, when looking at determinants that may impact a patient’s health, health care providers often place these in one of two “buckets:” biologic or non-biologic. She argued that some factors are more clearly definable as one or the other. For instance, obesity, hypertension, sex and age are frequently categorized as biological determinants, while poverty and education levels are typically placed in the non-biologic, or socioeconomic, category. However, sometimes the line between the two is blurry, Gibson said, asking the audience where race and ethnicity fit (these two factors, she argued, are “mishandled” if these are considered as biologic constructs).
“It is challenging to decipher unmeasured socioeconomic differences when assessing the impact of race on outcomes,” she said. “Often, we’re not measuring the impact of structural racism and discrimination. In pediatrics, how much of the disparity that we see in CKD outcomes is actually related to poverty? Unfortunately, this is very understudied; few data exist to help us understand any link between poverty and CKD.”
According to Gibson, many social factors (including low health literacy, community distrust in the health care system, chronic stress, low employment, poverty, structural and institutionalized racism, and residency in neighborhoods with greater exposure to environmental toxins) coalesce with biology to influence the development and progression of kidney disease.
One of the biggest challenges in determining the effect of these many factors on health outcomes, she argued, is the view that different measures of socioeconomic status (eg, ZIP code, income, education level) are interchangeable. For example, she noted there can be houses within one ZIP code that vary substantially in terms of cost.
It is critical to consider race and ethnicity as social constructs, according to Gibson, because these “may reflect unmeasured socioeconomic differences.” It is also necessary to examine the far-reaching effects of poverty (which Gibson attributes, in part, to structural racism).
To illustrate this point, Gibson cited a study from 2013. While this study did not find a direct link between poverty and CKD progression, it did uncover that for every 1 ug/dL increase in blood lead levels, there was an associated 12% decline in GFR. This, Gibson said, is an example of “environmental racism.”
Furthermore, poverty is frequently joined with a lack of transportation to medical care (Gibson said some families in rural areas are 100 miles from the nearest pediatric specialist or dialysis/transplant center) and the inability to afford out-of-pocket costs for treatment and medication.
“Not only can poverty be a risk factor in the progression of CKD, but the financial impact on a family caring for a child with CKD can be significant,” she added, noting many parents have inflexible work schedules, few benefits and no sick leave.
Children with kidney disease have multiple disadvantages that adults do not, Gibson said, because they are frequently excluded from clinical trials (the rationale being they are “vulnerable”) and medical equipment is often “adapted” for them from that originally designed for adults.
Gibson addressed some positive steps that have been taken, including the 2020 FDA approval of Medtronic’s Carpediem system (a continuous dialysis machine made specifically for lower-weight pediatric patients) and the 2017 Best Pharmaceuticals Act for Children, which “encourages pharmaceutical companies to perform pediatric studies so they’re incentivized to make sure they’re gathering the safety and efficacy data that we need.”
Finally, although Gibson expressed excitement about the Advancing American Kidney Health initiative, she emphasized none of its goals specifically mention children and the unique needs they have. Due to the cost discrepancies between pediatric and adult care (with dialysis nurse services costing up to 125%, social worker services costing up to 262% and registered dietician services costing up to 197% of adult baseline costs), Gibson argued we must be “thoughtful” when creating policies to ensure children will also benefit.
“Addressing the constellation of factors that influence health outcomes certainly seems like an arduous task for us as health care providers, but when we start to feel taxed by this, we have to remember that our community looks to us for leadership,” Gibson concluded. “They look to us for leadership, not just for their medical care, but for the broader issues that affect their health and well-being.
As we’re looking at policies that impact the general population, we need to think about the specific policies that we need to support and protect our children. We need to think about the full landscape of the village that is going to be needed to help ensure we’re doing the right things for them.”
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Gibson KL. Health care disparities in children and adolescents with kidney disease. Presented at: NKF Kidney and Transplant Symposium. March 2, 2021 (virtual meeting).
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