Social determinants of health impact access to CKD care, transplant
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Despite some progress in achieving equity in kidney care, important disparities – including insurance coverage for chronic kidney disease care and access to transplantation – are impacting underrepresented groups, a speaker said here.
“There are likely much larger disparities in CKD care among younger patients without Medicare coverage,” Kirsten L. Johansen, MD, FASN, director of the nephrology division at Hennepin County Medical Center and professor of medicine at the University of Minnesota, said in a presentation at ASN Kidney Week.
Johansen is also co-director of the Chronic Disease Research Group, which contracts with the NIH and the National Institute of Diabetes and Digestive and Kidney Diseases to produce the U.S. Renal Data System Annual Data Report (ADR). Data presented in Johansen’s talk are from a special supplement on disparities in CKD and end-stage renal disease to be released with the 2021 ADR in December.
Of patients with ESRD who are Medicare fee-for-service beneficiaries, care appears to be equitable among all groups, she said, but the incidence of end-stage kidney disease is three times higher among Black individuals than among white individuals, and prevalence of ESRD is four times higher among Black individuals.
While Black individuals are not more likely to have CKD compared with white individuals in the United States, more white individuals are likely to die before reaching ESRD.
“If you look at Black individuals and white individuals in CKD stage 4, for example, 57% of white individuals die without ever reaching ESRD, whereas that percentage is 43% for Black individuals,” Johansen said. “So there does appear to be faster progression among Black individuals in reaching ESRD than white individuals.”
Johansen showed recently published research that estimated the number of cases of CKD will climb among Black individuals when race is removed from the eGFR equation. The removal of race from the equation was recommended by a National Kidney Foundation/ASN study released in October.
Disparities in transplant
Black individuals also get fewer transplants – about half of what white individuals do, Johansen said. Both groups, however, have seen an uptick in obtaining transplants since 2015.
For patients already on dialysis, the Kidney Allocation System has “completely eliminated” the disparity between Black and white individuals already on dialysis from receiving a transplant, Johansen said. However, “Black patients are still far less likely to receive a living donor transplant than whites,” she said. “The data also shows that more white individuals get listed for preemptive transplants” compared with Black individuals, which leads to a longer waiting time for Black individuals.
Impact of neighborhoods
In explaining the disparities, Johansen said social determinants of health – aspects of a patient’s environment that influence access to care, including education and literacy, income and employment, housing and transportation – define neighborhood deprivation.
“People living in neighborhoods with more challenging circumstances are more likely to get ESRD,” Johansen said. Social determinants of health are also “very important” as a predictor of a patient having access to home dialysis. “White individuals are more likely to be on home dialysis” than Black and Hispanic patients, Johansen said.
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Johansen K. Signs of progress and troubling disparities in CKD and ESKD. Presented at: ASN Kidney Week; Nov. 4-7, 2021 (virtual meeting).
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