Gender and race disparities in the prevalence of chronic kidney disease among individuals with hypertension in the United States, 2001-2016.

Background: Chronic kidney disease (CKD) is a common complication among individuals with hypertension. We aimed to identify the prevalence of CKD and the sex and race disparities within the hypertensive population in the United States from 2001-2016. Methods: A total of 16,148 participants with hypertension were included, representing 561,909,480 individuals from the U.S. population between 2001 and 2016, as documented in the National Health and Nutrition Examination Survey. The prevalence of albuminuria and CKD stage were assessed using survey-weighted general linear regression analysis. Heterogeneity in the CKD stage among the hypertensive population, stratified by sex and race, was identified through survey-weighted logistic regression analysis. Results: Overall, the prevalence of albuminuria remained stable (p for trend = 0.3196), and changes in the CKD stage were minimal (p for trend > 0.05) from 2001-2016. In the analysis of CKD stage heterogeneity by sex and race, the prevalence of CKD was higher among women than men and higher among individuals of other races combined than non-Hispanic Whites, but the differences were not statistically significant. Conclusion: The overall CKD stage within the hypertensive population plateaued between 2001 and 2016. Our findings highlight the importance of continuous monitoring and potential refinement of renoprotection strategies in individuals with hypertension to mitigate the persistent burden of CKD and address health disparities among different demographic groups.

It matters who you are and where you live: Commonwealth, state and territory policies for access to care for Australians with chronic kidney disease and their caregivers.

OBJECTIVE: To describe how Commonwealth, state and territory policies address access to care for Australians living with chronic kidney disease (CKD) with an emphasis on Aboriginal and Torres Strait Islanders and people residing in rural and remote areas. METHODS: We searched government health department websites for current policies up to March 2022 that addressed access to care for people with CKD. RESULTS: We included 98 policies: 28 were Commonwealth, and 70 were state or territory-based. There was wide variation in the policies for people with CKD in number and type across the jurisdictions. Of CKD specific policies, only three policies were specific for people living with CKD in rural and remote areas and no policies were specific for Aboriginal and Torres Strait Islander people. CONCLUSION: There is a lack of CKD-specific policies addressing access to care for Aboriginal and Torres Strait Islander people and people living in rural and remote communities. IMPLICATIONS FOR PUBLIC HEALTH: Despite the known disparities in the burden of CKD there are few policies addressing CKD disparities for Aboriginal and Torres Strait Islander people and Australians living in rural and remote areas. Policies that specifically address the barriers to accessing care are required to reduce inequities.

Outcomes of Blacks Versus Whites with Cardiomyopathy.

Racial disparities in health outcomes have been widely documented in medicine, including in cardiovascular care. While some progress has been made, these disparities have continued to plague our healthcare system. Patients with cardiomyopathy are at an increased risk of death and cardiovascular hospitalizations. In the present analysis, we examined the baseline characteristics and outcomes of black and white men and women with cardiomyopathy. All patients with cardiomyopathy (left ventricular ejection fraction (LVEF) < 50%) cared for at University of Pittsburgh Medical Center (UPMC) between 2011 and 2017 were included in this analysis. Patients were stratified by race, and outcomes were compared between Black and White patients using Cox proportional hazard models. Of a total of 18,003 cardiomyopathy patients, 15,804 were white (88%), 1,824 were black (10%) and 375 identified as other (2%). Over a median follow-up time of 3.4 years, 7,899 patients died. Black patients were on average a decade younger (p <0.001) and demonstrated lower unadjusted all-cause mortality (hazard ratio [HR]: 0.83%; 95% CI 0.77 to 0.90; p < 0.001). However, after adjusting for age and other comorbidities, black patients had higher all-cause mortality compared to white patients (HR: 1.15, 95% CI 1.07 to 1.25; p < 0.001). These differences were seen in both men (HR:1.19, 95% CI 1.08 to 1.33; p < 0.001) and women (HR:1.12, 95% CI 0.99 to 1.25; p = 0.065). In conclusion, our data demonstrate higher all-cause mortality in black compared to white men and women with cardiomyopathy. These findings are likely explained, at least in part, by significantly higher rates of comorbidities in black patients. Earlier interventions targeting these comorbidities may mitigate the risk of progression to heart failure and improve outcomes.

Neural control of cardiovascular function in black adults: implications for racial differences in autonomic regulation.

Black adults are at increased risk for developing hypertension and cardiovascular and chronic kidney disease and have greater associated morbidity/mortality than white adults who are otherwise demographically similar. Despite the key role of the autonomic nervous system in the regulation of cardiovascular function, the mechanistic contributions of sympathetic nerves to racial differences in cardiovascular dysfunction and disease remain poorly understood. In this review, we present an update and synthesis of current understanding regarding the roles of autonomic neural mechanisms in normal and pathophysiological cardiovascular control in black and white adults. At rest, many hemodynamic and autonomic variables, including blood pressure, cardiac output, and sympathetic nerve activity, are similar in healthy black and white adults. However, resting sympathetic vascular transduction and carotid baroreflex responses are altered in ways that tend to promote increased vasoconstriction and higher blood pressure, even in healthy, normotensive black adults. Acute sympathoexcitatory maneuvers, including exercise and cold pressor test, often result in augmented sympathetic and hemodynamic responses in healthy black adults. Clinically, although mechanistic evidence is scarce in this area, existing data support the idea that excessive sympathetic activation and/or transduction into peripheral vasoconstriction contribute importantly to the pathophysiology of hypertension and chronic kidney disease in black compared with white adults. Important areas for future work include more detailed study of sympathetic and hemodynamic reactivity to exercise and other stressors in male and female black adults and, particularly, sympathetic control of renal function, an important area of clinical concern in black patients.

A narrative review of the impacts of income, education, and ethnicity on arterial hypertension, diabetes mellitus, and chronic kidney disease in the world.

Nontransmissible chronic diseases (NTCDs) are the leading causes of death worldwide, causing serious social and economic consequences in all societies and economies and emerging as a major public health problem. One of the ways of coping the social and economic impact caused by the NTCDs is the elaboration of effective public policies; one of the instruments used for the elaboration of public policies is the social indicators. The most popular indicator at present is the Human Development Index (HDI), which covers the dimensions of longevity, education, and income. The Inequality-adjusted HDI (IHDI) was implemented that quantifies the effects of inequality in development, measured in terms of HDI. The objective of the present study was to analyze the impact of income, education, and ethnicity in hypertension, diabetes mellitus (DM), and chronic kidney disease (CKD) in the world, through the narrative review of the literature and analyzing the social indicators HDI and IHDI of the countries analyzed. After analyzing 161 studies from 96 countries, we identified that income, education, and color impact on the prevalence, incidence, diagnosis, treatment, progression, and mortality of hypertension, DM, and CKD in both low- and middle-income countries' development, as well as high and very high human development. The HDI data for all countries change when adjusted for inequality. The theme related to social factors needs to be a constant in the elaboration of health policies, as well as present in the professional doing.

Is immunoglobulin A nephropathy different in different ethnic populations?

Immunoglobulin A nephropathy (IgAN) is one of the commonest global patterns of primary glomerulonephritis and remains a leading cause of chronic kidney disease and end-stage renal disease. The sole diagnostic criterion of IgAN remains the presence of dominant mesangial immunoglobulin A deposits on kidney biopsy. Beyond this defining feature, there is significant heterogeneity in the epidemiology, clinical presentation, renal progression and long-term outcomes of IgAN in different ethnic populations. Mirroring this heterogeneity in clinical phenotypes, there is also marked ethnic variation in the extent of histopathological lesions observed on kidney biopsy, which may partly explain the well-documented differences in response to immunomodulatory agents reported in different regions of the world. In parallel, disparities have been identified in genetic association studies and key pathogenic pathways in different ethnic populations. Understanding the basis for these differences in IgAN has important implications for both clinical care and future research. In this review, we will examine the impact of ethnicity on the epidemiology, clinical presentation and outcomes, pathogenesis and genetic associations in IgAN.

Racial Variation in the Complexity of Coronary Artery Disease in Patients with Acute ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Racial variations in presentation of patients with ST-segment elevation myocardial infarction (STEMI) have been suggested. METHODS: This was a retrospective analysis of a tertiary center from 2012 to 2016. We included patients presenting with acute STEMI who received primary percutaneous coronary intervention (PCI). The main outcome was racial variation in the complexity of coronary artery disease assessed by SYNTAX score. We also reported predictors of higher SYNTAX scores in the study population. RESULTS: Our final analysis included 260 patients: 201 Whites (77.3%), 24 African Americans-AA (9.2%), 19 Hispanics (7.3%) and 15 were of other ethnicities (5.8%). The mean SYNTAX score was 13.8 ±â€¯7.7. There was no significant difference between Whites, AA, Hispanics and other races in the SYNTAX score (13.8 ±â€¯7.7, 13.4 ±â€¯7.9, 14.5 ±â€¯9 and 13.5 ±â€¯6.6, p = 0.965). Logistic regression analysis identified chronic kidney disease as the only significant predictor of higher SYNTAX score (Coefficient = 3.5, 95%CI:0.41-6.60, p = 0.026), while no significant association was identified between different races and higher SYNTAX score. CONCLUSION: The current study did not identify racial variations in the complexity of coronary artery disease for STEMI patients. Further studies are needed at a larger scale to identify racial variations in STEMI patients.

Cost of chronic kidney disease attributable to diabetes from the perspective of the Brazilian Unified Health System.

INTRODUCTION: Diabetes is the most common cause of chronic kidney disease, with a high economic impact on health systems. OBJECTIVE: To estimate the cost of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) attributable to diabetes, stratified by sex, race/skin color, and age, from the perspective of the Brazilian public health system between 2010 and 2016. METHODS: Population attributable risk (PAR) was calculated from the Brazilian prevalence of diabetes and the relative risk (or odds ratio) of persons with diabetes developing CKD and ESKD as compared to non-diabetic subjects. The variables of interest were sex, race/skin color, and age. A top-down approach was used to measure the direct costs of the disease reimbursed by the Brazilian Ministry of Health, using data from outpatient and inpatient records. RESULTS: The cost of CKD and ESKD attributable to diabetes in the period 2010-2016 was US$1.2 billion (US$180 million per year) and trending upward. Female sex, age 65-75, and black race/skin color contributed substantially to the costs of CKD and ESKD (US$475 million, US$63 million, and US$25 million respectively). The clinical procedures accounting for the greatest share of disease-attributable costs are hemodialysis and peritoneal dialysis. CONCLUSION: Diabetes accounted for 22% of the costs of CKD and ESKD. Female sex, age 65-75 years, and black race/skin color were the variables which contributed most to disease-related expenditure. The economic burden of CKD may increase gradually in the coming years, with serious implications for the financial sustainability of the Brazilian public health system.

Kidney Disease Among African Americans: A Population Perspective.

End-stage kidney disease and earlier stages of chronic kidney disease (CKD) represent one of the most dramatic examples of racial/ethnic disparities in health in our nation. African Americans are 3 times more likely to require renal replacement therapy then their non-Hispanic white counterparts. This article describes CKD-related disparities linked to a variety of clinical, socioeconomic, and cultural factors, as well as to select social determinants of health that are defined by social positioning and often by race within the United States. Our advancing understanding of these issues has led to improvements in patient outcomes and is narrowing the gap in disparities across most aspects of CKD and CKD risk factors. There are also extensive data indicating similar improvements in quality measures for patients on dialysis therapy. This article also reviews the state of CKD in African Americans from a population perspective and provides recommendations for the way forward.

Social Justice as Epidemic Control: Two Latin American Case Studies.

In this article, we draw on two cases-one of the reproductive justice movements in the wake of the Latin American Zika epidemic, and one of an environmental justice movements spurred by an epidemic of chronic kidney disease among sugarcane workers-to argue for social justice as an "elastic" technology of epidemic control. In its compressed form, social justice simply refers to the fair distribution of medical goods. In its expanded form, it emphasizes the recognition and representation not just of medical problems, but of entangled histories of racial, gendered, and economic inequity.

Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease.

BACKGROUND: Black race has been shown to be a risk factor for amputation in peripheral artery disease (PAD); however, race has been argued to be a marker for socioeconomic status (SES) rather than true disparity. The aim of this study is to study the impact of race and SES on amputation risk in PAD patients. METHODS AND RESULTS: Patients with incident PAD in the national Veterans Affairs Corporate Data Warehouse were identified from 2003 to 2014 (N=155 647). The exposures were race and SES (measured by median income in residential ZIP codes). The outcome was incident major amputation. Black veterans were significantly more likely to live in low-SES neighborhoods and to present with advanced PAD. Black patients had a higher amputation risk in each SES stratum compared with white patients. In Cox models (adjusting for covariates), black race was associated with a 37% higher amputation risk compared with white race (hazard ratio: 1.37; 95% confidence interval, 1.30-1.45), whereas low SES was independently predictive of increased risk of amputation (hazard ratio: 1.12; 95% confidence interval, 1.06-1.17) and showed no evidence of interaction with race. In predicted amputation risk analysis, black race and low SES continued to be significant risk factors for amputation regardless of PAD presentation. CONCLUSIONS: Black race significantly increases the risk of amputation within the same SES stratum compared with white race and has an independent effect on limb loss after controlling for comorbidities, severity of PAD at presentation, and use of medications.

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.

Current State and Future Trends to Optimize the Care of Chronic Kidney Disease in African Americans.

BACKGROUND: African Americans (AAs) suffer the widest gaps in chronic kidney disease (CKD) outcomes compared to Caucasian Americans (CAs) and this is because of the disparities that exist in both health and healthcare. In fact, the prevalence of CKD is 3.5 times higher in AAs compared to CAs. The disparities exist at all stages of CKD. Importantly, AAs are 10 times more likely to develop hypertension-related kidney failure and 3 times more likely to progress to kidney failure compared to CAs. SUMMARY: Several factors contribute to these disparities including genetic and social determinants, late referrals, poor care coordination, medication adherence, and low recruitment in clinical trials. Key Messages: The development and implementation of CKD-related evidence-based approaches, such as clinical and social determinant assessment tools for medical interventions, more widespread outreach programs, strategies to improve medication adherence, safe and effective pharmacological treatments to control or eliminate CKD, as well as the use of health information technology, and patient-engagement programs for improved CKD outcomes may help to positively impact these disparities among AAs.

Real-world costs of autosomal dominant polycystic kidney disease in the Nordics.

BACKGROUND: There is limited real-world data on the economic burden of patients with autosomal dominant polycystic kidney disease (ADPKD). The objective of this study was to estimate the annual direct and indirect costs of patients with ADPKD by severity of the disease: chronic kidney disease (CKD) stages 1-3; CKD stages 4-5; transplant recipients; and maintenance dialysis patients. METHODS: A retrospective study of ADPKD patients was undertaken April-December 2014 in Denmark, Finland, Norway and Sweden. Data on medical resource utilisation were extracted from medical charts and patients were asked to complete a self-administered questionnaire. RESULTS: A total of 266 patients were contacted, 243 (91%) of whom provided consent to participate in the study. Results showed that the economic burden of ADPKD was substantial at all levels of the disease. Lost wages due to reduced productivity were large in absolute terms across all disease strata. Mean total annual costs were highest in dialysis patients, driven by maintenance dialysis care, while the use of immunosuppressants was the main cost component for transplant care. Costs were twice as high in patients with CKD stages 4-5 compared to CKD stages 1-3. CONCLUSIONS: Costs associated with ADPKD are significant and the progression of the disease is associated with an increased frequency and intensity of medical resource utilisation. Interventions that can slow the progression of the disease have the potential to lead to substantial reductions in costs for the treatment of ADPKD.

Screening for chronic kidney disease in Canadian indigenous peoples is cost-effective.

Canadian indigenous (First Nations) have rates of kidney failure that are 2- to 4-fold higher than the non-indigenous general Canadian population. As such, a strategy of targeted screening and treatment for CKD may be cost-effective in this population. Our objective was to assess the cost utility of screening and subsequent treatment for CKD in rural Canadian indigenous adults by both estimated glomerular filtration rate and the urine albumin-to-creatinine ratio. A decision analytic Markov model was constructed comparing the screening and treatment strategy to usual care. Primary outcomes were presented as incremental cost-effectiveness ratios (ICERs) presented as a cost per quality-adjusted life-year (QALY). Screening for CKD was associated with an ICER of $23,700/QALY in comparison to usual care. Restricting the model to screening in communities accessed only by air travel (CKD prevalence 34.4%), this ratio fell to $7,790/QALY. In road accessible communities (CKD prevalence 17.6%) the ICER was $52,480/QALY. The model was robust to changes in influential variables when tested in univariate sensitivity analyses. Probabilistic sensitivity analysis found 72% of simulations to be cost-effective at a $50,000/QALY threshold and 93% of simulations to be cost-effective at a $100,000/QALY threshold. Thus, targeted screening and treatment for CKD using point-of-care testing equipment in rural Canadian indigenous populations is cost-effective, particularly in remote air access-only communities with the highest risk of CKD and kidney failure. Evaluation of targeted screening initiatives with cluster randomized controlled trials and integration of screening into routine clinical visits in communities with the highest risk is recommended.

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.