Deidra C. Crews

Poverty, Race, and CKD in a Racially and Socioeconomically Diverse Urban Population

BACKGROUNDnLow socioeconomic status (SES) and African American race are both independently associated with end-stage renal disease and progressive chronic kidney disease (CKD). However, despite their frequent co-occurrence, the effect of low SES independent of race has not been well studied in CKD.nnnSTUDY DESIGNnCross-sectional study.nnnSETTING & PARTICIPANTSn2,375 community-dwelling adults aged 30-64 years residing within 12 neighborhoods selected for both socioeconomic and racial diversity in Baltimore City, MD.nnnPREDICTORSnLow SES (self-reported household income <125% of 2004 Department of Health and Human Services guideline), higher SES (> or =125% of guideline); white and African American race.nnnOUTCOMES & MEASUREMENTSnCKD defined as estimated glomerular filtration rate <60 mL/min/1.73 m(2). Logistic regression used to calculate ORs for relationship between poverty and CKD, stratified by race.nnnRESULTSnOf 2,375 participants, 955 were white (347 low SES and 608 higher SES) and 1,420 were African American (713 low SES and 707 higher SES). 146 (6.2%) participants had CKD. Overall, race was not associated with CKD (OR, 1.05; 95% CI, 0.57-1.96); however, African Americans had a much greater odds of advanced CKD (estimated glomerular filtration rate <30 mL/min/1.73 m(2)). Low SES was independently associated with 59% greater odds of CKD after adjustment for demographics, insurance status, and comorbid disease (OR, 1.59; 95% CI, 1.27-1.99). However, stratified by race, low SES was associated with CKD in African Americans (OR, 1.91; 95% CI, 1.54-2.38), but not whites (OR, 0.95; 95% CI, 0.58-1.55; P for interaction = 0.003).nnnLIMITATIONSnCross-sectional design; findings may not be generalizable to non-urban populations.nnnCONCLUSIONSnLow SES has a profound relationship with CKD in African Americans, but not whites, in an urban population of adults, and its role in the racial disparities seen in CKD is worthy of further investigation.

Quality of Patient-Physician Discussions About CKD in Primary Care: A Cross-sectional Study

BACKGROUNDnThe quality of patient-physician discussions about chronic kidney disease (CKD) in primary care has not been studied previously.nnnSTUDY DESIGNnCross-sectional study.nnnSETTINGS & PARTICIPANTSnWe audiotaped encounters between 236 patients with hypertension and their primary care physicians (n = 40).nnnPREDICTORSnPatient, physician, and encounter characteristics.nnnOUTCOMES & MEASUREMENTSnWe described the occurrence and characteristics (content, use of technical terms, and physician assessment of patient comprehension of new concepts) of CKD discussions. We assessed patient and physician characteristics associated with CKD discussion occurrence.nnnRESULTSnMany patients (mean age, 59 years) had uncontrolled hypertension (51%), diabetes (44%), and/or 3 or more comorbid conditions (51%). Most primary care physicians practiced (52%) fewer than 10 years. CKD discussions occurred in few (26%; n = 61) encounters, with content focused on laboratory assessment (89%), risk-factor treatment (28%), and causes (26%) of CKD. In encounters that included a CKD discussion, physicians used technical terms (28%; n = 17) and rarely assessed patients comprehension (2%; n = 1). CKD discussions were statistically significantly less common in visits of patients with some (vs no) college education (OR, 0.23; 95% CI, 0.09-0.56), with 3 or more (vs fewer) comorbid conditions (OR, 0.49; 95% CI, 0.25-0.96), and who saw physicians with more (vs fewer) than 10 years of practice experience (OR, 0.41; 95% CI, 0.21-0.80). CKD discussions were more common during longer encounters (OR, 1.31; 95% CI, 1.04-1.65) and encounters in which diabetes was (vs was not) discussed (OR, 2.87; 95% CI, 1.22-6.77).nnnLIMITATIONSnGeneralizability of our findings may be limited.nnnCONCLUSIONSnPatient-physician discussions about CKD in high-risk primary care patients were infrequent. Physicians used technical terms and infrequently assessed patients understanding of new CKD concepts. Efforts to improve the frequency and content of patient-physician CKD discussions in primary care could improve patients clinical outcomes.

CHALLENGES PERCEIVED BY PRIMARY CARE PROVIDERS TO EDUCATING PATIENTS ABOUT CHRONIC KIDNEY DISEASE

OBJECTIVEnTo identify primary care providers (PCPs) perceived barriers to educating patients about chronic kidney disease (CKD) during routine clinical visits.nnnMETHODSnWe conducted three focus groups of eighteen PCPs in Baltimore, Maryland (MD), USA. Focus groups began with the presentation of a hypothetical case of a patient with CKD, followed by open-ended questions to assess providers perceived barriers to delivering education about CKD. Groups were audiotaped, transcribed and coded independently by two investigators who identified major themes.nnnRESULTSnPCPs reported on several patient, provider and system level barriers contributing to poor education about CKD in primary care that were both common and unique to barriers previously reported in educating patients regarding other chronic diseases.nnnCONCLUSIONSnInterventions designed to address barriers to CKD education identified by PCPs could improve the delivery of education about CKD in primary care settings.

Food Insecurity, CKD, and Subsequent ESRD in US Adults

BACKGROUNDnPoor access to food among low-income adults has been recognized as a risk factor for chronic kidney disease (CKD), but there are no data for the impact of food insecurity on progression to end-stage renal disease (ESRD). We hypothesized that food insecurity would be independently associated with risk for ESRD among persons with and without earlier stages of CKD.nnnSTUDY DESIGNnLongitudinal cohort study.nnnSETTING & PARTICIPANTSn2,320 adults (agedxa0≥ 20 years) with CKD and 10,448 adults with no CKD enrolled in NHANES III (1988-1994) with household incomexa0≤ 400% of the federal poverty level linked to the Medicare ESRD Registry for a median follow-up of 12 years.nnnPREDICTORnFood insecurity, defined as an affirmative response to the food-insecurity screening question.nnnOUTCOMEnDevelopment of ESRD.nnnMEASUREMENTSnDemographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. Dietary acid load was estimated from 24-hour dietary recall. We used a Fine-Gray competing-risk model to estimate the relative hazard (RH) for ESRD associated with food insecurity after adjusting for covariates.nnnRESULTSn4.5% of adults with CKD were food insecure. Food-insecure individuals were more likely to be younger and have diabetes (29.9%), hypertension (73.9%), or albuminuria (90.4%) as compared with their counterparts (P<0.05). Median dietary acid load in the food-secure versus food-insecure group was 51.2 mEq/d versus 55.6 mEq/d, respectively (P=0.05). Food-insecure adults were more likely to develop ESRD (RH, 1.38; 95% CI, 1.08-3.10) compared with food-secure adults after adjustment for demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. In the non-CKD group, 5.7% were food insecure. We did not find a significant association between food insecurity and ESRD (RH, 0.77; 95% CI, 0.40-1.49).nnnLIMITATIONSnUse of single 24-hour diet recall; lack of laboratory follow-up data and measure of changes in food insecurity over time; follow-up of cohort ended 10 years ago.nnnCONCLUSIONSnAmong adults with CKD, food insecurity was independently associated with a higher likelihood of developing ESRD. Innovative approaches to address food insecurity should be tested for their impact on CKD outcomes.

Social disadvantage: Perpetual origin of kidney disease

C approximately 26 million Americans, is the ninth leading cause of death in the United States, and costs the federal government more than

Setting an agenda for comparative effectiveness systematic reviews in CKD care

79 billion annually, including

Reaching for Health Equity and Social Justice in Baltimore: The Evolution of an Academic-Community Partnership and Conceptual Framework to Address Hypertension Disparities

34 billion for ESRD. Progressive CKD disproportionately affects socially disadvantaged groups, particularly racial-ethnic minorities and persons of low socioeconomic means. The magnitude and persistence of these disparities have led the US government to prioritize their elimination while also attempting to reduce the overall burden and costs of CKD. Although socioeconomic inequities in health care access and outcomes persist in many areas of medicine, the nephrology community has focused increasing attention toward the social conditions that place people at heightened risk for kidney disease. The Aristotelian principles of horizontal and vertical equity play a prominent role in contemporary debates on health care including the pursuit of equal health outcomes and equal access to health care. The term “health disparity” refers to suboptimal health processes or outcomes experienced by demographically defined groups that occur in the context of social or economic inequality. Link and Phelan originally referred to social conditions, including social class, income, race, and education level as ‘‘fundamental causes of disease because these conditions govern access to resources that influence health and disease.” Previous studies have reported that the incidence of progressive CKD and ESRD is highest among persons living in the most impoverished neighborhoods. Additional studies have reported lack of health insurance coverage and residence in a high poverty area as exposures linked with worse CKD-related biochemical abnormalities at dialysis initiation and marked delays in receipt of a kidney transplant. Although these inequities arise from a variety of mechanisms including biologic susceptibility and economic vulnerability, contextual impediments to healthy living likely play a central role. Suboptimal surveillance further propagates these disparities in the United States because there is no national system for tracking the care of poor or uninsured patients. In other words, socially disadvantaged patients with nondialysis-dependent CKD are essentially “invisible” to much of the health care system unless and until they reach ESRD.

Racial differences in chronic kidney disease incidence and progression among individuals with HIV.

Systematic reviews comparing the effectiveness of strategies to prevent, detect, and treat chronic kidney disease are needed to inform patient care. We engaged stakeholders in the chronic kidney disease community to prioritize topics for future comparative effectiveness research systematic reviews. We developed a preliminary list of suggested topics and stakeholders refined and ranked topics based on their importance. Among 46 topics identified, stakeholders nominated 18 as ‘high’ priority. Most pertained to strategies to slow disease progression, including: (a) treat proteinuria, (b) improve access to care, (c) treat hypertension, (d) use health information technology, and (e) implement dietary strategies. Most (15 of 18) topics had been previously studied with two or more randomized controlled trials, indicating feasibility of rigorous systematic reviews. Chronic kidney disease topics rated by stakeholders as ‘high priority’ are varied in scope and may lead to quality systematic reviews impacting practice and policy.

Greater Burden of ESRD among Immigrants: Kwa nini?

Cardiovascular health disparities persist despite decades of recognition and the availability of evidence-based clinical and public health interventions. Racial and ethnic minorities and adults in urban and low-income communities are high-risk groups for uncontrolled hypertension (HTN), a major contributor to cardiovascular health disparities, in part due to inequitable social structures and economic systems that negatively impact daily environments and risk behaviors. This commentary presents the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities as a case study for highlighting the evolution of an academic-community partnership to overcome HTN disparities. Key elements of the iterative development process of a Community Advisory Board (CAB) are summarized, and major CAB activities and engagement with the Baltimore community are highlighted. Using a conceptual framework adapted from OMara-Eves and colleagues, the authors discuss how different population groups and needs, motivations, types and intensity of community participation, contextual factors, and actions have shaped the Centers approach to stakeholder engagement in research and community outreach efforts to achieve health equity.

Limited health literacy and adverse outcomes among kidney transplant candidates

This Practice Point commentary discusses the findings of Lucas et al.s longitudinal cohort study of chronic kidney disease (CKD) in African American and white individuals with HIV. The study found that—compared with whites—African Americans had a slightly increased risk of incident CKD, but markedly increased rates of estimated glomerular filtration rate decline and progression to end-stage renal disease. This commentary details the clinical implications and limitations of these findings in the context of known racial differences in CKD prevalence and progression to end-stage renal disease in the general population and highlights the importance of screening high-risk HIV patients for kidney disease. CKD is common among HIV patients, and—as in the general population—has a more-aggressive course among African Americans than whites.