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Kidney disease racial and ethnic inequities underscore challenges of achieving health equity
March is National Kidney Month and an ideal time to build awareness about the severe but often-overlooked impact chronic kidney disease (CKD) has on people of color, including those of African American, Latino and Hispanic, American Indian, Alaska Native, Asian American, and Native Hawaiian or Other Pacific Islander descent. It’s also an excellent opportunity to focus on some of the steps stakeholders are beginning to take to reduce the many barriers to equitable kidney health.
What is chronic kidney disease (CKD)?
Chronic Kidney Disease, or CKD, refers to the progressive loss of the kidney’s ability to filter blood and affects one in seven adults in the U.S., or approximately 37 million people. It kills more people annually than breast cancer or prostate cancer. Critically, nearly 90% of those who suffer from chronic kidney disease don’t know they have it until it’s advanced to dangerous late stages. In addition, kidney disease can be a precursor to other serious health problems, such as heart disease and stroke.
Addressing the prevalence of kidney disease among people of color
For various reasons, rates of CKD and its successor, kidney failure or end-stage renal disease (ESRD), are disproportionately high among people of color. For example, African American people are nearly four times more likely to have kidney failure than White people. Black people make up just 13% of the population but constitute 35% of patients receiving dialysis and experience higher rates of co-morbid conditions.
Although the incidence of CKD among Latino and Hispanic populations is similar to that of Whites, ESRD prevalence is 50% higher, with the rate of kidney failure increasing by more than 70% since 2000.
Chronic kidney disease typifies health equity disparities
The roots of kidney disease, coupled with widespread disparities in diagnosis and treatment, underscore the broader challenges of addressing entrenched health inequities.
Its leading causes—diabetes, high blood pressure, heart disease, and obesity—all occur with greater frequency among people of color. These conditions are themselves triggered to a greater or lesser extent by social determinants of health, or the substandard economic, health, and life conditions many Americans face day-to-day.
Reduced access for people of color limits preventive care
Compounding these risks are deficiencies in care access that often preclude early detection and appropriate treatment. African Americans are nearly twice as likely to be uninsured as Whites and consequently don’t always receive timely screening for kidney disease. Early detection is essential, since the disease is often asymptomatic early on. Black people also are less likely to get pre-ESRD kidney care and more likely to receive dialysis in centers versus the home.
Kidney transplants may be out of reach for people of color
Transplants represent the best possible treatment for kidney disease, but African Americans in particular face distinct disadvantages in this area. As the National Kidney Foundation points out: “Black patients face barriers to access at every step of the process and, on average, wait a year longer than White patients to receive a kidney transplant.”
According to the foundation, Black people are less likely to receive a transplant evaluation, have less access to the waitlist, spend longer on the transplant waitlist, are less likely to survive the waitlist, and have lower rates of graft survival post-transplant.
Next steps for improving health equity in kidney disease treatment
Stakeholder steps to ease care disparities
Helping close gaps in kidney care disparities is the goal behind a recent Center for Medicare and Medicaid Services (CMS) rulemaking action. In October 2021, the agency proposed fundamental structural and reimbursement changes to encourage dialysis facilities and providers to improve their rates of home dialysis and transplants for people of color and people with lower incomes. The changes mark one of the agency’s first significant steps designed to directly influence health equity.
Eliminate algorithms that perpetuate racial bias in healthcare
Separately, more fundamental changes aimed at eliminating long-standing racial bias in diagnosing kidney disease have been pursued by the nephrology community. For example, in December 2021, a task force formed by the National Kidney Foundation and American Society of Nephrology recommended that a racial modifier long-used in algorithms to interpret kidney function to be eliminated.
The modifier—the existence of which was never grounded in scientifically valid conclusions—resulted in lower detection of CKD among Black people, reduced interventions, delayed nephrology referral, and slower access to transplants. Notably, the change marked the first time a medical subspecialty had examined the role of race in its fundamental diagnosis algorithms and diagnosis assumptions.
The National Kidney Foundation’s year-old Health Equity Advisory Committee supported the efforts and is working with other organizations to strengthen earlier diagnosis of kidney disease while improving kidney disease laboratory testing.
Data increases visibility into chronic kidney disease risk profiles
For payers and providers, improving kidney disease diagnosis and treatment for underserved patients requires developing new visibility into at-risk populations.
Stratification, or the organization of member data by race, ethnicity, and social determinants of health, can help organizations isolate high-risk cohorts. From there, increasingly granular interventions can be developed to enhance prevention, increase detection, improve treatment, and monitor outcomes.
Information diversity and interoperability
The development of systems and protocols enabling stakeholders to pull and share data from a wide range of sources is essential to achieving health data stratification. Information sources can include insurance claims, patient health records, self-reported data, community-based services, and non-affiliated providers.
Primary care access for people of color
Also crucial for both payers and providers is a commitment to robust and proactive primary care. This can help mitigate disease precursors, like diabetes and high blood pressure, while improving regular kidney disease screening, treatment, and referrals to specialist care. Too often, people of color don’t have ready access to uninterrupted primary care across life stages. Experiencing medical mistrust and fewer financial resources, they may instead seek reactive treatment in the emergency room only after problems become acute.
Dismantling racism for better kidney disease care
Like so many other health inequities, kidney disease challenges are rooted in the pernicious and cumulative history of structural racism across generations and decades. Unraveling this Gordian knot can’t happen overnight. Yet once an injustice has been recognized, efforts to rectify it inevitably emerge, accelerate and multiply.
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