Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society

Abstract

End-stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non-Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences persistence in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre-ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together these factors conspire to influence dialysis outcomes among African Americans with ESRD.

Avoidable visits to the emergency department(ED) and their association with sex, age and race in a cohort of low socio-economic status patients on hemodialysis in the Bronx

“…[ 11 , 12 , 15 , 16 , 19 , 26 ] These studies of national cohorts, however, do not adjust for regional/community level determinants of health (race, access to care, psychosocial factors and health literacy) which have been shown to be important in the outcomes of the ESRD population. [ 8 , 9 , 27 – 29 ] Regional and community level disparities with regard to access to care and psychosocial stressors contribute to hospitalization outcomes. [ 10 ] In communities with low SES and Black majority, patients on hemodialysis are at a higher risk for mortality as compared to White communities and patients with higher SES.…”

Racial Disparities in Nephrology Consultation and Disease Progression among Veterans with CKD: An Observational Cohort Study

“…Racial disparities in renal disease outcomes may be caused by diverse factors, including limited access to or use of quality health care, lower socioeconomic status, environmental toxins, health behaviors, and genetics. [6][7][8][9] From a biologic standpoint, individuals who are homozygous for specific mutations of the APOL1 gene experience more rapid CKD progression, independent of diabetes status. 10 These pathologic APOL1 gene mutations have been identified almost exclusively among individuals of African ancestry.…”

Hemodialysis Adequacy and Its Impact on Long-Term Patient Survival in Demographically, Socially, and Culturally Homogeneous Patients

“…As discussed in some studies, an association exists between decrement in Kt/V and increased hospitalizations, lengthier hospital days, and higher inpatient insurance costs [15]. Lack of access to high quality nephrology care before initiating renal replacement therapy is linked to the hemodialysis outcome [16][17][18]. Although poverty level [19], race [3,16,17], religion [20], gender [21,22], health care provider's beliefs, or behavior [23,24] has been proposed as factors contributing to health disparity, however, in these respects, there was no difference between the two study groups (Tables 2 and 4).…”

“…Lack of access to high quality nephrology care before initiating renal replacement therapy is linked to the hemodialysis outcome [ 16 – 18 ]. Although poverty level [ 19 ], race [ 3 , 16 , 17 ], religion [ 20 ], gender [ 21 , 22 ], health care provider's beliefs, or behavior [ 23 , 24 ] has been proposed as factors contributing to health disparity, however, in these respects, there was no difference between the two study groups (Tables 2 and 4 ). During the study's time period, only one patient from each group had underwent a kidney transplant, but returned immediately to hemodialysis due to acute allograft rejection, thus rejecting the idea of a selection bias against Afghan patients.…”