Trends in Chronic Kidney Disease Care in the US by Race and Ethnicity, 2012-2019

Abstract

IMPORTANCE Significant racial and ethnic disparities in chronic kidney disease (CKD) progression and outcomes are well documented, as is low use of guideline-recommended CKD care.OBJECTIVE To examine guideline-recommended CKD care delivery by race and ethnicity in a large, diverse population. DESIGN, SETTING, AND PARTICIPANTSIn this serial cross-sectional study, adult patients with CKD that did not require dialysis, defined as a persistent estimated glomerular filtration rate less than 60 mL/min/1.73 m 2 or a urine albumin-creatinine ratio of 30 mg/g or higher for at least 90 days, were identified in 2-year cross-sections from January 1, 2012, to December 31, 2019. Data from the OptumLabs Data Warehouse, a national data set of administrative and electronic health record data for commercially insured and Medicare Advantage patients, were used. EXPOSURESThe independent variables were race and ethnicity, as reported in linked electronic health records. MAIN OUTCOMES AND MEASURESOn the basis of guideline-recommended CKD care, the study examined care delivery process measures (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker prescription for albuminuria, statin prescription, albuminuria testing, nephrology care for CKD stage 4 or higher, and avoidance of chronic nonsteroidal anti-inflammatory drug prescription) and care delivery outcome measures (blood pressure and diabetes control). RESULTSA total of 452 238 patients met the inclusion criteria (mean [SD] age, 74.0 [10.2] years; 262 089 [58.0%] female; a total of 7573 [1.7%] Asian, 49 970 [11.0%] Black, 15 540 [3.4%] Hispanic, and 379 155 [83.8%] White). Performance on process measures was higher among Asian, Black, and Hispanic patients compared with White patients for angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use (79.8% for Asian patients, 76.7% for Black patients, and 79.9% for Hispanic patients compared with 72.3% for White patients in 2018-2019), statin use (72.6% for Asian patients, 69.1% for Black patients, and 74.1% for Hispanic patients compared with 61.5% for White patients), nephrology care (64.8% for Asian patients, 72.9% for Black patients, and 69.4% for Hispanic patients compared with 58.3% for White patients), and albuminuria testing (53.9% for Asian patients, 41.0% for Black patients, and 52.6% for Hispanic patients compared with 30.7% for White patients). Achievement of blood pressure control to less than 140/90 mm Hg was similar or lower among Asian (71.8%), Black (63.3%), and Hispanic (69.8%) patients compared with White patients (72.9%). Achievement of diabetes control with hemoglobin A 1c less than 7.0% was 50.1% in Asian patients, 49.3% in Black patients, and 46.0% in Hispanic patients compared with 50.3% for White patients.

Demographic and clinical profile of black patients with chronic kidney disease attending a tertiary hospital in Johannesburg, South Africa

“…Metabolic acidosis is common in CKD and it can lead to dysfunction of many organs and systems including the kidney resulting in CKD progression [ 42 , 43 ], the prevalence of metabolic acidosis was 62.4% in advanced CKD and 46.6% in early CKD; this prevalence is higher than the 33% - 40% among patients with CKD stage 3–4 from other continents [ 43 – 45 ]. The possible explanation could be firstly, the more rapid CKD progression which has been shown to occur in black patients even early in their CKD stages [ 15 , 19 ] and secondly, diet where replacement of traditional diets with contemporary/ western foods which contain mainly animal proteins, less vegetables and low intake of fruits might increase CKD patients’ dietary acid load [ 46 , 47 ]. Patients with low serum bicarbonate levels were 2-fold more likely to have advanced CKD, as reported also in other studies [ 18 , 44 ].…”

“…Inclusion criteria included patients who were >18 years of age, CKD stages 1–4, who had controlled hypertension (blood pressure < 140/90 mm Hg) and diabetes mellitus (HbA1C < 7%), attending the KOPD clinic for at least 6 months and were able to provide informed consent. Patients who had active infections, active malignancies, autoimmune diseases and who were not black were excluded, black patients have an increased risk of developing CKD and end stage kidney disease (ESKD) at significantly higher rates than other races [ 13 , 15 ].…”

“…Individuals of black ethnicity due to their genetics, including the presence of APOL1 high-risk genotypes, are at higher risk of death due to CKD as a result of social, economic and medical causes [ 12 , 13 ]. African ancestry has been associated with higher serum creatinine levels, lower eGFR estimates and more rapid CKD progression [ 14 , 15 ]. In addition to the known risk factors for advanced CKD, which are age, male sex, black race, arterial hypertension and proteinuria, other modifiable factors including medications (traditional and herbal), hyperuricemia, hyperlipidemia, elevated phosphate levels, heart failure and anemia are common in CKD at later stages [ 16 , 17 ].…”

Demographic and clinical profile of black patients with chronic kidney disease attending Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in Johannesburg, South Africa

“…The prevalence of metabolic acidosis was 62.4 % in advanced CKD and 46.6 % in early CKD; this prevalence is higher than the 33% - 40% among patients with CKD stage 3 – 4 from other continents (14, 40, 41). The possible explanation could be firstly, the more rapid CKD progression which has been shown to occur in black patients even early in their CKD stages (16, 28) and secondly, diet where replacement of traditional diets with contemporary/ western foods which contain mainly animal proteins, less vegetables and low intake of fruits might increase CKD patients’ dietary acid load (29, 42-45). Patients with low serum bicarbonate levels were 2-fold more likely to have advanced CKD, as reported also in other studies (14, 15).…”

“…Individuals of black ethnicity due to their genetics, including the presence of APOL1 high risk genotypes, are at higher risk of death due to CKD as a result of social, economic and medical causes (25, 26). African ancestry has been associated with higher serum creatinine levels, lower eGFR estimates and more rapid CKD progression (27, 28). Thus, the aim of this study was to determine the demographic and clinical profile of black patients with CKD attending Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in Johannesburg, South Africa.…”