Clinical care alone may not help close racial gap for chronic kidney disease, study finds
Adherence to most recommended care practices to slow the progression of chronic kidney disease was consistently higher among people of color compared to white patients yet those groups still have poorer outcomes from the disease, according to new research.
The analysis, published Monday in JAMA Network Open, examined de-identified medical and pharmacy claims, electronic health records, and laboratory results from more than 450,000 commercially insured and Medicare Advantage enrollees from 2012 through 2019.
Asian, Black, and Hispanic patients had higher rates of adherence to most of the chronic kidney disease care practices recommended by leading professional clinical societies. Patients consistently had higher use of blood pressure-lowering ACE inhibitor and angiotensin II receptor blocker drugs. Use of such drugs among Asian adults was 79.8%, 79.9% among Hispanics, and 76.7% among Blacks in 2019 compared to 72.3% among white patients.
Ethnic and racial minority patients had higher use of statin medications throughout the study period. Those patients were more likely to get care from a nephrologist if they had an estimated kidney filtration rate below 30, which usually is considered moderate to severe kidney damage, and had a higher likelihood of having their urine tested for containing levels of the protein albumin, another indicator of potential kidney damage.
Yet racial and ethnic minority patients had either similar or lower rates compared to white patients of achieving important health outcomes, like manageable blood pressure levels and meeting diabetes control targets, the study found. High blood pressure and diabetes, as well as obesity and heart disease, can increase the risk of kidney damage.
Overall, one in three adults in the U.S. are at risk of having chronic kidney disease, according to the National Kidney Foundation. But the risk rises exponentially for Black adults, who are nearly four times more likely than whites to develop kidney failure while Latino adults are 1.3 times more likely.
So why would minority patients continue to have poorer outcomes from chronic kidney disease despite having higher adherence to care for the condition?
Study researchers don’t have clear answers yet, though they noted unmeasured comorbidities in some patients. The lower prevalence of managed blood pressure and controlled blood sugar levels among racial and ethnic minority patients suggests an increased focus solely on clinical approaches might be insufficient to improve the health disparity.
Researchers stated providers might benefit from focusing on addressing the role non-medical, social factors like poverty, housing instability, health literacy and food insecurity.
“Directing greater attention upstream (ie, toward interventions for optimizing care for CKD and preventing kidney failure) of ESKD [end stage kidney disease] may provide the opportunity to prevent the morbidity, mortality, and costs associated with progressive kidney disease,” the study noted.
Researchers hypothesized the recognition of an increased risk for chronic kidney disease among certain racial and ethnic groups may have spurred clinicians to do more testing and provide more preventive treatment compared to white patients. If that was the case, the study’s findings would seem to run counter to recent trends within medicine that have called for eliminating the use of race as a factor in making clinical diagnostic and treatment decisions.
Last week, NKF along with the American Society of Nephrology released a report published in the New England Journal of Medicine that called for a new “race-free approach” to diagnosing kidney disease that proposed the adoption of a new equation to assess kidney function.
Clinicians’ use of race-based calculations to help make medical assessments has a long and troubled history in American medicine that many have contributed to creating different standards of illness based on race. Adjustments in clinical risk scores based on the race of the patient for conditions like kidney and lung function, breast cancer, heart disease, eligibility for organ transplantation and donation, vaginal birth, urinary tract infections, bone density, and rectal cancer in nearly every case makes it less likely patients of color will be diagnosed and receive interventions for their diseases as early as patients who identify as white.