key: cord-297103-f3jdbv47
authors: Longino, Kevin; Kramer, Holly
title: Racial and Ethnic Disparities, Kidney Disease, and COVID-19: A Call to Action
date: 2020-07-21
journal: Kidney Med
DOI: 10.1016/j.xkme.2020.07.001
sha: 
doc_id: 297103
cord_uid: f3jdbv47

nan

Kevin Longino, MBA, Holly Kramer, MD, MPH As the nation once again turns its attention to the Black Lives Matter movement, we must ask ourselves how the movement applies to our community of kidney patients and the professionals who care for them. The fact that the call for racial justice is occurring in the midst of a public health epidemic is not a coincidence. The same factors that have spurred nationwide protests -poverty, inequality, implicit bias, and systemic racism -contribute to the disproportionate impact that kidney disease has on communities of color.

While the National Kidney Foundation (NKF) alone cannot end the 400+ year legacy of racism that affects the day-to-day lives of so many patients, we hear our moral calling to look the challenge square in the eye. It is incumbent upon all of us -as healthcare professionals, patients, and advocates -to confront racial and ethnic disparities and work together to ensure that all people with kidney disease receive nothing but the best care our system has to offer.

COVID-19 is the most significant health crisis in the modern era. It has directly and indirectly resulted in overwhelming rates of illness and death, has created major disruptions to economies and everyday life both in the United States and throughout the world, and might leave survivors with chronic, permanent health complications. Notably, severe COVID-19 has been associated with acute kidney injury (AKI), which can increase the risk of chronic kidney disease (CKD) over time. 1,2 CKD has also been associated with more severe COVID-19 infection. 2, 3 COVID-19 has had devastating and disproportionate consequences for communities of color. People of African American, American Indian or Alaska Native American descent are five times more likely to be hospitalized due to COVID-19 than Whites, while Hispanics are approximately four times more likely to be hospitalized. One in four Americans dying of COVID-19 are Black or African American, even though members of this community represent only 13 percent of the US population. 4 The reasons for these unconscionable disparities are multifactorial but are likely closely tied to social determinants of health such as access to healthcare, socioeconomic status (SES), employment, food security, education, housing, environment, and social support. These factors in turn have been driven and exacerbated by a long history of systemic racism. Some specific factors can include the higher likelihood of living in densely populated areas or in crowded housing conditions; being an essential worker who cannot work remotely; and relying on a job with a lower income or without sick leave.

Another significant disparity is a lack of access to healthcare, as Hispanics are about three times as likely to be uninsured, and Black or African Americans are almost twice as likely to be uninsured. 4

Many of the healthcare and socioeconomic disparities that make communities of color more vulnerable to COVID-19 also make them vulnerable to kidney disease.

Communities of color often have higher rates of diabetes and high blood pressure, which are the first and second leading causes of kidney failure, respectively. 5 The risk of CKD increases for Black or African American patients compared to White patients at every stage. Early referral to nephrology is associated with improved CKD outcomes, however Black or African American patients are more likely to have delayed referral or no nephrology referral at all. Communities of color are also overrepresented among patients with end-stage kidney disease. For every three non-Hispanics who develop kidney failure, four Hispanics develop kidney failure. Black or African Americans are three times more likely to suffer from kidney failure than Whites. 5 These disparities extend into treatment modalities as well. Black and Hispanic patients are less likely to receive home dialysis, and when they do begin peritoneal dialysis (PD), they are more likely to fail within the first 90 days. Black or African American patients have less access to the optimal treatment of kidney transplantation.

They are less likely to be waitlisted for an organ, and when they are transplanted, they wait longer, are less likely to receive a deceased or living donor organ (i.e., die on the waitlist) and have poorer graft survival at first year post-transplant.

In an effort to address these challenges, NKF is advocating for access to affordable healthcare, to increase our federal investment in research, prevention, and innovations in care for people with kidney disease, and to ensure that racial and ethnic communities are not left behind. 6 The issues that underlie kidney disease, COVID-19, and healthcare disparities are complex. However there are some specific strategies NKF is advocating, including calling on the federal government to provide quality, disaggregated data on all tests, hospitalizations, discharges, and deaths from COVID-19 in order to fully understand the scope of the problem; and to ensure priority testing, contact tracing, access to a future vaccine, and funding for high-risk and minority communities and kidney patients. 6 NKF also supports long-term investments in public health infrastructure in historically underserved communities and increased funding for kidney disease research and awareness.

The NKF and the American Society of Nephrology (ASN) established a joint task force to reassess the inclusion of race in diagnosing kidney disease. The task force aims to evaluate the use of race in calculating eGFR and ensure that GFR estimation equations provide an unbiased assessment of kidney function so that laboratories, clinicians, patients, and public health officials can make informed decisions to ensure equity and personalized care for patients with kidney disease. This work is important, but it alone cannot solve the many health and socioeconomic disparities facing Black or African American and other minority communities, which are rooted in historical and ongoing systemic racism. However, this work can make progress towards addressing healthcare disparities that continue to fuel disenfranchisement among these communities. 6 The NKF is also advocating to address areas of concern for people with kidney disease in the context of the COVID-19 pandemic, including prioritizing kidney patients' and clinicians' access to personal protective equipment; preserving access to essential kidney-related surgical procedures (e.g., organ transplantation, vascular access); and fighting policies that discriminate against kidney patients. 7 The NKF is also working with several partners to implement policies that accelerate patients' access to home dialysis; ensure timely implementation of kidney care payment models; ensure kidney patients and transplant patients can access greater-than-30-day supplies of critical prescriptions including immunosuppressive drugs; and ensure that vulnerable home dialysis, transplant patients, and living donors can receive needed blood draws in their homes.

Acute kidney injury in patients hospitalized with COVID-19

Kidney disease is associated with in-hospital death of patients with COVID-19

Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID 19) infection

COVID-19 in Racial and Ethnic Minority Groups

Chronic Kidney Disease in the United States

The NKF will continue work that is tangible, results-focused, and lifesaving. The NKF will also continue long-term and focused outreach to our Black or African American patients and all patients of color who develop kidney disease and the devastating complications which accompany it. 
