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Racial and Ethnic Disparities, Kidney Disease, and COVID-19: A Call to Action

  • Kevin Longino
    Affiliations
    National Kidney Foundation, New York, NY
    Search for articles by this author
  • Holly Kramer
    Correspondence
    Address for Correspondence: Holly Kramer, MD, MPH, Departments of Public Health Sciences and Medicine, Division of Nephrology and Hypertension, Loyola University Chicago, Maywood, IL, 60153.
    Affiliations
    National Kidney Foundation, New York, NY

    Department of Public Health Sciences and Medicine, Division of Nephrology and Hypertension, Loyola University Chicago, Maywood, IL
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Open AccessPublished:July 20, 2020DOI:https://doi.org/10.1016/j.xkme.2020.07.001
      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 patients with kidney disease 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.
      Although the National Kidney Foundation (NKF) alone cannot end the 400-plus–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 health care 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 and Its Impact on Communities of Color

      Coronavirus disease 2019 (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 infection has been associated with acute kidney injury, which can increase the risk for chronic kidney disease (CKD) over time.
      • Hirsch J.S.
      • Ng J.H.
      • Ross D.W.
      • et al.
      Acute kidney injury in patients hospitalized with COVID-19.
      ,
      • Cheng Y.
      • Luo R.
      • Wang K.
      • et al.
      Kidney disease is associated with in-hospital death of patients with COVID-19.
      CKD has also been associated with more severe COVID-19 infection.
      • Cheng Y.
      • Luo R.
      • Wang K.
      • et al.
      Kidney disease is associated with in-hospital death of patients with COVID-19.
      ,
      • Henry B.M.
      • Lippi G.
      Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID 19) infection.
      COVID-19 infection has had devastating and disproportionate consequences for communities of color. People of African American, American Indian, or Alaska Native American descent are 5 times more likely to be hospitalized due to COVID-19 infection than Whites, whereas Hispanics are approximately 4 times more likely to be hospitalized. One in 4 Americans dying of COVID-19 infection are Black or African American, although members of this community represent only 13% of the US population.
      Centers for Disease Control and Prevention (CDC)
      COVID-19 in racial and ethnic minority groups.
      The reasons for these unconscionable disparities are multifactorial but are likely closely tied to social determinants of health, such as access to health care, socioeconomic status, 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 health care because Hispanics are about 3 times as likely to be uninsured and Black or African Americans are almost twice as likely to be uninsured.
      Centers for Disease Control and Prevention (CDC)
      COVID-19 in racial and ethnic minority groups.

      Disparities and Kidney Disease

      Many of the health care and socioeconomic disparities that make communities of color more vulnerable to COVID-19 infection 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.
      CDC Fact Sheet
      Chronic kidney disease in the United States, 2019.
      The risk for CKD increases for Black or African American patients compared with 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 3 non-Hispanics who develop kidney failure, 4 Hispanics develop kidney failure. Black or African Americans are 3 times more likely to experience kidney failure than Whites.
      CDC Fact Sheet
      Chronic kidney disease in the United States, 2019.
      These disparities extend into treatment modalities as well. Black and Hispanic patients are less likely to receive home dialysis, and when they begin peritoneal dialysis, 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 undergo transplantation, they wait longer, are less likely to receive a deceased or living donor organ (ie, die on the waitlist), and have poorer graft survival at the first year posttransplantation.

      A Call to Action

      In an effort to address these challenges, the NKF is advocating for access to affordable health care; 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.
      National Kidney Foundation
      Statement on racial violence and disparities in America.
      The issues that underlie kidney disease, COVID-19 infection, and health care disparities are complex. However, there are some specific strategies that the NKF is advocating, including calling on the federal government to provide quality disaggregated data on all tests, hospitalizations, discharges, and deaths from COVID-19 to fully understand the scope of the problem and ensure priority testing, contact tracing, access to a future vaccine, and funding for high-risk and minority communities and patients with kidney disease.
      National Kidney Foundation
      Statement on racial violence and disparities in America.
      The 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 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 estimated glomerular filtration rate and ensure that glomerular filtration rate 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 toward addressing health care disparities that continue to fuel disenfranchisement among these communities.
      National Kidney Foundation
      Statement on racial violence and disparities in America.
      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 access of patients with kidney disease and clinicians to personal protective equipment, preserving access to essential kidney-related surgical procedures (eg, organ transplantation and vascular access), and fighting policies that discriminate against patients with kidney disease.
      National Kidney Foundation
      NKF advocacy COVID-19 response.
      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 that patients with kidney disease and transplant recipients can access greater than 30-day supplies of critical prescriptions including immunosuppressive drugs, and ensure that vulnerable home dialysis patients, transplant recipients, and living donors can receive needed blood draws in their homes.
      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 that accompany it.

      Article Information

      Authors’ Full Names and Academic Degrees

      Kevin Longino, MBA, and Holly Kramer, MD, MPH.

      Support

      None.

      Financial Disclosure

      The authors declare that they have no relevant financial interests.

      Other Disclosures

      Mr Longino is the Chief Executive Officer of the NKF. Dr Kramer is the President of the NKF.

      Peer Review

      Received July 10, 2020, in response to an invitation from the journal. Direct editorial input from an Associate Editor and a Deputy Editor. Accepted in revised form July 15, 2020.

      References

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        • Ng J.H.
        • Ross D.W.
        • et al.
        Acute kidney injury in patients hospitalized with COVID-19.
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        • Cheng Y.
        • Luo R.
        • Wang K.
        • et al.
        Kidney disease is associated with in-hospital death of patients with COVID-19.
        Kidney Int. 2020; 97: 829-838
        • Henry B.M.
        • Lippi G.
        Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID 19) infection.
        Int Urol Nephrol. 2020; 52: 1193-1194
        • Centers for Disease Control and Prevention (CDC)
        COVID-19 in racial and ethnic minority groups.
        • CDC Fact Sheet
        Chronic kidney disease in the United States, 2019.
        • National Kidney Foundation
        Statement on racial violence and disparities in America.
        • National Kidney Foundation
        NKF advocacy COVID-19 response.