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My first exposure to kidney disease and its impact on communities of color occurred when I was in high school. An elderly neighbor, who was like a grandfather to me, was diagnosed with kidney failure. Around the same time, my older first cousin, who had children around my age, was starting dialysis due to kidney failure attributed to high blood pressure. She was going to have a kidney transplant. If you ask an African American, he or she is likely to have at least one relative with kidney disease requiring dialysis or a transplant.
Disparities in renal failure not noted in the medical literature until the early 1980s
When I started my training in nephrology (kidney disease) in 1993 in Birmingham, Alabama, it was already evident to me that people of African descent were much more likely to suffer from kidney disease than people of African descent. European. Birmingham’s dialysis units were filled with black and brown people of all ages, and sometimes several family members. In one of the dialysis units, my patients included an African American grandfather and grandson, an African American mother and daughter, and two African American sisters.
Nephrologists anecdotally noted the striking disparities in rates of kidney disease in African Americans compared to white patients, but this was not widely reported in the medical literature until 1982, when a report titled “Racial Differences in the Incidence of End-Stage Renal Disease Treatment” was published in the New England Journal of Medicine. The authors found that in Jefferson County, Alabama, the risk of end-stage kidney disease from hypertension was approximately 18 times more for African Americans versus whites.
The underlying conditions do not adequately explain the disparities
The explanations for the higher rates of kidney disease in African Americans generally fall into two broad categories: higher rates of diseases such as diabetes and hypertension that lead to kidney disease; and more limited access to insurance and medical care, leading to late diagnosis and faster progression of kidney disease. Therefore, efforts to reduce the rates of kidney disease in African Americans have generally focused on diagnosing and treating diabetes and hypertension.
Despite these efforts, disparities persisted. The most recent report The US Kidney Data Service shows a prevalence of end-stage kidney disease of 5,855 cases per million for African Americans, compared with 1,704 cases per million for white Americans.
Genetics and biology play only a minor role in excess risk
A game changer in terms of understanding some of the excessive risks of kidney disease in African Americans compared to other racial and ethnic groups came in 2010, with the publication of reports showing that variants of the APOL1 gene could confer an additional risk. Inheriting two copies of the risky APOL1 alleles carries a significantly increased risk of kidney disease. African Americans who are HIV positive with two copies of the risk allele are essentially the only people who develop kidney disease associated with HIV infection. African Americans who develop COVID-19 and carry two of these risky alleles also appear to be at higher risk of acute kidney injury from coronavirus infection.
Just as the sickle cell gene provided evolutionary benefits in the form of protection against malaria, the risk alleles APOL1 conferred protection against the parasite responsible for African sleeping sickness.
Social determinants of health, race and racism key to health disparities among African Americans
While we now understand more about the genetics and biology of kidney disease in African Americans, they play a relatively minor role in their excess risk. Social determinants of health, race and racism are just as – if not more – important in explaining the excessive risk of kidney disease in African Americans compared to white Americans.
Kidney disease is not unique in that it presents a marked difference between ethnic groups in terms of risks and outcomes. The same can be said for many chronic diseases including diabetes, heart failure, peripheral artery disease, asthma, and cancer, as well as pregnancy. Maternal and fetal outcomes are known to be worse for African American women and infants compared to their white counterparts, even after accounting for education and income.
These disparate health outcomes are indelibly linked to decades of social and economic injustice rooted in racism, the legacy of Jim Crow segregation laws, unfair housing laws, the redlining of communities of color, systems separate and unequal education, environmental racism, an unfair criminal justice system – and the list goes on.
In his presentation at Harvard Medical School’s webinar series, “Tackling Health Disparities: Clinical Insights on Race and Social Justice,” Reverend Traci Blackmon, a former nurse and nationally recognized social justice advocate, described the fractures seen in major cities across the United States. United, where African Americans live in food deserts with depressed family values, few jobs, and substandard schools. These divisions result from government policies and societal choices. In order to better understand the disparities in kidney disease outcomes, it is not enough to understand only the genetics and biology of the disease. Societal and institutional barriers that have been erected for the benefit of one group of individuals rather than another must be removed.
Access and advocacy will help, but systemic change is needed to significantly improve outcomes
As a further step in improving outcomes for people of color with kidney disease, people with kidney disease should be referred to specialist care in a timely manner. People from low-resource communities are less likely to see a nephrologist before starting dialysis and therefore are also more likely to have poorer results on dialysis. In addition, they are less likely to have been assessed and listed for kidney transplantation before the start of dialysis. Patients with renal failure should be empowered to understand the stage of their kidney disease by knowing their eGFR (a way to measure the filtering function of the kidney), to advocate for themselves for referral to a nephrologist, and to advocate for themselves for a kidney transplant. .
It will take patients, families, clinicians and community health advocates to work together to eliminate disparities in the rates of kidney disease and its outcomes.
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