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Chronic Kidney Disease and Racial Disparities in Healthcare

The Barriers

The higher number of Black Americans with kidney failure compared to the lower number of White Americans with kidney failure is a gap or health disparity. A health disparity is the difference in quality of care or health outcomes for a nonminority group compared to a minority group.

Primary factors that contribute to increased chronic kidney disease (CKD) in Black communities are higher rates of diabetes and high blood pressure. But these are not the only factors. Other barriers are social determinants of health. These include income, employment, education, housing, insurance status, and access to healthcare.

For example, diagnosis and treatment of kidney disease often are delayed for patients in Black communities who have poor access to healthcare. More than 30% of patients with CKD hadn’t seen a nephrologist until the point of kidney failure according to one study. Without timely treatment, CKD can progress more quickly to kidney failure.

Learn more about Social Determinants of Kidney Disease here.

Word cloud of the social determinants of health

Barriers to Transplant Access

Black Americans with kidney failure have lower access to transplantation. While Black Americans account for 35% of people receiving dialysis, they are less likely to be identified as kidney transplant candidates compared to White Americans. Black patients with kidney disease often encounter barriers throughout the steps to transplant access. They have to wait a year longer on average than white patients to receive a kidney transplant.

Eligibility

Black patients with late stage CKD often are not identified as eligible for transplantation. A contributing factor, recently addressed by the medical community, was inequity in eGFR calculation. Researchers found that about 1 out of 3 Black patients with late-stage CKD had been classified incorrectly in a recent population-based study. Eliminating this inequity in calculation will improve access to appropriate, timely care.

Referral

The most significant barrier to kidney transplantation is timely referral for evaluation. Patients must have an evaluation to be recommended for a kidney transplant.

There are many benefits to early referral. Early referral allows patients

Access to the waitlist before starting dialysis
More time to look for a potential living donor
More time to receive education about transplantation
More time to complete a transplant evaluation
Access to a kidney specialist

Black patients are less likely than White patients to be referred for transplantation. Patients from Black communities who are receiving dialysis are less likely to be referred to a nephrologist before beginning dialysis.

Medically appropriate patients should be referred for evaluation once an eGFR of less than 30 mL/minute is reached. In an analysis of one US healthcare system, even when 64 Black patients were reassigned to an eGFR of less than 20 mL/minute, none were referred for kidney transplant.

Evaluation completion

It is difficult for many patients to complete an evaluation required for recommendation for kidney transplantation. Transplant evaluation requires many trips to healthcare facilities. Patients typically meet with a transplant nephrologist, transplant surgeon, transplant coordinator, social worker, and psychologist. They also may meet with a financial coordinator, pharmacist, and dietician. The patient must undergo several tests, including cardiac testing, chest x-rays, blood tests, routine health screenings (eg, mammogram, colonoscopy), and a dental examination. Other testing may be needed based on the patient’s medical conditions.

Attending all of these appointments requires time off from work as well as transportation to and from the facility. Sometimes workers have no paid sick leave. For those who earn hourly wages, going to medical appointments instead of going to work creates financial stress. Patients who live in rural areas may find it difficult to travel long distances for multiple appointments. In many cases, transportation is not available.

Women have particular challenges as primary caretakers for children, elderly, or ill family members. Taking care of their own needs creates gaps in care for loved ones.

Waitlist

Black patients are less likely than White patients to gain access to a waitlist for transplantation. One barrier is that many transplant centers have a Body Mass Index (BMI) requirement. This can limit kidney transplant as an option for overweight patients.

Transplant

Black transplant candidates wait longer than White transplant candidates for kidney, heart, and lung transplants and have less access to both living donor and deceased donor transplants. The greatest disparity exists in access to living donor transplants.

Historical Impact of the eGFR Race Correction

In the past, the eGFR race correction multiplier was used in formulas to calculate how well the kidneys were working. In 2021, the National Kidney Foundation and American Society of Nephrology recommended a new approach to eliminate this inequity.

eGFR Calculation

Providers calculate the estimated glomerular filtration rate (eGFR) to determine the severity of a patient’s kidney disease. The eGFR is calculated from the amount of creatinine in the blood using a math equation. Different people can have different creatinine levels in their blood. This difference is not always related to kidney disease. It can be affected by other factors, such as age, sex, and body weight. In the past the eGFR for a Black patient often was multiplied by 1.2 or 1.6, depending upon the formula. However, unlike age, sex, and body weight, race is a social construct. It is not biological. This multiplier prevented Black Americans from getting timely treatment to slow the progression of chronic kidney disease.

Chart that explains eGFR and stages of chronic kidney disease

eGFR Race Correction as a Barrier to Timely Medical Care

Using race as a factor when calculating eGFR created barriers to timely medical care for Black patients. The multiplier for race can make Black patients seem to have better kidney function than they actually do. When the eGFR race correction multiplier was used, a Black woman who is 5 feet tall and weighs 150 pounds with a creatinine of 2.9 mg/dL and eGFR of >20 ml/min would not be referred for kidney transplantation; a White woman who is 5 feet tall and weighs 150 pounds with a creatinine of 2.9 mg/dL and eGFR of <20 ml/min would be referred. This means that the White patient could get on the transplant waitlist much earlier than the Black patient.

Not only did the eGFR race correction impact access to a kidney transplant, this inequity created other barriers for Black patients with severe CKD:

Delayed referral to a nephrologist
Lack of patient education about transplant options
Inappropriate choice or dosing of medicines
Potentially harmful levels of contrast dyes used in diagnostic tests

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Other pages you may be interested in!

The facts: Prevalence of chronic kidney disease in Black Americans

Know the facts. Compared to other ethnic groups, Black Americans are at increased risk of diabetes, high blood pressure, chronic kidney disease (CKD), and kidney failure.

The biology: Inherited disorders that affect the kidneys

Certain inherited disorders that affect the kidneys are more common in the Black community. These include lupus, polycystic kidney disease, and mutations to the APOL1 gene.