Drs Feldman and Agarwal consider the health disparities commonly seen with patients that have CKD and their impact in the treatment landscape.
Ryan Haumschild, PharmD, MS, MBA: When we think about kidney disease really does disproportionately affect communities of color and something that we’re very aware of, particularly the African American population. And with these individuals almost 4 times more likely to have kidney failure compared to their white counterparts. Considering that health disparities and inequities, things that’ve we’ve spoken about thus far negatively impact patient outcomes, what are some of the consequences of these health disparities in CKD?
Rajiv Agarwal, MD, MS: I’d like to echo a lot of good points others have raised and start out by saying that zip code is sometimes more important than the genetic code and this is paraphrasing someone who is an expert in public health. There are many examples of this. And a Harvard professor once said that sometimes if you’re born on the north side of the street or the southside of the street might make all difference in the outcomes related to as others have pointed out transportation, education, access to healthcare, dietary interventions, they’re all important. But let me go back to 2018 where there was a landmark article published by Crews, Bello, and Saadi on behalf of The World Kidney Day Steering Committee. It deals with the burden access and disparities in kidney disease. Let’s not forget they’re only 5% of the patients with kidney disease in United States. In fact, CKD is a global public health problem that effects almost a billion people worldwide. 1 in 7, the 8 billion people who share this word. You’re talking about 1 billion people. And the burden of kidney disease there is substantially across the world as the detection and treatment for example, in many settings the rates of kidney disease and the provision of its care are defined by the socioeconomic, the cultural and political factors rather than the access to care. There are still many countries that lack access to basic diagnostics, a trained nephrology workforce, universal, many African countries where there might be two nephrologists for the entire country. Universal access to primary healthcare is a problem, and of course, renal replacement therapies is a bit of a stretch in many other places. There's a great need for strengthening the basic infrastructure for kidney care services for the early detection and management of kidney disease. For example, screening for albuminuria and screening for chronic kidney disease. Across all countries, an advocate for more pragmatic approaches to provide renal replacement therapies. It is a World Health Organization goal are to achieve universal world health coverage by 2030. And there are substantial advances are being made in this space. For example, when I was practicing in India, I remember when patients used to come with end-stage kidney disease to the emergency room. We would have to tell the family that there's no treatment for it and they would be sent home. It's kind of very delightful now that in many states in India, our dialysis has become pretty much like in United States. People, when they get on dialysis, the government steps in and provides dialysis. Not to the same extent as we do in United States, but at least it's not a death sentence for many patients. I think even in United States there are some clever strategies people are thinking of. For example, I remember there was a trial published in the New England Journal of Medicine. There, the investigators intervened in barber shops for the treatment of hypertension. And this was an immensely successful trial where Black patients were being targeted in barber shops, and they had better blood pressure control. I think if we are sensitive to the social determinants of health, and they almost always play a role when you are treating patients. And if we simply scratch the surface, we'll find out the reason the patient is here has a lot to do with the access, transportation, the education, their beliefs, and their diets rather than hey, they are just noncompliant with therapy. That's sometimes our buzzword. Patients are not taking what they're supposed to be taking. But if we scratch the surface, we'll find that there's a much more complex social structure, especially in people with kidney disease, which is more of a social disease than just a medical condition. So if we don't address these social determinants of health for every patient that we see at the bedside, I don't think we will make much of a dent.
Ryan Haumschild, PharmD, MS, MBA: Well said, and I feel like now we've got the platform more than ever before to really make an impact and start to move these strategies forward. And it's also important for us to understand that it's not just right by the patient, because it is right by the patient. But it's also the more we take care of these patients, we can steward overall health care spend.
Transcript edited for clarity.