Predictors of End-stage Renal Disease in the Urban Poor

Abstract

<bold>Background<bold>: Despite the disproportionate burden of end-stage renal disease (ESRD) among traditionally underserved populations, the influence of social and clinical factors on incident ESRD in the urban poor is poorly understood. We sought to examine the prognostic values of social and clinical factors on risk of progression of established chronic kidney disease (CKD) to ESRD in the urban poor. <bold>Methods<bold>: We studied 15,353 individuals with moderate to advanced CKD who had received ambulatory care within a large public health system in northern California during 1996-2005. The primary outcome was progression to ESRD through December 31, 2005 as ascertained by the US Renal Data System registry. <bold>Results<bold>: Overall, 559 cases of ESRD occurred during 55,538 person-years of follow-up. In this public healthcare setting, among traditional predictors of ESRD, younger age, male sex, non-white race-ethnicity, Medicaid or Medicare health insurance coverage, diabetes, lower kidney function, higher proteinuria, lower hemoglobin level and lower serum albumin concentration were significantly associated with a higher adjusted risk of progression to ESRD (P<0.001 for all variables). There was no significant association between HIV/AIDS (P=0.07), viral hepatitis (P=0.11), homelessness (P=0.89) or non-English language (P=0.27) and risk of incident ESRD after concomitant adjustment for age, sex, race-ethnicity, health insurance, kidney function, proteinuria, comorbid conditions, hemoglobin and serum albumin levels. In contrast, a history of substance abuse was associated with a significantly lower adjusted risk of progressing to ESRD (P<0.001). <bold>Conclusions<bold>: In the urban healthcare safety net, we found no evidence that social factors including homelessness, substance abuse, non-English language status, or chronic viral diseases were associated with a higher risk of ESRD. Our results highlight the importance of addressing traditional risk factors for progressive CKD to reduce the disproportionate burden of ESRD among disadvantaged populations.