Social Determinants of Health and End Stage Kidney Disease among Survivors of Critical Illness and AKI
Dilaram Acharya, Seda Babroudi, Udeme E. Ekrikpo, Tomonori Takeuchi, Lama Ghazi, Orlando M. Gutierrez, Javier A. NeyraBackground:
Adverse social determinants of health (SDOH) are associated with higher risk of acute kidney injury (AKI). This study evaluated the association of individual- and neighborhood-level SDOH with incident ESKD among intensive care unit (ICU) survivors of AKI.
Methods:
30,498 adult ICU survivors of AKI at a major academic medical center between January 1, 2012, and December 31, 2022, were included. Individual-level SDOH (race, ethnicity, and insurance status) were obtained from the hospital electronic health record, whereas neighborhood-level SDOH (Area Deprivation Index (ADI), among others) were derived from census-based indices. ESKD was defined by kidney failure with an estimated glomerular filtration rate <15 mL/min/1.73 m 2 or the initiation of kidney replacement therapy, including maintenance dialysis or kidney transplantation. Association of individual- and neighborhood-level SDOH with incident ESKD were evaluated using multivariable cause-specific Cox proportional hazards models adjusting for clinical factors.
Results:
The median age was 58 years, 40% were women, 31% were Black, and 12% were uninsured. The median follow-up time was 730 days, during which 326 (1%) patients developed ESKD and 2,723 (9%) died. In adjusted models, Black race was associated with a higher hazard of ESKD compared with White race (adjusted hazard ratio [aHR] 1.43, 95% CI 1.05–1.94), whereas having health insurance was associated with a lower hazard of ESKD (aHR 0.60, 95% CI 0.39–0.92). Higher neighborhood-level socioeconomic disadvantage was also independently associated with higher risk of ESKD (ADI tertile 2: aHR 1.42, 95% CI 1.01–2.00; tertile 3: aHR 1.58, 95% CI 1.08–2.33).
Conclusions:
Black race, lack of health insurance, and residence in socioeconomically deprived neighborhoods were independently associated with a higher hazard of incident ESKD among ICU survivors of AKI. Standardized SDOH assessment in clinical practice may improve risk stratification of ESKD and identify AKI survivors most likely to benefit from post-discharge interventions.