Social Determinants of Racial Disparities in CKD : Journal of the American Society of Nephrology

Journal Logo

Up Front Matters: Brief Reviews

Social Determinants of Racial Disparities in CKD

Norton, Jenna M.*,†; Moxey-Mims, Marva M.*,†; Eggers, Paul W.*,†; Narva, Andrew S.*,†; Star, Robert A.*,†; Kimmel, Paul L.*,†; Rodgers, Griffin P.†,‡

Author Information
Journal of the American Society of Nephrology 27(9):p 2576-2595, September 2016. | DOI: 10.1681/ASN.2016010027
  • Free


Significant disparities in CKD rates and outcomes exist between black and white Americans. Although other schema exist,1,2 the National Institutes of Health defines a health disparity as a health difference that adversely affects disadvantaged populations, based on one or more health outcomes.3 To fully understand the genesis and implications of these disparities, one must consider the concept of race. Early attempts to classify people by race—based largely on physical appearance and geographic origin—emerged during the 17th century, took root as a system for stratifying people by class, and ultimately became generally accepted.4 In the United States, race categories have changed markedly over time. The first United States census in 1790 included four categories: free white male, free white female, all other free persons, and slaves. Since then, the census has used a variety of categories to indicate individuals of African origin.5 The US Office of Management and Budget currently identifies five race categories: American Indian or Alaska Native, Asian, black or African American, Native Hawaiian or Other Pacific Islander, and white.6

Race as a Social Construct

Sociologists have long argued that race is arbitrary, based on social rather than biologic constructs.7 Despite associations between specific gene variants and certain races, race designations accurately reflect only a portion of ancestral differences in genotype.8–12 Studies comparing self-reported race with ancestral genetic markers suggest nearly a quarter of ancestry informative markers in individuals who identify as black are of non-African origin,13 undoubtedly in part because of the legacy of slavery. Blacks or African Americans in the United States are not a uniform group, but rather are composed of individuals and families with complex ancestries and diverse genetic architectures, which may have potential biologic, medical and therapeutic relevance.10,14–16 The inadequacy of racial classification systems in the United States will become increasingly apparent as the number of “mixed race” people in the United States increases. Individuals identifying as “mixed race” grew by 32% between 2000 and 2010.17

There has been much debate about racial classification in medical research and care.18–22 Some suggest that race imprecisely reflects biologic endpoints and opine that there exists limited evidence of benefit for its use in clinical care.18–20 Others argue linking genotype with race would enhance understanding of racial health disparities, and suggest excluding race from research could be detrimental to the study of group health differences.21 Race, as a social classification system, must be distinguished from ancestry, which describes an individual’s genealogical history.12,23 Some have called for eliminating the use of racial categories or skin color as surrogates for genetics.10,23 In the era of precision medicine,24 race will be insufficient and perhaps irrelevant as a proxy measure for ancestry, given continuing advances in genetic technologies. At best, race is an oversimplified proxy measure that inadequately and often inaccurately describes the genetic and cultural variations resulting from differing ancestral origins. At worst, race is a socially constructed system that enables intentional or implicit bias in the treatment of certain groups.7,25 Shortcomings of the current race classification system in nephrology are demonstrated below.

A 26-year-old black woman presented with microscopic hematuria, proteinuria, and slightly decreased kidney function, to an urban University Hospital medical subspecialty clinic, staffed by one of the authors. She had no symptoms, but had a brief upper respiratory tract infection 6 months ago. Her BP was 147/94 mmHg, pulse was 74 bpm, and temperature was 36.9° C. Physical examination was unremarkable except for trace pedal edema. Urinalysis revealed hematuria and scattered red blood cell casts. “Nearly a classic case of IgA nephropathy,” the nephrologist thought, “but IgA nephropathy is so rare in black patients.”

A biopsy was done, consistent with IgA nephropathy. At follow-up, the nephrologist asked the patient about her family background, and learned her mother was from Taiwan. Her paternal grandmother descended from Greek immigrants, and her paternal grandfather was black. The nephrologist realized he had decided on the patient’s “race” and categorized her as “black” without asking her about her ancestry or eliciting a detailed family history.

As demonstrated by this vignette, the pervasive use of race in medicine poses profound challenges. This social construct creates a conundrum. Race categories have potentially positive and negative ramifications. Nevertheless, the US Government and the medical profession use such distinctions. Self-identified race, however, is a strong predictor of both self-rated health and health outcomes. Race categories may allow the US Government and other organizations to study, understand and ultimately work to eliminate disparities between populations. However, such distinctions may culminate in implicit and explicit biases.

We outline the disparities associated with race categories and explore potential factors underlying black-white disparities in patients with ESRD and CKD, emphasizing the role of social determinants of health as potential nonbiologic contributors (Figure 1).

Figure 1.:
Theoretical model: interconnected mechanisms underlying associations between SES and health. Socioeconomic factors may contribute to a complex and overlapping set of social determinants that interact and combine to affect health outcomes. Racial biases may amplify associations between SES, social determinants, and health outcomes

Racial Disparities in ESRD

In the United States, the burden of ESRD falls disproportionately on black Americans, as well as other minority populations. Black Americans comprise approximately 13% of the United States population26 but more than 30% of patients with ESRD in the United States.27 This disparity largely results from a 3.5 times greater risk for progression from early stage CKD to ESRD among black compared with white Americans.27–30


Although there is a much higher risk for progression to ESRD among black Americans, national31–35 and regional30,36,37 data demonstrate lower mortality in black than white patients receiving dialysis. This survival advantage exists despite delayed nephrology referrals,38 differences in delivery of dialysis,39 lower rates of arteriovenous fistula placement,40 home hemodialysis,35 and peritoneal dialysis (PD),35,41 and increased infection during PD42,43 in black versus white patients.

Potential explanations for racial differences in hemodialysis mortality include higher perceived health-related quality of life—which has been associated with lower risk of death44—among black patients receiving dialysis,45–47 increased cardiovascular risk among white patients with ESRD,32 and racial variations in mineral and bone metabolism.48,49 Associations between mortality and both dialysis delivery39,50 and nutritional and inflammatory markers51,52 may also differ across race. An analysis of nearly 7000 patients receiving hemodialysis in the United States found no difference in mortality between black and white patients when adjusting for demographic, social, and clinical characteristics,53 suggesting these factors contribute to racial mortality disparities. Further research is needed to understand contributors to racial disparities in mortality among patients receiving dialysis. However, this racial disparity in mortality among patients receiving dialysis is not uniform across age groups. Studies accounting for kidney transplantation as a competing risk54 and residential characteristics55 among patients aged 18–30 years receiving dialysis found black patients had higher mortality than white patients.


Although kidney transplantation is generally considered the preferred treatment option for patients with ESRD regardless of race, it is not provided uniformly across racial groups. Disparities between black and white patients are evident at every step of the transplantation process. Black patients are less likely to be identified as kidney transplant candidates,56–58 be referred for transplant evaluation,57–59 complete the evaluation,60,61 and be placed on the waiting list57–59,62,63 than white patients. Once on the waiting list, black patients wait longer,60,64,65 are less likely to receive a deceased donor transplant,57,58,63 and are more likely to receive expanded criteria donor kidneys66 than white patients. Additionally, black patients are less likely than white patients to receive a kidney transplant from a living donor,67–69 perhaps as a result of socioeconomic factors, associated with lower rates of living kidney donation among poor black compared with poor white Americans.70 Differences between black and white patients in clinical factors,57,63 modality preference,59,60 and early and multiple waitlisting63 are potential factors underlying racial disparities in transplantation access.57,59,63

As early as one year after transplantation, black transplant recipients have poorer graft survival than white patients with both deceased and living donor kidneys, although the gap appears to be narrowing slightly over time.71,72 Black recipients may be more likely to receive kidneys from black donors who have APOL1 variants.73 Such kidneys are more likely to fail.74 However, presence of APOL1 variants in kidney transplant recipients evidently is not associated with increased likelihood of kidney failure after transplantation.75

Racial Disparities in CKD

Despite higher incidence of ESRD among black Americans, prevalence estimates of early CKD—based on an eGFR≤60 ml/min per 1.73m2—show lower rates of CKD in black than white individuals in the United States.27 The risk of CKD, however, becomes increasingly greater for black than white individuals at progressively higher CKD stages.76

In general, incidence and prevalence of albuminuria are greater in black than white individuals.76–78 National Health and Nutrition Examination Survey (NHANES) data show black Americans with and without diabetes have 2.8- and 2.2-fold greater odds, respectively, of having abnormal albuminuria than white Americans.77 Assessments of black-white disparities in nondialysis-dependent CKD mortality have yielded inconsistent results, perhaps because of differences between populations assessed. Studies within single payer systems and among Veterans have found lower mortality in black than white patients with CKD.30,79,80 However, among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, black patients with CKD had higher mortality than white patients, even after adjusting for socioeconomic and clinical factors.81

Biologic and Clinical Issues in CKD Disparities

Primary strategies to slow CKD progression include management of hypertension and albuminuria.82 Treatment with renin-angiotensin-aldosterone system (RAAS) blockers—including angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB)—reduces albuminuria,83,84 improves BP control,83,85 and is associated with slower CKD progression.83,85–89 Because of this dual effect on hypertension and albuminuria, many guidelines for hypertension management in CKD recommend use of an ACEI or ARB alone or in addition to other antihypertensive therapies.68,82,90,91

In addition to pharmacologic treatment, sodium restriction in patients with CKD improves BP control,92–94 reduces albuminuria,92,93 and enhances efficacy of RAAS blockers.92,93,95–98 Blood glucose control is associated with lower risk of GFR decline in individuals with diabetes and CKD99 and reduces the incidence of albuminuria in patients with diabetes.100 Early referral to a nephrologist is also associated with improved CKD patient outcomes.101–105

Racial disparities exist in the application of these treatments.106 Black patients with CKD are more likely than whites to have delayed38 or no107 nephrology referral. Early reviews by leading hypertension experts in the 1970s and 1980s—and as recently as 2006—suggested differential treatment of hypertension by race, based on theoretical grounds, including differences in presumed volume and renin-angiotensin-aldosterone axis status.108–114 In absence of evidence based on hard outcomes, calcium channel blockers were recommended for black patients,108–111 while ACEIs were recommended for white patients.108,111,112 Before the African American Study of Kidney Disease and Hypertension (AASK) demonstrated the benefits of RAAS antagonists in black populations,115 such recommendations may have led to reduced ACEI and ARB use in black patients.116

Men progress more quickly to ESRD than women.117–119 Prevalence of reduced kidney function increases with older age, but controversy exists regarding whether small decrements in eGFR among the elderly reflect normal aging or disease.120–123 Neither sex nor age fully account for racial disparities in CKD. Adjusted for these variables, the prevalence of CKD and the incidence of ESRD are higher in black than white patients (C. Fwu, personal communication).

APOL1 gene variants may account for much of the increased risk of nondiabetic kidney disease in individuals of African descent.124 APOL1 variants are relatively common in people of African descent, but generally absent in individuals of European descent.14 Homozygosity for one of the APOL1 risk variants is associated with increased albuminuria,125 decreased GFR,125,126 and more rapid progression of CKD.126,127 Yet, many individuals with two APOL1 risk variants do not develop CKD,128 suggesting factors besides APOL1 must be present to produce disease. Social and environmental factors, as well as viral infections, have been suggested as possible “second hits” leading to progressive kidney disease in individuals with APOL1 variants.129–132

Clinical factors, including diabetes, hypertension, and obesity, are likely contributors to racial disparities in CKD. In the United States, diabetes, hypertension and nondiabetic glomerular disease are the leading causes of ESRD.27 The proportion of CKD attributable to diabetes or hypertension may be up to 12-fold higher in black than white Americans.133 The prevalence of diabetes is 13.2% in black Americans versus 7.6% in white Americans.134 Nearly 45% of black men and 46% of black women have hypertension, versus 33% and 30% of white men and women.135 Black Americans tend to develop hypertension at younger ages than white Americans.135 Obesity may increase risk for CKD incidence and progression, both directly and by increasing diabetes and hypertension rates.136–139 Obesity prevalence is 48% in black and 33% in white Americans.140

Maternal and Fetal Deprivation and CKD Disparities

Developmental programming—“the ability of the normal developing organism to undergo durable changes in response to environmental conditions without change in DNA sequence”141—is a potential contributor to nephropathy, and aspects of racial disparities in CKD. Animal models show maternal-fetal undernutrition (MFUN) is associated with reduced birth weight, decreased postnatal growth, and increased hypertension risk later in life.142 Epidemiologic studies demonstrate associations between maternal nutritional status and birth weight.143,144 Associations exist between low birth weight—which is more common among black than white infants145—and increased adulthood risk for CKD146,147 and related conditions, including hypertension,148 diabetes,149,150 obesity,151 and cardiovascular disease.152,153 Reduced nephron number/body mass ratio is associated with low birth weight, and has been proposed as a primary mechanism of prenatally programmed CKD.154–158

Developmental programming may increase risk for CKD through prenatal and postnatal pathways.141 Adverse exposures during fetal development, including MFUN, maternal-fetal energy excess, and maternal-fetal psychosocial stress (MFPS), may (1) permanently alter epigenetic regulation of gene expression and kidney structure to yield a high-risk renal phenotype characterized by low nephron number; (2) program changes in postnatal energy homeostasis that promote accelerated pediatric growth, ultimately creating a “mismatch” between kidney capacity and increased excretory load; and (3) increase risk for diabetes and hypertension, which may interact with mechanisms engendered by low nephron number and kidney/body mass mismatch.

MFUN, maternal-fetal energy excess, and MFPS are all associated with socioeconomic disadvantage, which is experienced disproportionately by black Americans. Additionally, MFPS, as a result of stressors, such as perceived or actual racism, may disproportionately affect black women across the spectrum of socioeconomic status (SES). Therefore, the children of black women—especially impoverished black women—may be particularly susceptible to perturbations in kidney physiology, energy homeostasis, and kidney/body mass ratios as a result of adverse prenatal exposures. Autopsy findings in 111 adult men showed greater glomerular volume (a surrogate for lower nephron number) in black than white males.159 While there is limited evidence regarding connections among socioeconomic factors, maternal-fetal exposures, and CKD, investigators have called for more research on how SES across the lifespan—including in fetal and childhood development—relates to CKD risk.160,161

Social Determinants of Health in CKD Disparities

Social determinants, defined as the “conditions in which people are born, grow, live, work, and age,”162 include a variety of factors such as income, employment, education, housing, environment, social support, and access to healthcare. These factors may influence health by mediating availability of resources to maintain health (e.g., healthy food, safe places to exercise, affordable medications) or access to healthcare (e.g., health insurance, proximity of clinical centers, transportation). Social determinants may modify risk of exposure to environmental hazards (e.g., lead, air pollution, water contaminants), produce stressors (e.g., financial worries) that amplify stress and stress-related health outcomes, and generate competing economic and social demands which may affect health outcomes (Figure 1). National and international organizations— including the World Health Organization,162 the US Department of Health and Human Services,163 and the Institute of Medicine (IOM)1—recognize the significant effect of social determinants on public health and health disparities. A growing body of evidence supports the potential role of social determinants in CKD outcomes and disparities.58,116,129,164–169


SES—perhaps the most studied social determinant of CKD—is a measure of social and economic wellbeing, often assessed through three aspects: education, occupation, and income. Low SES is associated with increased mortality and numerous chronic diseases.170,171 The Whitehall study, which tracked 17,530 male civil servants in London over 10 years, found mortality increased as employment status decreased.171 A large United States-based study found an inverse relationship between mortality and both income and education.172 Despite an overall decrease in mortality rates in the United States between 1960 and 1986, SES-related disparities in mortality grew over the same time period.172 Both insurance status and risk behaviors have been suggested as primary mechanisms for the relationship between SES and health. Neither, however, accounts fully for the association. Other mechanisms, including adverse social conditions, likely are involved. Disability may be a key mediator of disparities, as disabled persons are overrepresented in the black population in Medicare. Accounting for disability and SES abrogated differences in mortality between black and white beneficiaries.173 SES may contribute to a complex and overlapping set of social determinants that combine to affect health outcomes (Figure 1).

Black individuals have lower SES than white individuals across all three SES metrics.174 Compared with white Americans, a greater proportion of black Americans do not graduate high school,175 are unemployed, underemployed, or employed in low-paying jobs,176 and live below the federal poverty level (FPL).177

The incidence and prevalence of early and late stage CKD, and the rate of progression to ESRD, varies by race and SES.178 Self-reported income below the FPL or less than high school education are associated with microalbuminuria in the United States.179 Prevalence of eGFR<60 ml/min per 1.73m2 was greater among Americans who had fewer than 12 years of education, had lower income, or were unemployed.180 Among black participants in the Jackson Heart Study, risk of abnormal albuminuria and eGFR<60 ml/min per 1.73m2 was lower in individuals who had a household income at least 3.5 times the FPL or at least one undergraduate degree.181 In the REGARDS cohort, low income was associated with increased prevalence of albuminuria182 and an eGFR<60 ml/min per 1.73m2.183 The association between income and albuminuria was stronger in black than white participants.182 Odds of CKD defined by International Classification of Diseases, Ninth Revision codes or eGFR<45ml/min per 1.73m2 were elevated for working class, versus nonworking class, participants in the Atherosclerosis Risk in Communities study.184,185

Lower income and education were associated with lower eGFR in the Chronic Renal Insufficiency Cohort (CRIC) study.186 The prevalence of disability was lower for those with higher levels of income and education in the NHANES CKD population.187 Incident ESRD is more likely among individuals with low income188,189 and education.190 Patients with ESRD who are unemployed191 or have less education192 may be less likely to be placed on transplantation waiting lists and to receive a transplant. Additionally, lower educational attainment is associated with higher risk of peritonitis in patients receiving PD193,194 and graft failure in transplant patients.195

Despite recommendations for standardizing SES measurement to (1) include individual, household, and area level data, (2) account for fluctuations in SES over time, and (3) consider other aspects of SES (e.g., class), inconsistent measurement of SES may obscure the relationship between SES and health outcomes.196 For instance, use of average area income to assess the association between poverty and disease may mask potential effects of income inequality on health, as areas with pockets of very high and very low income may appear to be areas of moderate income. While individual poverty measures consistently predict adverse kidney outcomes, associations between area poverty and adverse kidney outcomes have been demonstrated in some,197–199 but not all,183,188,200 CKD and ESRD studies. Even within specific studies, individual188 and household,183 but not area, incomes were associated with CKD prevalence, ESRD incidence, and mortality.

Measurement of SES is further complicated by the correlation between each of its component measures (i.e., educational attainment is associated with employment and, therefore, income), making it difficult to identify the degree to which each factor individually affects outcomes. For example, controlling for income weakens the association between education and CKD.201 These issues make it important to deal with these factors in multilevel, comprehensive analyses.

Psychosocial Factors

Psychosocial factors—including stress, depression, and social support—may affect the interaction between race and CKD, however, more research is necessary to delineate causal relationships.


The role of stress in health has been acknowledged since Selye202 first introduced the concept in the 1950s. Physical and psychologic stressors create demands that require a matched response within an individual’s internal environment to maintain stability. The term “allostasis” describes the ability to maintain stability in response to stress.203 Allostasis is maintained through physiologic changes in the endocrine, cardiovascular, metabolic, immune, and autonomic nervous systems. The allostatic load—repeated stress responses or maintained elevated activity in these systems—may predispose individuals to disease.204

McEwen205 proposed four pathways for increased allostatic load: (1) frequent stress, (2) inability to adapt to repeated stressors, (3) inability to shut off the stress response after exposure to the stressor has ended, and (4) an unbalanced allostatic response in which an insufficient response from one system leads to a compensatory response in another.

Associations between stress and disease—particularly hypertension and cardiovascular disease—are well documented.206–209 Research on associations between stress and CKD is limited, but potential mechanisms (e.g., increased sympathetic nervous system activity, alterations in the hypothalamic-pituitary-adrenal axis, changes in levels of inflammatory cytokines and endothelin-A) have been suggested.210–212 Because stress hormones are both metabolized and cleared by the kidneys, patients with reduced renal function may experience extended or heightened biochemical responses consistent with increased allostatic load.212,213 Therefore, patients with CKD may be unable to downregulate stress responses.

Black individuals may be more susceptible to allostatic load through McEwen’s first mechanism—increased frequency of stress. Given racial disparities in wealth and access to resources in the United States, stress from social issues may disproportionately affect black Americans. Neighborhood stressors, including physical disorder and violence, were more common in black than white participants in the Multi-Ethnic Study of Atherosclerosis, accounting for a significant portion of the increased risk of hypertension in black participants.214 Race consciousness, “the frequency with which one thinks about his or her own race,” was associated with increased diastolic BP among black patients from urban primary care clinics.215 Anticipated discrimination—or racism-related vigilance—was more prevalent and resulted in a greater degree of vigilant behaviors (e.g., preparing for insults) in black than white community members in Chicago.216 The odds of hypertension increased with vigilance in black study participants.216 Race consciousness,215 anticipated discrimination,216 perceived discrimination,217–221 medical mistrust,222,223 and low perceived involvement in health decision making224 are documented among black Americans and are likely contributors to stress.225

Both perceived discrimination and medical mistrust are associated with negative health outcomes,225 including the CKD risk factors hypertension219,226 and diabetes.227,228 Perceived discrimination and related stress may promote negative coping behaviors, including unhealthy eating, overconsumption of alcohol, and/or tobacco or drug use.219,229


Depression may exacerbate kidney outcomes by modifying immunologic and stress responses, nutritional status, and/or adherence to medical regimens.212 In CKD, assessment of depression is complicated by varying definitions, overlap between symptoms of depression and uremia, and confounding effects of medications.230 Depression has been associated with increased risk of ESRD incidence in patients with CKD,231 but associations between depression and kidney function are inconsistent. Data from CRIC demonstrate an independent association between lower levels of kidney function and elevated depressive symptoms,232 while data from AASK and other studies show no association.233–235 The REGARDS study found a linear association between depression and reduced GFR before, but not after, adjusting for demographic, clinical, social, and behavioral factors,236 suggesting these covariates may mediate the relationship between depression and CKD. In patients with ESRD, depression is associated with lower adherence to medical recommendations237–242 and increased morbidity,243 hospitalization,244–246 and mortality.245–249

Despite measurement challenges, depression appears to be highly prevalent in both black and white patients with CKD250 and ESRD.230,251 Whether racial disparities in depression and CKD are present, however, is unclear. Among CRIC participants, non-Hispanic black patients had 1.5-fold greater odds of elevated levels of depressive affect and were less likely to be taking antidepressants than non-Hispanic white patients.232 However, depression rates were similar between black and white patients receiving hemodialysis in a small study.252

Interrelationships between race, depression and CKD are further complicated by social factors. Experiences of race and class discrimination among black individuals are associated with increased prevalence of depression.221 In studies of older adults, black participants had greater prevalence of depression than white participants before, but not after, controlling for sociodemographic factors.253,254 Lower educational achievement magnified associations between black race, elevated body mass index and depression.255 Unemployment and low income were strongly associated with increased levels of depressive affect in black patients with hypertensive CKD.234

Social Support

Social support refers to the network of people who exchange emotional, informational, and/or material assistance with individuals. Patients with chronic disease may receive support—including resources, information/advice, or empathy/understanding—from a variety of sources, including spouses, family members, healthcare providers, community members, members of faith-based groups, and fellow patients. The link between social support and health outcomes is well established across numerous illnesses.256 In the ESRD population, higher levels of social support have been associated with enhanced treatment adherence,257 increased patient satisfaction,258,259 improved perceptions of quality of life,258,260 decreased hospitalizations,258 and lower mortality.242,261,262 In a predominantly black population of patients with ESRD, religious service attendance was associated with improved perceptions of quality of life, increased satisfaction with life, and decreased depression levels.263

Social support may enhance the health of patients with CKD by several mechanisms, including (1) facilitating access to healthcare by providing financial resources to pay for care, transportation to and from healthcare facilities, advice about how and where to access care, and/or a companion at medical appointments; (2) buffering against depression by providing emotional or functional support and reducing the perception of isolation that often accompanies depression; (3) improving perceived quality of life; (4) promoting patient compliance with medical and lifestyle recommendations; and (5) improving immune function.264 Social support may also improve individuals’ ability to cope with stress,212,256,264 which may be particularly relevant for black Americans, for whom low SES and perceived discrimination may increase stress.214–221,225,265

Assessment of social support across race groups is hampered by the variety of social support sources included in research. Some studies point to smaller social networks and lower social engagement in black than white populations,266,267 while others report no difference.268

Spousal and Familial Relationships

Black Americans are less likely to get married, tend to marry later in life, and are more likely to divorce than white Americans.269 Once married, black Americans report lower levels of happiness, poorer communication, greater conflict, and lower marriage quality than white Americans.270–272 Marital status and the quality of spousal relationships have been associated with several health outcomes,273–277 including ESRD.278 Development of chronic diseases, like CKD, may be a source of marital discord or dissatisfaction, as the disease may significantly alter patient-spouse relationship dynamics. CKD may modify patients’ ability to work outside the home, inhibit patient contributions inside the home, shift spouses into caregiver roles, or cause sexual dysfunction.

The connection between spousal relationship quality and outcomes in patients with ESRD was explored as early as the 1970s. Early hemodialysis research showed an association between marital discord and depression,279,280 which was recently replicated in a small study of patients receiving hemodialysis and their spouses.281 It remains unclear, however, whether marital stress leads to depression or depression to marital stress.281 Patients with ESRD function in a psychosocial dyad with their spouses, as depression in patients with ESRD increases with increasing levels of depression and decreasing levels of social support in the spouse.282 Satisfaction with spousal relationships was associated with decreased mortality for women, but not men, in a cohort of primarily black patients receiving hemodialysis.278 Relationships with other family members and friends are also associated with outcomes in CKD. In a 3-year study of nearly 500 black patients receiving hemodialysis, survival was greater among women, but not men, living alone or with a spouse only, compared with those living in households with additional relatives and/or nonrelatives.283 Further research is necessary to ascertain how race may interact with such factors to affect CKD disparities.

Patient-Clinician Relationships

Relationships between patients and clinicians may affect patients’ perceived level of support. A survey of primary care patients found black patients and patients who saw physicians of a different race than their own were less likely to feel the provider used a participatory decision-making style.224 Potential contributions of patient-physician race concordance to perceived quality of care may place black Americans at a disadvantage, as black individuals comprise 13% of the United States population26 and more than 30% of patients with ESRD,27 but only 4% of the United States physician workforce284 and nephrology fellows.285 Racial biases may not only result in differential provision of care—or patient perceptions of care and patient-physician relationships—but also may result in adverse outcomes.286

Patient-physician relationships may be particularly important for patients receiving hemodialysis, who spend considerable time in the dialysis unit. Among patients receiving hemodialysis, greater satisfaction with care from the nephrologist, but not other dialysis personnel, was associated with increased perception of support and dialysis attendance,259 illustrating the key role that patients’ perceptions of physician characteristics may play in determining outcomes.

Healthcare Access

The Agency for Healthcare Research and Quality287 found black Americans had less access to care than white Americans across ten of 21 measures, including insurance, usual source of care, and timeliness of care. In seeking medical care, black patients reported a 25% longer time burden than white patients, despite reporting less time spent with clinicians.288 Level of community integration and race are associated with differential healthcare access.289 Nationally, black individuals were less likely than whites to have had a healthcare visit over the prior year. Within an integrated, low-income community in Maryland, however, black community members were more likely than white members to have had a healthcare visit within the past year.289 Reduced access to care—measured by insurance status, number of missing teeth, usual source of care, and use of preventive services—was associated with ESRD incidence.290 Lack of insurance is associated with ESRD incidence.291 Lack of insurance and a usual source of care explained approximately 10% of the disparity in CKD incidence between black and white patients.292

Racial disparities in healthcare access and outcomes are major factors in the Healthy People 2020 objectives,293 including CKD monitoring and treatment measures. United States Renal Data System (USRDS) data27 show that CKD care is improving, and racial disparities are small (Figure 2). Currently, black patients with CKD are more likely to receive prescriptions for RAAS blockers than white patients.27

Figure 2.:
The proportion of persons with CKD who receive medical evaluation with serum creatinine, lipid, and urinary albumin levels. The proportion of persons with CKD who receive medical evaluation with serum creatinine concentration, lipid levels, and urinary albumin assessments has increased for all race groups between 2001 and 2013. Black, white, and Asian populations have all surpassed the Healthy People 2020 target (CKD-4.1) of 28.4%. The proportion of persons with CKD who receive medical evaluation with serum creatinine, lipids, and microalbumin is slightly higher in black than white persons. Reprinted from United States Renal Data System. 2015 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2015, with permission. Af Am; African American.

The Patient Protection and Affordable Care Act (ACA) has been heralded as providing significant opportunity to reduce racial and ethnic disparities in access to health insurance and health care.294,295 Early assessment of changes to healthcare access following implementation of the ACA suggest it has already begun to equalize access to care by reducing disparities in insurance status.296–298 The prevalence of uninsured individuals decreased to a greater degree among both black and Latino Americans compared with white Americans.296–298

However, insurance coverage alone will not eliminate disparities. Among Medicare recipients, both black race and low income are associated with increased mortality and lower use of services.299 Similar black-white disparities exist within the Veterans Affairs healthcare system, where financial barriers to care are minimal.300 Even with insurance, barriers including cost of care, transportation limitations, and lack of paid sick leave and childcare may alter healthcare access for disadvantaged groups. In a survey of 1731 insured individuals in Minnesota, minority groups were more likely to report such barriers.301

Limited health literacy and numeracy may interfere with optimal care. The IOM defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”302 Health numeracy has been defined as “the degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions.”303 Health literacy and numeracy extend beyond reading and mathematical ability, to include contextual knowledge, arithmetic skills (e.g., understanding percentages), listening, writing, and application of information. Only 2% of black Americans had proficient health literacy compared with 14% of white Americans.304 It is undoubtedly difficult to manage a complex disease such as CKD with less than optimal health literacy and numeracy skills. Health literacy, health numeracy, and the related lack of accessible CKD information are major barriers to CKD patient education.305 Poor health literacy is associated with decreased CKD knowledge306 and kidney function.307,308 In the ESRD population, low health literacy is associated with lower rates of kidney transplantation,309 poorer BP control,310 decreased self-management,311 more frequent hospitalization,312 and increased mortality.313 Limitations in health numeracy are associated with lower kidney transplantation rates.314

Neighborhood and Environment

Despite declining racial residential segregation in the United States since 1970, many United States neighborhoods remain segregated by race—particularly in the Northeast and Midwest.315 Additionally, reductions in racial segregation are believed to be primarily the result of migration of other minority groups into predominantly black communities, rather than integration of black and white communities.316 Racial segregation and poverty often overlap, with black Americans disproportionately living in high poverty areas. Compared with only 4% of white children, 30% of black children live in high poverty neighborhoods.317

States with higher, versus lower, income inequality have elevated mortality and disease rates.318 Similarly, developed nations with higher income inequality have higher mortality rates.319 However, in United States metropolitan areas, income inequality and degree of racial segregation were associated with lower mortality rates for white individuals but higher mortality rates for black individuals,320 suggesting race may modify these associations.

Racial segregation is associated with negative health outcomes among black Americans,320–322 including poor pregnancy outcomes.321 Such fetal insults may increase lifelong risk of CKD. Increased residential racial segregation was associated with higher hemodialysis mortality rates, but only for black patients, suggesting racial segregation may influence ESRD outcomes differently across groups.199 Adjusting for neighborhood characteristics eliminated associations between segregation and mortality among black patients,323 suggesting such characteristics may explain the association.

While individual poverty is strongly associated with CKD, associations between area poverty and CKD are inconsistent—perhaps because of income variation within geographic regions. Area poverty was not associated with prevalence of CKD183 or ESRD188 in the REGARDS study. However, a study of more than 34,000 patients from ESRD Network 6 found census tracts with more poverty had higher ESRD incidence among both black and white residents, and greater racial disparity in ESRD incidence.197 A recent analysis of USRDS and US Census data found the incidence of ESRD increases with the level of area poverty.198 Another analysis of USRDS and Census data found mortality rates among patients receiving dialysis follow a similar pattern, with increased survival in areas of higher median household income.199 Additionally, neighborhood poverty has been associated with lower likelihood of placement on transplantation waiting lists.324,325 Black patients from ESRD Network 6 were less likely than white patients to be placed on the transplantation waiting list, and this disparity increased as neighborhood poverty increased.324

Predominantly black, low-income communities are often characterized by reduced access to resources that are important to health. These communities have poorer performing dialysis centers,323 more toxic waste sites,326 poorer air quality,327,328 fewer areas that are walkable and safe for physical activity,329,330 fewer sources of healthy food like supermarkets331,332 and fresh fruit markets,332 and greater density of fast food restaurants and convenience stores333—particularly in urban areas334—than majority white communities. These poor environmental conditions may disproportionately expose black residents to health risks (Figure 1).335 For example, lead exposure, associated with CKD incidence and progression, which can occur in homes with lead-based paint, is more common among black than white children.336,337

Neighborhood conditions may impede nutrition and physical activity-related self-management activities,338 potentially contributing to CKD progression and CKD risk factors, including obesity, diabetes, and hypertension. Poor dietary habits are associated with CKD prevalence among those living in poverty,339 and mortality among patients with CKD.340 The processed foods widely available in many predominantly black, low-income communities have poor nutritional quality and may exacerbate CKD, as they are often high in sodium and may have high, and undisclosed, amounts of phosphorus.341 Additionally, low availability of fresh fruits and vegetables may contribute to increased dietary acid load, which is associated with reduced eGFR,342 increased albuminuria,342 and progression of CKD to ESRD.343

The relationship between neighborhood and health is demonstrated by the Moving to Opportunity for Fair Housing Demonstration, which randomly provided predominantly black and Hispanic families living in public housing in low-income neighborhoods with a housing voucher and assistance to move to a higher income neighborhood, a standard housing voucher with no neighborhood restriction, or no housing voucher.344 Despite limitations of the study—including voluntary participation, which may mean positive effects of the study were in part due to unidentified characteristics that motivated certain families to participate, and incomplete follow-up—families moving to higher income neighborhoods experienced improvements.344,345 After 3 years, in families who moved to higher income neighborhoods, parents reported less distress and children reported less anxiety and depression than in standard or no voucher families.344 After 10–15 years, families who moved to higher income neighborhoods had lower risk of obesity and diabetes than standard or no voucher families.345


As with all acute and chronic diseases, CKD is the complex result of genetic and environmental factors, reflecting the balance of nature versus nurture (Figure 3). Social determinants of health play an important role as environmental components, especially for black populations which are disproportionately disadvantaged. It is incumbent upon nephrologists and other clinicians who care for patients with CKD to understand social factors in their patients, and how these factors may impede appropriate disease management.

Figure 3.:
Theoretical model: interaction of biologic and clinical factors with the social determinants of health affecting CKD risk and progression. Biologic and clinical factors likely interact with the social determinants of health at several levels to increase risk of CKD incidence and progression. CVD, cardiovascular disease; DM, diabetes mellitus; HTN, hypertension.

Social determinants also comprise fertile fields for future CKD research. Transdisciplinary research efforts that bring together investigators from social, behavioral, and biologic disciplines will be essential to fully understand the relationship between social factors and health.346,347 Currently, factors associated with maternal-fetal deprivation, health literacy and numeracy, clinician-patient relationships, residential segregation, and housing and neighborhood characteristics may be particularly attractive areas for innovative interventions. The societal underpinnings of the diabetes and obesity epidemics in the United States are opportune areas for intervention.

Successful efforts to reduce racial disparities in CKD—such as those conducted within the Indian Health Service (IHS)348,349—may provide models for reducing disparities among other high-risk underserved populations. IHS implemented an effort to improve care for people with kidney disease within the existing comprehensive interdisciplinary diabetes program.348,349 Systematic interventions, which included routine eGFR reporting, yearly urine albumin monitoring, use of RAAS blockers, aggressive BP control, and enhanced patient and provider education, have been associated with significantly reduced ESRD incidence among Native Americans (Figure 4).348,349 Policy efforts outside nephrology have been effective in reducing health disparities, including the Presidential Childhood Immunization Initiative.350

Figure 4.:
Trends in adjusted ESRD incidence rate by race in the United States, 1980–2012. Trends in age- and sex-adjusted ESRD incidence rate, per million/year, by race, in the United States population, 1980–2012, with the United States population in 2011 as the standard population. The incidence of ESRD among Native Americans fell dramatically between the late 1990s and 2012. Reprinted from United States Renal Data System. 2014 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014, with permission. Af Am, African American.

The implications of the societal and medical classification of people by race are profound, and not necessarily always beneficial.23 However, it is remarkable that these categorizations are associated with considerable disparities affecting health. Although such classifications can be used constructively to diminish or eliminate disparities, researchers and clinicians must recognize that race categories are proxy measures that imperfectly capture genetic and cultural variation in ancestral groups. In research and practice, use of race categories must be accompanied by an understanding of their limitations. Racial bias may result in adverse outcomes for disadvantaged populations, and therefore must be addressed by all institutions that provide medical care, and all physicians, caretakers, and health care personnel.

Although individuals with the same disease process may have vastly different illness experiences that are associated with socially constructed racial categories, clinicians must take care not to make assumptions about patient race without obtaining a detailed family history, which includes a discussion of ancestry, and must guard against implicit racial biases that may unconsciously affect clinical decisions, as illustrated in the vignette.23 Implicit biases can be measured through implicit association tests.351,352 People cannot be medically evaluated on the basis of superficial visible aspects alone. Despite our neurophysiologic programming, clinical training and cultural frameworks, we must retrain ourselves not to judge our patients solely by appearances.

Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing disparities between groups.



Published online ahead of print. Publication date available at

The authors deeply appreciate the review of the manuscript by and helpful comments from Mr. Vence Bonham (National Human Genome Research Institute [NHGRI]), as well as Drs. Rebekah Rasooly (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK]), Tracy Rankin (NIDDK), Charles Rotimi (NHGRI), Derrick Tabor (National Institute on Minority Health and Health Disparities), Salina Waddy (National Institute of Neurological Disorders and Stroke), and Saul Malozowski (NIDDK), who are not responsible for the final content.

The opinions expressed do not necessarily reflect those of the NIDDK, the National Institutes of Health, the Department of Health and Human Services, and the Government of the United States of America.


1. Smedley BD, Stith AY, Nelson AR: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Washington, DC, National Academies Press, 2003, p 29
2. U.S. Department of Health and Human Services: The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020 2016. Available from: Accessed February 9, 2016
3. National Institutes of Health: NIH Health Disparities Strategic Plan and Budget Fiscal Years 2009-2013, Bethesda, MD, U.S. Department of Health and Human Services, 2010
4. Smedley A: “Race” and the Construction of Human Identity. Am Anthropol 100: 690–702, 1998
5. Pew Research Center: What Census Calls Us: A Historical Timeline Washington, DC: Pew Research Center; 2015. Available from: Accessed December 1, 2015
6. Office of Management and Budget: Revisions to the standards for the classification of federal data on race and ethnicity. Washington, DC: Office of Information and Regulatory Affairs, 1997.
7. Williams DR, Sternthal M: Understanding racial-ethnic disparities in health: sociological contributions. J Health Soc Behav 51[Suppl]: S15–S27, 201020943580
8. Bamshad M, Wooding S, Salisbury BA, Stephens JC: Deconstructing the relationship between genetics and race. Nat Rev Genet 5: 598–609, 200415266342
9. Rotimi C, Shriner D, Adeyemo A: Genome science and health disparities: a growing success story? Genome Med 5: 61, 201323899246
10. Rotimi CN: Are medical and nonmedical uses of large-scale genomic markers conflating genetics and ‘race’? Nat Genet 36[Suppl]: S43–S47, 200415508002
11. Rotimi CN, Jorde LB: Ancestry and disease in the age of genomic medicine. N Engl J Med 363: 1551–1558, 201020942671
12. Mersha TB, Abebe T: Self-reported race/ethnicity in the age of genomic research: its potential impact on understanding health disparities. Hum Genomics 9: 1–15, 201525563503
13. Lee YL, Teitelbaum S, Wolff MS, Wetmur JG, Chen J: Comparing genetic ancestry and self-reported race/ethnicity in a multiethnic population in New York City. J Genet 89: 417–423, 201021273692
14. Genovese G, Friedman DJ, Ross MD, Lecordier L, Uzureau P, Freedman BI, Bowden DW, Langefeld CD, Oleksyk TK, Uscinski Knob AL, Bernhardy AJ, Hicks PJ, Nelson GW, Vanhollebeke B, Winkler CA, Kopp JB, Pays E, Pollak MR: Association of trypanolytic ApoL1 variants with kidney disease in African Americans. Science 329: 841–845, 201020647424
15. Bentley AR, Chen G, Shriner D, Doumatey AP, Zhou J, Huang H, Mullikin JC, Blakesley RW, Hansen NF, Bouffard GG, Cherukuri PF, Maskeri B, Young AC, Adeyemo A, Rotimi CN: Gene-based sequencing identifies lipid-influencing variants with ethnicity-specific effects in African Americans. PLoS Genet 10: e1004190, 201424603370
16. Liggett SB, Cresci S, Kelly RJ, Syed FM, Matkovich SJ, Hahn HS, Diwan A, Martini JS, Sparks L, Parekh RR, Spertus JA, Koch WJ, Kardia SL, Dorn GW 2nd: A GRK5 polymorphism that inhibits beta-adrenergic receptor signaling is protective in heart failure. Nat Med 14: 510–517, 200818425130
17. Jones NA, Bullock J: 2010 Census briefs: the two or more races population: 2010, Washington, DC, The U.S. Census Bureau, 2012
18. Schwartz RS: Racial profiling in medical research. N Engl J Med 344: 1392–1393, 200111333999
19. Roberts DE: What’s Wrong with Race-Based Medicine?: Genes, Drugs, and Health Disparities. Minn J Law Sci Technol 12: 1–21, 2011
20. Roberts DE: Is race-based medicine good for us?: African American approaches to race, biomedicine, and equality. J Law Med Ethics 36: 537–545, 2008
21. Burchard EG, Ziv E, Coyle N, Gomez SL, Tang H, Karter AJ, Mountain JL, Pérez-Stable EJ, Sheppard D, Risch N: The importance of race and ethnic background in biomedical research and clinical practice. N Engl J Med 348: 1170–1175, 200312646676
22. Cooper RS, Kaufman JS, Ward R: Race and genomics. N Engl J Med 348: 1166–1170, 200312646675
23. Yudell M, Roberts D, DeSalle R, Tishkoff S: Taking race out of human genetics. Science 351: 564–565, 201626912690
24. Collins FS, Varmus H: A new initiative on precision medicine. N Engl J Med 372: 793–795, 201525635347
25. Williams DR, Wyatt R: Racial Bias in Health Care and Health: Challenges and Opportunities. JAMA 314: 555–556, 201526262792
26. US Census Bureau: State and County QuickFacts, Washington, DC, 2015. Available at: Accessed August 28, 201515149345
27. Saran R, Li Y, Robinson B, Ayanian J, Balkrishnan R, Bragg-Gresham J, Chen JT, Cope E, Gipson D, He K, Herman W, Heung M, Hirth RA, Jacobsen SS, Kalantar-Zadeh K, Kovesdy CP, Leichtman AB, Lu Y, Molnar MZ, Morgenstern H, Nallamothu B, O’Hare AM, Pisoni R, Plattner B, Port FK, Rao P, Rhee CM, Schaubel DE, Selewski DT, Shahinian V, Sim JJ, Song P, Streja E, Kurella Tamura M, Tentori F, Eggers PW, Agodoa LY, Abbott KC: US Renal Data System 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 66[Suppl 1]: S1–S305, 201526111994
28. Hsu CY, Lin F, Vittinghoff E, Shlipak MG: Racial differences in the progression from chronic renal insufficiency to end-stage renal disease in the United States. J Am Soc Nephrol 14: 2902–2907, 200314569100
29. McClellan W, Warnock DG, McClure L, Campbell RC, Newsome BB, Howard V, Cushman M, Howard G: Racial differences in the prevalence of chronic kidney disease among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort Study. J Am Soc Nephrol 17: 1710–1715, 200616641151
30. Derose SF, Rutkowski MP, Crooks PW, Shi JM, Wang JQ, Kalantar-Zadeh K, Kovesdy CP, Levin NW, Jacobsen SJ: Racial differences in estimated GFR decline, ESRD, and mortality in an integrated health system. Am J Kidney Dis 62: 236–244, 201323499049
31. Bloembergen WE, Port FK, Mauger EA, Wolfe RA: Causes of death in dialysis patients: racial and gender differences. J Am Soc Nephrol 5: 1231–1242, 19947873734
32. Parekh RS, Zhang L, Fivush BA, Klag MJ: Incidence of atherosclerosis by race in the dialysis morbidity and mortality study: a sample of the US ESRD population. J Am Soc Nephrol 16: 1420–1426, 200515788470
33. Mesler DE, McCarthy EP, Byrne-Logan S, Ash AS, Moskowitz MA: Does the survival advantage of nonwhite dialysis patients persist after case mix adjustment? Am J Med 106: 300–306, 199910190378
34. Yan G, Norris KC, Yu AJ, Ma JZ, Greene T, Yu W, Cheung AK: The relationship of age, race, and ethnicity with survival in dialysis patients. Clin J Am Soc Nephrol 8: 953–961, 201323539227
35. Mehrotra R, Soohoo M, Rivara MB, Himmelfarb J, Cheung AK, Arah OA, Nissenson AR, Ravel V, Streja E, Kuttykrishnan S, Katz R, Molnar MZ, Kalantar-Zadeh K: Racial and Ethnic Disparities in Use of and Outcomes with Home Dialysis in the United States [published online ahead of print December 10, 2015]. J Am Soc Nephrol doi: 10.1681/ASN.2015050472
36. Cowie CC, Port FK, Rust KF, Harris MI: Differences in survival between black and white patients with diabetic end-stage renal disease. Diabetes Care 17: 681–687, 19947924777
37. Pugh JA, Tuley MR, Basu S: Survival among Mexican-Americans, non-Hispanic whites, and African-Americans with end-stage renal disease: the emergence of a minority pattern of increased incidence and prolonged survival. Am J Kidney Dis 23: 803–807, 19948203362
38. Navaneethan SD, Aloudat S, Singh S: A systematic review of patient and health system characteristics associated with late referral in chronic kidney disease. BMC Nephrol 9: 3, 200818298850
39. Owen WF Jr, Chertow GM, Lazarus JM, Lowrie EG: Dose of hemodialysis and survival: differences by race and sex. JAMA 280: 1764–1768, 19989842952
40. Hopson S, Frankenfield D, Rocco M, McClellan W: Variability in reasons for hemodialysis catheter use by race, sex, and geography: findings from the ESRD Clinical Performance Measures Project. Am J Kidney Dis 52: 753–760, 200818514986
41. Barker-Cummings C, McClellan W, Soucie JM, Krisher J: Ethnic differences in the use of peritoneal dialysis as initial treatment for end-stage renal disease. JAMA 274: 1858–1862, 19957500535
42. Farias MG, Soucie JM, McClellan W, Mitch WE: Race and the risk of peritonitis: an analysis of factors associated with the initial episode. Kidney Int 46: 1392–1396, 19947853799
43. Juergensen PH, Gorban-Brennan N, Troidle L, Finkelstein FO: Racial differences and peritonitis in an urban peritoneal dialysis center. Adv Perit Dial 18: 117–118, 200212402601
44. Mapes DL, Lopes AA, Satayathum S, McCullough KP, Goodkin DA, Locatelli F, Fukuhara S, Young EW, Kurokawa K, Saito A, Bommer J, Wolfe RA, Held PJ, Port FK: Health-related quality of life as a predictor of mortality and hospitalization: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Kidney Int 64: 339–349, 200312787427
45. Lopes AA, Bragg-Gresham JL, Satayathum S, McCullough K, Pifer T, Goodkin DA, Mapes DL, Young EW, Wolfe RA, Held PJ, Port FK; Worldwide Dialysis Outcomes and Practice Patterns Study Committee: Health-related quality of life and associated outcomes among hemodialysis patients of different ethnicities in the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 41: 605–615, 200312612984
46. Feroze U, Noori N, Kovesdy CP, Molnar MZ, Martin DJ, Reina-Patton A, Benner D, Bross R, Norris KC, Kopple JD, Kalantar-Zadeh K: Quality-of-life and mortality in hemodialysis patients: roles of race and nutritional status. Clin J Am Soc Nephrol 6: 1100–1111, 201121527646
47. Mapes DL, Bragg-Gresham JL, Bommer J, Fukuhara S, McKevitt P, Wikström B, Lopes AA: Health-related quality of life in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 44[Suppl 2]: 54–60, 200415486875
48. Kalantar-Zadeh K, Miller JE, Kovesdy CP, Mehrotra R, Lukowsky LR, Streja E, Ricks J, Jing J, Nissenson AR, Greenland S, Norris KC: Impact of race on hyperparathyroidism, mineral disarrays, administered vitamin D mimetic, and survival in hemodialysis patients. J Bone Miner Res 25: 2724–2734, 2010
49. Lau WL, Kalantar-Zadeh K: Why Is the Association of Phosphorus and FGF23 with Mortality Stronger in African-American Hemodialysis Patients. Am J Nephrol 42: 22–24, 201526288017
50. Miller JE, Kovesdy CP, Nissenson AR, Mehrotra R, Streja E, Van Wyck D, Greenland S, Kalantar-Zadeh K: Association of hemodialysis treatment time and dose with mortality and the role of race and sex. Am J Kidney Dis 55: 100–112, 201019853336
51. Streja E, Kovesdy CP, Molnar MZ, Norris KC, Greenland S, Nissenson AR, Kopple JD, Kalantar-Zadeh K: Role of nutritional status and inflammation in higher survival of African American and Hispanic hemodialysis patients. Am J Kidney Dis 57: 883–893, 201121239093
52. Crews DC, Sozio SM, Liu Y, Coresh J, Powe NR: Inflammation and the paradox of racial differences in dialysis survival. J Am Soc Nephrol 22: 2279–2286, 201122021717
53. Robinson BM, Joffe MM, Pisoni RL, Port FK, Feldman HI: Revisiting survival differences by race and ethnicity among hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study. J Am Soc Nephrol 17: 2910–2918, 200616988065
54. Kucirka LM, Grams ME, Lessler J, Hall EC, James N, Massie AB, Montgomery RA, Segev DL: Association of race and age with survival among patients undergoing dialysis. JAMA 306: 620–626, 201121828325
55. Johns TS, Estrella MM, Crews DC, Appel LJ, Anderson CA, Ephraim PL, Cook C, Boulware LE: Neighborhood socioeconomic status, race, and mortality in young adult dialysis patients. J Am Soc Nephrol 25: 2649–2657, 201424925723
56. Soucie JM, Neylan JF, McClellan W: Race and sex differences in the identification of candidates for renal transplantation. Am J Kidney Dis 19: 414–419, 19921585927
57. Epstein AM, Ayanian JZ, Keogh JH, Noonan SJ, Armistead N, Cleary PD, Weissman JS, David-Kasdan JA, Carlson D, Fuller J, Marsh D, Conti RM: Racial disparities in access to renal transplantation–clinically appropriate or due to underuse or overuse? N Engl J Med 343: 1537–1544, 2000
58. Patzer RE, Perryman JP, Schrager JD, Pastan S, Amaral S, Gazmararian JA, Klein M, Kutner N, McClellan WM: The role of race and poverty on steps to kidney transplantation in the Southeastern United States. Am J Transplant 12: 358–368, 2012
59. Ayanian JZ, Cleary PD, Weissman JS, Epstein AM: The effect of patients’ preferences on racial differences in access to renal transplantation. N Engl J Med 341: 1661–1669, 199910572155
60. Alexander GC, Sehgal AR: Barriers to cadaveric renal transplantation among blacks, women, and the poor. JAMA 280: 1148–1152, 19989777814
61. Monson RS, Kemerley P, Walczak D, Benedetti E, Oberholzer J, Danielson KK: Disparities in completion rates of the medical prerenal transplant evaluation by race or ethnicity and gender. Transplantation 99: 236–242, 201525531896
62. Kasiske BL, London W, Ellison MD: Race and socioeconomic factors influencing early placement on the kidney transplant waiting list. J Am Soc Nephrol 9: 2142–2147, 19989808103
63. Wolfe RA, Ashby VB, Milford EL, Bloembergen WE, Agodoa LY, Held PJ, Port FK: Differences in access to cadaveric renal transplantation in the United States. Am J Kidney Dis 36: 1025–1033, 200011054361
64. Sanfilippo FP, Vaughn WK, Peters TG, Shield CF 3rd, Adams PL, Lorber MI, Williams GM: Factors affecting the waiting time of cadaveric kidney transplant candidates in the United States. JAMA 267: 247–252, 19921727521
65. Hall YN, Choi AI, Xu P, O’Hare AM, Chertow GM: Racial ethnic differences in rates and determinants of deceased donor kidney transplantation. J Am Soc Nephrol 22: 743–751, 201121372209
66. Mohandas R, Casey MJ, Cook RL, Lamb KE, Wen X, Segal MS: Racial and socioeconomic disparities in the allocation of expanded criteria donor kidneys. Clin J Am Soc Nephrol 8: 2158–2164, 201324115196
67. Hall EC, James NT, Garonzik Wang JM, Berger JC, Montgomery RA, Dagher NN, Desai NM, Segev DL: Center-level factors and racial disparities in living donor kidney transplantation. Am J Kidney Dis 59: 849–857, 201222370021
68. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E: 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 311: 507–520, 201424352797
69. Gore JL, Danovitch GM, Litwin MS, Pham PT, Singer JS: Disparities in the utilization of live donor renal transplantation. Am J Transplant 9: 1124–1133, 2009
70. Gill J, Dong J, Rose C, Johnston O, Landsberg D, Gill J: The effect of race and income on living kidney donation in the United States. J Am Soc Nephrol 24: 1872–1879, 201323990679
71. Fan PY, Ashby VB, Fuller DS, Boulware LE, Kao A, Norman SP, Randall HB, Young C, Kalbfleisch JD, Leichtman AB: Access and outcomes among minority transplant patients, 1999-2008, with a focus on determinants of kidney graft survival. Am J Transplant 10: 1090–1107, 2010
72. Purnell TS, Luo X, Kucirka LM, Cooper LA, Crews DC, Massie AB, Boulware LE, Segev DL: Reduced Racial Disparity in Kidney Transplant Outcomes in the United States from 1990 to 2012 [published online ahead of print February 4, 2016]. J Am Soc Nephrol doi: 10.1681/ASN.2015030293
73. Freedman BI, Julian BA, Pastan SO, Israni AK, Schladt D, Gautreaux MD, Hauptfeld V, Bray RA, Gebel HM, Kirk AD, Gaston RS, Rogers J, Farney AC, Orlando G, Stratta RJ, Mohan S, Ma L, Langefeld CD, Hicks PJ, Palmer ND, Adams PL, Palanisamy A, Reeves-Daniel AM, Divers J: Apolipoprotein L1 gene variants in deceased organ donors are associated with renal allograft failure. Am J Transplant 15: 1615–1622, 201525809272
74. Reeves-Daniel AM, DePalma JA, Bleyer AJ, Rocco MV, Murea M, Adams PL, Langefeld CD, Bowden DW, Hicks PJ, Stratta RJ, Lin J-J, Kiger DF, Gautreaux MD, Divers J, Freedman BI: The APOL1 gene and allograft survival after kidney transplantation. Am J Transplant 11: 1025–1030, 2011
75. Lee BT, Kumar V, Williams TA, Abdi R, Dyer BC, Conte S, Genovese G, Ross MD, Friedman DJ, Gaston R, Milford E, Pollak MR, Chandraker A: The APOL1 genotype of African American kidney transplant recipients does not impact 5-year allograft survival. Am J Transplant 12: 1924–1928, 2012
76. Grams ME, Chow EK, Segev DL, Coresh J: Lifetime incidence of CKD stages 3-5 in the United States. Am J Kidney Dis 62: 245–252, 201323566637
77. Bryson CL, Ross HJ, Boyko EJ, Young BA: Racial and ethnic variations in albuminuria in the US Third National Health and Nutrition Examination Survey (NHANES III) population: associations with diabetes and level of CKD. Am J Kidney Dis 48: 720–726, 200617059991
78. Choi AI, Karter AJ, Liu JY, Young BA, Go AS, Schillinger D: Ethnic differences in the development of albuminuria: the DISTANCE study. Am J Manag Care 17: 737–745, 201122084893
79. Kovesdy CP, Anderson JE, Derose SF, Kalantar-Zadeh K: Outcomes associated with race in males with nondialysis-dependent chronic kidney disease. Clin J Am Soc Nephrol 4: 973–978, 200919369403
80. Kovesdy CP, Quarles LD, Lott EH, Lu JL, Ma JZ, Molnar MZ, Kalantar-Zadeh K: Survival advantage in black versus white men with CKD: effect of estimated GFR and case mix. Am J Kidney Dis 62: 228–235, 201323369826
81. Fedewa SA, McClellan WM, Judd S, Gutiérrez OM, Crews DC: The association between race and income on risk of mortality in patients with moderate chronic kidney disease. BMC Nephrol 15: 136, 201425150057
82. Kidney Disease; Improving Global Outcomes (KDIGO) CKD Work Group: KDIGO 2012 Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 3: 1–150, 2013
83. Jafar TH, Schmid CH, Landa M, Giatras I, Toto R, Remuzzi G, Maschio G, Brenner BM, Kamper A, Zucchelli P, Becker G, Himmelmann A, Bannister K, Landais P, Shahinfar S, de Jong PE, de Zeeuw D, Lau J, Levey AS: Angiotensin-converting enzyme inhibitors and progression of nondiabetic renal disease. A meta-analysis of patient-level data. Ann Intern Med 135: 73–87, 200111453706
84. ACE Inhibitors in Diabetic Nephropathy Trialist Group: Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme inhibitors? A meta-analysis of individual patient data. Ann Intern Med 134: 370–379, 200111242497
85. Marin R, Ruilope LM, Aljama P, Aranda P, Segura J, Diez J; Investigators of the ESPIRAL Study. Efecto del tratamiento antihipertensivo Sobre la Progresión de la Insuficiencia RenAL en pacientes no diabéticos: A random comparison of fosinopril and nifedipine GITS in patients with primary renal disease. J Hypertens 19: 1871–1876, 200111593109
86. Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, Remuzzi G, Snapinn SM, Zhang Z, Shahinfar S; RENAAL Study Investigators: Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 345: 861–869, 200111565518
87. Cinotti GA, Zucchelli PC; Collaborative Study Group: Effect of Lisinopril on the progression of renal insufficiency in mild proteinuric non-diabetic nephropathies. Nephrol Dial Transplant 16: 961–966, 200111328901
88. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD; The Collaborative Study Group: The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. N Engl J Med 329: 1456–1462, 19938413456
89. Maschio G, Alberti D, Janin G, Locatelli F, Mann JF, Motolese M, Ponticelli C, Ritz E, Zucchelli P; The Angiotensin-Converting-Enzyme Inhibition in Progressive Renal Insufficiency Study Group: Effect of the angiotensin-converting-enzyme inhibitor benazepril on the progression of chronic renal insufficiency. N Engl J Med 334: 939–945, 19968596594
90. Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, Christiaens T, Cifkova R, De Backer G, Dominiczak A, Galderisi M, Grobbee DE, Jaarsma T, Kirchhof P, Kjeldsen SE, Laurent S, Manolis AJ, Nilsson PM, Ruilope LM, Schmieder RE, Sirnes PA, Sleight P, Viigimaa M, Waeber B, Zannad F; Task Force Members: 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 31: 1281–1357, 201323817082
91. Daskalopoulou SS, Rabi DM, Zarnke KB, Dasgupta K, Nerenberg K, Cloutier L, Gelfer M, Lamarre-Cliche M, Milot A, Bolli P, McKay DW, Tremblay G, McLean D, Tobe SW, Ruzicka M, Burns KD, Vallée M, Ramesh Prasad GV, Lebel M, Feldman RD, Selby P, Pipe A, Schiffrin EL, McFarlane PA, Oh P, Hegele RA, Khara M, Wilson TW, Brian Penner S, Burgess E, Herman RJ, Bacon SL, Rabkin SW, Gilbert RE, Campbell TS, Grover S, Honos G, Lindsay P, Hill MD, Coutts SB, Gubitz G, Campbell NR, Moe GW, Howlett JG, Boulanger JM, Prebtani A, Larochelle P, Leiter LA, Jones C, Ogilvie RI, Woo V, Kaczorowski J, Trudeau L, Petrella RJ, Hiremath S, Stone JA, Drouin D, Lavoie KL, Hamet P, Fodor G, Grégoire JC, Fournier A, Lewanczuk R, Dresser GK, Sharma M, Reid D, Benoit G, Feber J, Harris KC, Poirier L, Padwal RS: The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 31: 549–568, 201525936483
92. Krikken JA, Laverman GD, Navis G: Benefits of dietary sodium restriction in the management of chronic kidney disease. Curr Opin Nephrol Hypertens 18: 531–538, 200919713840
93. Humalda JK, Navis G: Dietary sodium restriction: a neglected therapeutic opportunity in chronic kidney disease. Curr Opin Nephrol Hypertens 23: 533–540, 201425222815
94. McMahon EJ, Bauer JD, Hawley CM, Isbel NM, Stowasser M, Johnson DW, Campbell KL: A randomized trial of dietary sodium restriction in CKD. J Am Soc Nephrol 24: 2096–2103, 201324204003
95. Vogt L, Waanders F, Boomsma F, de Zeeuw D, Navis G: Effects of dietary sodium and hydrochlorothiazide on the antiproteinuric efficacy of losartan. J Am Soc Nephrol 19: 999–1007, 200818272844
96. Vegter S, Perna A, Postma MJ, Navis G, Remuzzi G, Ruggenenti P: Sodium intake, ACE inhibition, and progression to ESRD. J Am Soc Nephrol 23: 165–173, 201222135311
97. Kwakernaak AJ, Waanders F, Slagman MC, Dokter MM, Laverman GD, de Boer RA, Navis G: Sodium restriction on top of renin-angiotensin-aldosterone system blockade increases circulating levels of N-acetyl-seryl-aspartyl-lysyl-proline in chronic kidney disease patients. J Hypertens 31: 2425–2432, 201324029871
98. Lambers Heerspink HJ, de Borst MH, Bakker SJ, Navis GJ: Improving the efficacy of RAAS blockade in patients with chronic kidney disease. Nat Rev Nephrol 9: 112–121, 201323247573
99. Herget-Rosenthal S, Dehnen D, Kribben A, Quellmann T: Progressive chronic kidney disease in primary care: modifiable risk factors and predictive model. Prev Med 57: 357–362, 201323783072
100. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329: 977–986, 19938366922
101. Taskapan H, Tam P, Au V, Chow S, Fung J, Nagai G, Roscoe J, Ng P, Sikaneta T, Ting R, Oreopoulos DG: Improvement in eGFR in patients with chronic kidney disease attending a nephrology clinic. Int Urol Nephrol 40: 841–848, 200818386153
102. Orlando LA, Owen WF, Matchar DB: Relationship between nephrologist care and progression of chronic kidney disease. N C Med J 68: 9–16, 200717500426
103. Nakamura S, Nakata H, Yoshihara F, Kamide K, Horio T, Nakahama H, Kawano Y: Effect of early nephrology referral on the initiation of hemodialysis and survival in patients with chronic kidney disease and cardiovascular diseases. Circ J 71: 511–516, 2007
    104. Jones C, Roderick P, Harris S, Rogerson M: Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease. Nephrol Dial Transplant 21: 2133–2143, 200616644779
    105. Kazmi WH, Obrador GT, Khan SS, Pereira BJ, Kausz AT: Late nephrology referral and mortality among patients with end-stage renal disease: a propensity score analysis. Nephrol Dial Transplant 19: 1808–1814, 200415199194
    106. Powe NR, Melamed ML: Racial disparities in the optimal delivery of chronic kidney disease care. Med Clin North Am 89: 475–488, 200515755463
    107. Navaneethan SD, Kandula P, Jeevanantham V, Nally JV Jr, Liebman SE: Referral patterns of primary care physicians for chronic kidney disease in general population and geriatric patients. Clin Nephrol 73: 260–267, 201020353733
    108. Brown MJ: Hypertension and ethnic group. BMJ 332: 833–836, 200616601044
    109. Khan JM, Beevers DG: Management of hypertension in ethnic minorities. Heart 91: 1105–1109, 200516020613
    110. Richardson AD, Piepho RW: Effect of race on hypertension and antihypertensive therapy. Int J Clin Pharmacol Ther 38: 75–79, 200010706194
    111. Brownley KA, Hurwitz BE, Schneiderman N: Ethnic variations in the pharmacological and nonpharmacological treatment of hypertension: biopsychosocial perspective. Hum Biol 71: 607–639, 199910453104
    112. Khan NA, McAlister FA, Campbell NR, Feldman RD, Rabkin S, Mahon J, Lewanczuk R, Zarnke KB, Hemmelgarn B, Lebel M, Levine M, Herbert C; Canadian Hypertension Education Program: The 2004 Canadian recommendations for the management of hypertension: Part II--Therapy. Can J Cardiol 20: 41–54, 200414968142
    113. Gadegbeku CA, Lea JP, Jamerson KA. Update on disparities in the pathophysiology and management of hypertension: focus on African Americans. Med Clin North Am 89: 921–933, 930, 2005
      114. Douglas JG, Bakris GL, Epstein M, Ferdinand KC, Ferrario C, Flack JM, Jamerson KA, Jones WE, Haywood J, Maxey R, Ofili EO, Saunders E, Schiffrin EL, Sica DA, Sowers JR, Vidt DG; Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks: Management of high blood pressure in African Americans: consensus statement of the Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks. Arch Intern Med 163: 525–541, 200312622600
      115. Wright JT Jr, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J, Cheek D, Douglas-Baltimore JG, Gassman J, Glassock R, Hebert L, Jamerson K, Lewis J, Phillips RA, Toto RD, Middleton JP, Rostand SG; African American Study of Kidney Disease and Hypertension Study Group: Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA 288: 2421–2431, 200212435255
      116. Norris KC, Agodoa LY: Unraveling the racial disparities associated with kidney disease. Kidney Int 68: 914–924, 200516105022
      117. Silbiger S, Neugarten J. Gender and human chronic renal disease. Gend Med 5 [Suppl A]: S3-S10, 2008
      118. Silbiger SR, Neugarten J: The impact of gender on the progression of chronic renal disease. Am J Kidney Dis 25: 515–533, 19957702046
      119. Sandberg K, Ji H: Sex and the renin angiotensin system: implications for gender differences in the progression of kidney disease. Adv Ren Replace Ther 10: 15–23, 200312616459
      120. Glassock R, Delanaye P, El Nahas M: An Age-Calibrated Classification of Chronic Kidney Disease. JAMA 314: 559–560, 201526023760
      121. Glassock RJ, Rule AD: The implications of anatomical and functional changes of the aging kidney: with an emphasis on the glomeruli. Kidney Int 82: 270–277, 201222437416
      122. Moynihan R, Glassock R, Doust J: Chronic kidney disease controversy: how expanding definitions are unnecessarily labelling many people as diseased. BMJ 347: f4298, 201323900313
      123. Levey AS, Inker LA, Coresh J: Chronic Kidney Disease in Older People. JAMA 314: 557–558, 201526023868
      124. Freedman BI, Kopp JB, Langefeld CD, Genovese G, Friedman DJ, Nelson GW, Winkler CA, Bowden DW, Pollak MR: The apolipoprotein L1 (APOL1) gene and nondiabetic nephropathy in African Americans. J Am Soc Nephrol 21: 1422–1426, 201020688934
      125. Peralta CA, Bibbins-Domingo K, Vittinghoff E, Lin F, Fornage M, Kopp JB, Winkler CA: APOL1 Genotype and Race Differences in Incident Albuminuria and Renal Function Decline [published online ahead of print July 15, 2015]. J Am Soc Nephrol doi: 10.1681/ASN.2015020124
      126. Parsa A, Kao WH, Xie D, Astor BC, Li M, Hsu CY, Feldman HI, Parekh RS, Kusek JW, Greene TH, Fink JC, Anderson AH, Choi MJ, Wright JT Jr, Lash JP, Freedman BI, Ojo A, Winkler CA, Raj DS, Kopp JB, He J, Jensvold NG, Tao K, Lipkowitz MS, Appel LJ; AASK Study Investigators; CRIC Study Investigators: APOL1 risk variants, race, and progression of chronic kidney disease. N Engl J Med 369: 2183–2196, 201324206458
      127. Kopp JB, Nelson GW, Sampath K, Johnson RC, Genovese G, An P, Friedman D, Briggs W, Dart R, Korbet S, Mokrzycki MH, Kimmel PL, Limou S, Ahuja TS, Berns JS, Fryc J, Simon EE, Smith MC, Trachtman H, Michel DM, Schelling JR, Vlahov D, Pollak M, Winkler CA: APOL1 genetic variants in focal segmental glomerulosclerosis and HIV-associated nephropathy. J Am Soc Nephrol 22: 2129–2137, 201121997394
      128. Bostrom MA, Freedman BI: The spectrum of MYH9-associated nephropathy. Clin J Am Soc Nephrol 5: 1107–1113, 201020299374
      129. Crews DC, Pfaff T, Powe NR: Socioeconomic factors and racial disparities in kidney disease outcomes. Semin Nephrol 33: 468–475, 201324119852
      130. Freedman BI: APOL1 and nephropathy progression in populations of African ancestry. Semin Nephrol 33: 425–432, 201324119848
      131. Freedman BI, Divers J, Palmer ND: Population ancestry and genetic risk for diabetes and kidney, cardiovascular, and bone disease: modifiable environmental factors may produce the cures. Am J Kidney Dis 62: 1165–1175, 201323896482
      132. Freedman BI, Skorecki K: Gene-gene and gene-environment interactions in apolipoprotein L1 gene-associated nephropathy. Clin J Am Soc Nephrol 9: 2006–2013, 201424903390
      133. Tarver-Carr ME, Powe NR, Eberhardt MS, LaVeist TA, Kington RS, Coresh J, Brancati FL: Excess risk of chronic kidney disease among African-American versus white subjects in the United States: a population-based study of potential explanatory factors. J Am Soc Nephrol 13: 2363–2370, 200212191981
      134. Centers for Disease Control and Prevention: National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014, Atlanta, GA, U.S. Department of Health and Human Services, 2014
      135. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler ER 3rd, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB; American Heart Association Statistics Committee and Stroke Statistics Subcommittee: Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation 131: e29–e322, 201525520374
      136. Ricardo AC, Anderson CA, Yang W, Zhang X, Fischer MJ, Dember LM, Fink JC, Frydrych A, Jensvold NG, Lustigova E, Nessel LC, Porter AC, Rahman M, Wright Nunes JA, Daviglus ML, Lash JP; CRIC Study Investigators: Healthy lifestyle and risk of kidney disease progression, atherosclerotic events, and death in CKD: findings from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 65: 412–424, 201525458663
      137. MacLaughlin HL, Hall WL, Sanders TA, Macdougall IC: Risk for chronic kidney disease increases with obesity: Health Survey for England 2010. Public Health Nutr 18: 3349–3354, 201525743030
      138. Kramer H, Gutiérrez OM, Judd SE, Muntner P, Warnock DG, Tanner RM, Panwar B, Shoham DA, McClellan W: Waist Circumference, Body Mass Index, and ESRD in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study. Am J Kidney Dis 67: 62–69, 201626187471
      139. Hsu CY, McCulloch CE, Iribarren C, Darbinian J, Go AS: Body mass index and risk for end-stage renal disease. Ann Intern Med 144: 21–28, 200616389251
      140. Ogden CL, Carroll MD, Kit BK, Flegal KM: Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 311: 806–814, 201424570244
      141. Bagby SP: Prenatal Origins of Chronic Kidney Disease. In: Chronic Renal Disease, edited by Kimmel PL, Rosenberg ME, Waltham, MA, Elsevier Inc., 2015, pp 783–799
      142. Kwong WY, Wild AE, Roberts P, Willis AC, Fleming TP: Maternal undernutrition during the preimplantation period of rat development causes blastocyst abnormalities and programming of postnatal hypertension. Development 127: 4195–4202, 200010976051
      143. Duggleby SL, Jackson AA: Higher weight at birth is related to decreased maternal amino acid oxidation during pregnancy. Am J Clin Nutr 76: 852–857, 200212324300
      144. Duggleby SL, Jackson AA: Relationship of maternal protein turnover and lean body mass during pregnancy and birth length. Clin Sci (Lond) 101: 65–72, 200111410116
      145. Wise PH: The anatomy of a disparity in infant mortality. Annu Rev Public Health 24: 341–362, 200312471271
      146. Lackland DT, Bendall HE, Osmond C, Egan BM, Barker DJ: Low birth weights contribute to high rates of early-onset chronic renal failure in the Southeastern United States. Arch Intern Med 160: 1472–1476, 200010826460
      147. White SL, Perkovic V, Cass A, Chang CL, Poulter NR, Spector T, Haysom L, Craig JC, Salmi IA, Chadban SJ, Huxley RR: Is low birth weight an antecedent of CKD in later life? A systematic review of observational studies. Am J Kidney Dis 54: 248–261, 200919339091
      148. Barker DJ, Forsén T, Eriksson JG, Osmond C: Growth and living conditions in childhood and hypertension in adult life: a longitudinal study. J Hypertens 20: 1951–1956, 200212359972
      149. Eriksson JG, Osmond C, Kajantie E, Forsén TJ, Barker DJ: Patterns of growth among children who later develop type 2 diabetes or its risk factors. Diabetologia 49: 2853–2858, 200617096117
      150. Phillips DIW, Barker DJP, Hales CN, Hirst S, Osmond C: Thinness at birth and insulin resistance in adult life. Diabetologia 37: 150–154, 19948163048
      151. Eriksson J, Forsen T, Tuomilehto J, Osmond C, Barker D: Size at birth, childhood growth and obesity in adult life. Int J Obes 25: 735–740, 2001
      152. Forsén TJ, Eriksson JG, Osmond C, Barker DJ: The infant growth of boys who later develop coronary heart disease. Ann Med 36: 389–392, 200415478313
      153. Osmond C, Kajantie E, Forsén TJ, Eriksson JG, Barker DJ: Infant growth and stroke in adult life: the Helsinki birth cohort study. Stroke 38: 264–270, 200717218608
      154. Brenner BM, Chertow GM: Congenital oligonephropathy and the etiology of adult hypertension and progressive renal injury. Am J Kidney Dis 23: 171–175, 19948311070
      155. Simeoni U, Ligi I, Buffat C, Boubred F: Adverse consequences of accelerated neonatal growth: cardiovascular and renal issues. Pediatr Nephrol 26: 493–508, 201120938692
      156. McMillen IC, Robinson JS: Developmental origins of the metabolic syndrome: prediction, plasticity, and programming. Physiol Rev 85: 571–633, 200515788706
      157. Vehaskari VM, Woods LL: Prenatal programming of hypertension: lessons from experimental models. J Am Soc Nephrol 16: 2545–2556, 200516049066
      158. Luyckx VA, Brenner BM: Birth weight, malnutrition and kidney-associated outcomes--a global concern. Nat Rev Nephrol 11: 135–149, 201525599618
      159. Hoy WE, Hughson MD, Diouf B, Zimanyi M, Samuel T, McNamara BJ, Douglas-Denton RN, Holden L, Mott SA, Bertram JF: Distribution of volumes of individual glomeruli in kidneys at autopsy: association with physical and clinical characteristics and with ethnic group. Am J Nephrol 33[Suppl 1]: 15–20, 201121659730
      160. Shoham DA, Vupputuri S, Kshirsagar AV: Chronic kidney disease and life course socioeconomic status: a review. Adv Chronic Kidney Dis 12: 56–63, 200515719334
      161. Brophy PD, Shoham DA, Charlton JR, Carmody J, Reidy KJ, Harshman L, Segar J, Askenazi D; CKD Life Course Group: Early-life course socioeconomic factors and chronic kidney disease. Adv Chronic Kidney Dis 22: 16–23, 201525573508
      162. World Health Organization: What are social determinants of health? 2015. Available from: Accessed November 16, 2015
      163. HealthyPeople 2020. Social Determinants of Health Washington, DC: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services; 2015. Available from: Accessed November 16, 2015
      164. Martins D, Agodoa L, Norris K: Kidney disease in disadvantaged populations. Int J Nephrol 2012: 469265, 201222567281
      165. Nicholas SB, Kalantar-Zadeh K, Norris KC: Socioeconomic disparities in chronic kidney disease. Adv Chronic Kidney Dis 22: 6–15, 201525573507
      166. Nicholas SB, Kalantar-Zadeh K, Norris KC: Racial disparities in kidney disease outcomes. Semin Nephrol 33: 409–415, 201324119846
      167. Norris K, Nissenson AR: Race, gender, and socioeconomic disparities in CKD in the United States. J Am Soc Nephrol 19: 1261–1270, 200818525000
      168. Powe NR: Let’s get serious about racial and ethnic disparities. J Am Soc Nephrol 19: 1271–1275, 200818524999
      169. Powe NR: To have and have not: Health and health care disparities in chronic kidney disease. Kidney Int 64: 763–772, 200312846781
      170. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL: Socioeconomic inequalities in health. No easy solution. JAMA 269: 3140–3145, 19938505817
      171. Marmot MG, Shipley MJ, Rose G: Inequalities in death--specific explanations of a general pattern? Lancet 1: 1003–1006, 19846143919
      172. Pappas G, Queen S, Hadden W, Fisher G: The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med 329: 103–109, 19938510686
      173. Kimmel PL, Fwu C-W, Abbott KC, Abbott KC, Ratner J, Eggers PW: Racial disparities in poverty account for mortality differences in US medicare beneficiaries. SSM - Population Health 2: 123–129, 2016
      174. Isaacs SL, Schroeder SA: Class - the ignored determinant of the nation’s health. N Engl J Med 351: 1137–1142, 200415356313
      175. National Center for Education Statistics: Public High School Graduation Rates, Washington, DC, US Department of Education, 2015
      176. US Bureau of Labor Statistics: Labor Force Characteristics by Race and Ethnicity, 2013, Washington, DC, US Department of Labor, 2014
      177. US Census Bureau: Poverty Rates for Selected Detailed Race and Hispanic Groups by State and Place: 2007–2011. Washington, DC, US Department of Commerce, 2013.
      178. Patzer RE, McClellan WM: Influence of race, ethnicity and socioeconomic status on kidney disease. Nat Rev Nephrol 8: 533–541, 201222735764
      179. Martins D, Tareen N, Zadshir A, Pan D, Vargas R, Nissenson A, Norris K: The association of poverty with the prevalence of albuminuria: data from the Third National Health and Nutrition Examination Survey (NHANES III). Am J Kidney Dis 47: 965–971, 200616731291
      180. White SL, McGeechan K, Jones M, Cass A, Chadban SJ, Polkinghorne KR, Perkovic V, Roderick PJ: Socioeconomic disadvantage and kidney disease in the United States, Australia, and Thailand. Am J Public Health 98: 1306–1313, 200818511730
      181. Bruce MA, Beech BM, Crook ED, Sims M, Wyatt SB, Flessner MF, Taylor HA, Williams DR, Akylbekova EL, Ikizler TA: Association of socioeconomic status and CKD among African Americans: the Jackson Heart Study. Am J Kidney Dis 55: 1001–1008, 201020381223
      182. Crews DC, McClellan WM, Shoham DA, Gao L, Warnock DG, Judd S, Muntner P, Miller ER, Powe NR: Low income and albuminuria among REGARDS (Reasons for Geographic and Racial Differences in Stroke) study participants. Am J Kidney Dis 60: 779–786, 201222694949
      183. McClellan WM, Newsome BB, McClure LA, Howard G, Volkova N, Audhya P, Warnock DG: Poverty and racial disparities in kidney disease: the REGARDS study. Am J Nephrol 32: 38–46, 201020516678
      184. Shoham DA, Vupputuri S, Diez Roux AV, Kaufman JS, Coresh J, Kshirsagar AV, Zeng D, Heiss G: Kidney disease in life-course socioeconomic context: the Atherosclerosis Risk in Communities (ARIC) Study. Am J Kidney Dis 49: 217–226, 200717261424
      185. Shoham DA, Vupputuri S, Kaufman JS, Kshirsagar AV, Roux AVD, Coresh J, Heiss G: Kidney disease and the cumulative burden of life course socioeconomic conditions: the Atherosclerosis Risk in Communities (ARIC) study. Soc Sci Med 67: 1311–1320, 2008
      186. Lash JP, Go AS, Appel LJ, He J, Ojo A, Rahman M, Townsend RR, Xie D, Cifelli D, Cohan J, Fink JC, Fischer MJ, Gadegbeku C, Hamm LL, Kusek JW, Landis JR, Narva A, Robinson N, Teal V, Feldman HI; Chronic Renal Insufficiency Cohort (CRIC) Study Group: Chronic Renal Insufficiency Cohort (CRIC) Study: baseline characteristics and associations with kidney function. Clin J Am Soc Nephrol 4: 1302–1311, 200919541818
      187. Plantinga LC, Johansen KL, Schillinger D, Powe NR: Lower socioeconomic status and disability among US adults with chronic kidney disease, 1999-2008. Prev Chronic Dis 9: E12, 201222172179
      188. Crews DC, Gutiérrez OM, Fedewa SA, Luthi JC, Shoham D, Judd SE, Powe NR, McClellan WM: Low income, community poverty and risk of end stage renal disease. BMC Nephrol 15: 192, 201425471628
      189. Lipworth L, Mumma MT, Cavanaugh KL, Edwards TL, Ikizler TA, Tarone RE, McLaughlin JK, Blot WJ: Incidence and predictors of end stage renal disease among low-income blacks and whites. PLoS One 7: e48407, 201223110237
      190. Hsu CY, Iribarren C, McCulloch CE, Darbinian J, Go AS: Risk factors for end-stage renal disease: 25-year follow-up. Arch Intern Med 169: 342–350, 200919237717
      191. Sandhu GS, Khattak M, Pavlakis M, Woodward R, Hanto DW, Wasilewski MA, Dimitri N, Goldfarb-Rumyantzev A: Recipient’s unemployment restricts access to renal transplantation. Clin Transplant 27: 598–606, 201323808849
      192. Goldfarb-Rumyantzev AS, Sandhu GS, Baird B, Barenbaum A, Yoon JH, Dimitri N, Koford JK, Shihab F: Effect of education on racial disparities in access to kidney transplantation. Clin Transplant 26: 74–81, 201221198857
      193. Chow KM, Szeto CC, Leung CB, Law MC, Li PK: Impact of social factors on patients on peritoneal dialysis. Nephrol Dial Transplant 20: 2504–2510, 200516091376
      194. Martin LC, Caramori JC, Fernandes N, Divino-Filho JC, Pecoits-Filho R, Barretti P; Brazilian Peritoneal Dialysis Multicenter Study BRAZPD Group: Geographic and educational factors and risk of the first peritonitis episode in Brazilian Peritoneal Dialysis study (BRAZPD) patients. Clin J Am Soc Nephrol 6: 1944–1951, 201121737854
      195. Goldfarb-Rumyantzev AS, Sandhu GS, Barenbaum A, Baird BC, Patibandla BK, Narra A, Koford JK, Barenbaum L: Education is associated with reduction in racial disparities in kidney transplant outcome. Clin Transplant 26: 891–899, 201222694749
      196. Krieger N, Williams DR, Moss NE: Measuring social class in US public health research: concepts, methodologies, and guidelines. Annu Rev Public Health 18: 341–378, 19979143723
      197. Volkova N, McClellan W, Klein M, Flanders D, Kleinbaum D, Soucie JM, Presley R: Neighborhood poverty and racial differences in ESRD incidence. J Am Soc Nephrol 19: 356–364, 200818057219
      198. Garrity BH, Kramer H, Vellanki K, Leehey D, Brown J, Shoham DA: Time trends in the association of ESRD incidence with area-level poverty in the US population. Hemodial Int 2015.
      199. Kimmel PL, Fwu CW, Eggers PW: Segregation, income disparities, and survival in hemodialysis patients. J Am Soc Nephrol 24: 293–301, 201323334394
      200. Eisenstein EL, Sun JL, Anstrom KJ, Stafford JA, Szczech LA, Muhlbaier LH, Mark DB: Do income level and race influence survival in patients receiving hemodialysis? Am J Med 122: 170–180, 200919185093
      201. Merkin SS, Diez Roux AV, Coresh J, Fried LF, Jackson SA, Powe NR: Individual and neighborhood socioeconomic status and progressive chronic kidney disease in an elderly population: The Cardiovascular Health Study. Soc Sci Med 65: 809–821, 2007
      202. Selye H: The Stess of Life, New York, NY, McGraw-Hill, 1956
      203. Sterling P, Eyer J: Allostasis: A New Paradigm to Explain Arousal Pathology. In: Handbook of life stress, cognition and health, edited by Fisher S, Reason J, New York, NY, John Wiley, 1988, pp 629–649
      204. McEwen BS, Stellar E: Stress and the individual. Mechanisms leading to disease. Arch Intern Med 153: 2093–2101, 19938379800
      205. McEwen BS: Protective and damaging effects of stress mediators. N Engl J Med 338: 171–179, 19989428819
      206. Theorell T, Karasek RA: Current issues relating to psychosocial job strain and cardiovascular disease research. J Occup Health Psychol 1: 9–26, 19969547038
      207. Everson-Rose SA, Lewis TT: Psychosocial factors and cardiovascular diseases. Annu Rev Public Health 26: 469–500, 200515760298
      208. Dimsdale JE: Psychological stress and cardiovascular disease. J Am Coll Cardiol 51: 1237–1246, 200818371552
      209. Sternberg EM, Chrousos GP, Wilder RL, Gold PW: The stress response and the regulation of inflammatory disease. Ann Intern Med 117: 854–866, 19921416562
      210. Bruce MA, Beech BM, Sims M, Brown TN, Wyatt SB, Taylor HA, Williams DR, Crook E: Social environmental stressors, psychological factors, and kidney disease. J Investig Med 57: 583–589, 2009
      211. Bruce MA, Griffith DM, Thorpe RJ Jr: Stress and the kidney. Adv Chronic Kidney Dis 22: 46–53, 201525573512
      212. Cukor D, Cohen SD, Peterson RA, Kimmel PL: Psychosocial aspects of chronic disease: ESRD as a paradigmatic illness. J Am Soc Nephrol 18: 3042–3055, 200718003775
      213. Himmelfarb J, Holbrook D, McMonagle E, Robinson R, Nye L, Spratt D: Kt/V, nutritional parameters, serum cortisol, and insulin growth factor-1 levels and patient outcome in hemodialysis. Am J Kidney Dis 24: 473–479, 19948079972
      214. Mujahid MS, Diez Roux AV, Cooper RC, Shea S, Williams DR: Neighborhood stressors and race/ethnic differences in hypertension prevalence (the Multi-Ethnic Study of Atherosclerosis). Am J Hypertens 24: 187–193, 201120847728
      215. Brewer LC, Carson KA, Williams DR, Allen A, Jones CP, Cooper LA: Association of race consciousness with the patient-physician relationship, medication adherence, and blood pressure in urban primary care patients. Am J Hypertens 26: 1346–1352, 201323864583
      216. Hicken MT, Lee H, Morenoff J, House JS, Williams DR: Racial/ethnic disparities in hypertension prevalence: reconsidering the role of chronic stress. Am J Public Health 104: 117–123, 201424228644
      217. Greene ML, Way N, Pahl K: Trajectories of perceived adult and peer discrimination among Black, Latino, and Asian American adolescents: patterns and psychological correlates. Dev Psychol 42: 218–236, 200616569162
      218. Barnes LL, Mendes De Leon CF, Wilson RS, Bienias JL, Bennett DA, Evans DA: Racial differences in perceived discrimination in a community population of older blacks and whites. J Aging Health 16: 315–337, 200415155065
      219. Sims M, Diez-Roux AV, Dudley A, Gebreab S, Wyatt SB, Bruce MA, James SA, Robinson JC, Williams DR, Taylor HA: Perceived discrimination and hypertension among African Americans in the Jackson Heart Study. Am J Public Health 102[Suppl 2]: S258–S265, 201222401510
      220. Williams DR, Haile R, Mohammed SA, Herman A, Sonnega J, Jackson JS, Stein DJ: Perceived discrimination and psychological well-being in the U.S.A. and South Africa. Ethn Health 17: 111–133, 201222339224
      221. Ren XS, Amick BC, Williams DR: Racial/ethnic disparities in health: the interplay between discrimination and socioeconomic status. Ethn Dis 9: 151–165, 199910421078
      222. Lillie-Blanton M, Brodie M, Rowland D, Altman D, McIntosh M: Race, ethnicity, and the health care system: public perceptions and experiences. Med Care Res Rev 57[Suppl 1]: 218–235, 200011092164
      223. Boulware LE, Cooper LA, Ratner LE, Laveist T, Powe NR: Race and trust in the health care system. Public Health Rep 118: 358–365, 2003
      224. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, Ford DE: Race, gender, and partnership in the patient-physician relationship. JAMA 282: 583–589, 199910450723
      225. Pascoe EA, Smart Richman L: Perceived discrimination and health: a meta-analytic review. Psychol Bull 135: 531–554, 200919586161
      226. Dolezsar CM, McGrath JJ, Herzig AJ, Miller SB: Perceived racial discrimination and hypertension: a comprehensive systematic review. Health Psychol 33: 20–34, 2014
      227. Ryan AM, Gee GC, Griffith D: The effects of perceived discrimination on diabetes management. J Health Care Poor Underserved 19: 149–163, 200818263991
      228. Wagner J, Abbott G: Depression and depression care in diabetes: relationship to perceived discrimination in African Americans. Diabetes Care 30: 364–366, 200717259510
      229. Borrell LN, Kiefe CI, Diez-Roux AV, Williams DR, Gordon-Larsen P: Racial discrimination, racial/ethnic segregation, and health behaviors in the CARDIA study. Ethn Health 18: 227–243, 201322913715
      230. Cukor D, Peterson RA, Cohen SD, Kimmel PL: Depression in end-stage renal disease hemodialysis patients. Nat Clin Pract Nephrol 2: 678–687, 200617124525
      231. Yu MK, Weiss NS, Ding X, Katon WJ, Zhou XH, Young BA: Associations between depressive symptoms and incident ESRD in a diabetic cohort. Clin J Am Soc Nephrol 9: 920–928, 201424677559
      232. Fischer MJ, Xie D, Jordan N, Kop WJ, Krousel-Wood M, Kurella Tamura M, Kusek JW, Ford V, Rosen LK, Strauss L, Teal VL, Yaffe K, Powe NR, Lash JP; CRIC Study Group Investigators: Factors associated with depressive symptoms and use of antidepressant medications among participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC Studies. Am J Kidney Dis 60: 27–38, 201222497791
      233. Fischer MJ, Kimmel PL, Greene T, Gassman JJ, Wang X, Brooks DH, Charleston J, Dowie D, Thornley-Brown D, Cooper LA, Bruce MA, Kusek JW, Norris KC, Lash JP; AASK Study Group: Elevated depressive affect is associated with adverse cardiovascular outcomes among African Americans with chronic kidney disease. Kidney Int 80: 670–678, 201121633409
      234. Fischer MJ, Kimmel PL, Greene T, Gassman JJ, Wang X, Brooks DH, Charleston J, Dowie D, Thornley-Brown D, Cooper LA, Bruce MA, Kusek JW, Norris KC, Lash JP; AASK study group: Sociodemographic factors contribute to the depressive affect among African Americans with chronic kidney disease. Kidney Int 77: 1010–1019, 201020200503
      235. Gholson GK, Mwendwa DT, Wright RS, Callender CO, Campbell AL: The Combined Influence of Psychological Factors on Biomarkers of Renal Functioning in African Americans. Ethn Dis 25: 117–122, 201526118136
      236. McClellan WM, Abramson J, Newsome B, Temple E, Wadley VG, Audhya P, McClure LA, Howard VJ, Warnock DG, Kimmel P: Physical and psychological burden of chronic kidney disease among older adults. Am J Nephrol 31: 309–317, 201020164652
      237. Jindal RM, Neff RT, Abbott KC, Hurst FP, Elster EA, Falta EM, Patel P, Cukor D: Association between depression and nonadherence in recipients of kidney transplants: analysis of the United States renal data system. Transplant Proc 41: 3662–3666, 200919917363
      238. Cukor D, Rosenthal DS, Jindal RM, Brown CD, Kimmel PL: Depression is an important contributor to low medication adherence in hemodialyzed patients and transplant recipients. Kidney Int 75: 1223–1229, 200919242502
      239. Khalil AA, Frazier SK, Lennie TA, Sawaya BP: Depressive symptoms and dietary adherence in patients with end-stage renal disease. J Ren Care 37: 30–39, 201121288315
      240. Akman B, Uyar M, Afsar B, Sezer S, Ozdemir FN, Haberal M: Adherence, depression and quality of life in patients on a renal transplantation waiting list. Transpl Int 20: 682–687, 2007
        241. Lindberg M, Wikström B, Lindberg P: Subgroups of haemodialysis patients in relation to fluid intake restrictions: a cluster analytical approach. J Clin Nurs 19: 2997–3005, 201021040006
        242. Kimmel PL, Peterson RA, Weihs KL, Simmens SJ, Alleyne S, Cruz I, Veis JH: Psychosocial factors, behavioral compliance and survival in urban hemodialysis patients. Kidney Int 54: 245–254, 19989648085
        243. Dobbels F, Skeans MA, Snyder JJ, Tuomari AV, Maclean JR, Kasiske BL: Depressive disorder in renal transplantation: an analysis of Medicare claims. Am J Kidney Dis 51: 819–828, 200818436093
        244. Hedayati SS, Grambow SC, Szczech LA, Stechuchak KM, Allen AS, Bosworth HB: Physician-diagnosed depression as a correlate of hospitalizations in patients receiving long-term hemodialysis. Am J Kidney Dis 46: 642–649, 200516183419
        245. Hedayati SS, Bosworth HB, Briley LP, Sloane RJ, Pieper CF, Kimmel PL, Szczech LA: Death or hospitalization of patients on chronic hemodialysis is associated with a physician-based diagnosis of depression. Kidney Int 74: 930–936, 200818580856
        246. Lopes AA, Bragg J, Young E, Goodkin D, Mapes D, Combe C, Piera L, Held P, Gillespie B, Port FK; Dialysis Outcomes and Practice Patterns Study (DOPPS): Depression as a predictor of mortality and hospitalization among hemodialysis patients in the United States and Europe. Kidney Int 62: 199–207, 200212081579
        247. Kimmel PL, Peterson RA, Weihs KL, Simmens SJ, Alleyne S, Cruz I, Veis JH: Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis outpatients. Kidney Int 57: 2093–2098, 200010792629
        248. Drayer RA, Piraino B, Reynolds CF 3rd, Houck PR, Mazumdar S, Bernardini J, Shear MK, Rollman BL: Characteristics of depression in hemodialysis patients: symptoms, quality of life and mortality risk. Gen Hosp Psychiatry 28: 306–312, 200616814629
        249. Fan L, Sarnak MJ, Tighiouart H, Drew DA, Kantor AL, Lou KV, Shaffi K, Scott TM, Weiner DE: Depression and all-cause mortality in hemodialysis patients. Am J Nephrol 40: 12–18, 201424969267
        250. Bautovich A, Katz I, Smith M, Loo CK, Harvey SB: Depression and chronic kidney disease: A review for clinicians. Aust N Z J Psychiatry 48: 530–541, 201424658294
        251. Halen NV, Cukor D, Constantiner M, Kimmel PL: Depression and mortality in end-stage renal disease. Curr Psychiatry Rep 14: 36–44, 201222105534
        252. Weisbord SD, Fried LF, Unruh ML, Kimmel PL, Switzer GE, Fine MJ, Arnold RM: Associations of race with depression and symptoms in patients on maintenance haemodialysis. Nephrol Dial Transplant 22: 203–208, 200716998218
        253. Sachs-Ericsson N, Plant EA, Blazer DG: Racial differences in the frequency of depressive symptoms among community dwelling elders: the role of socioeconomic factors. Aging Ment Health 9: 201–209, 200516019274
        254. Blazer DG, Landerman LR, Hays JC, Simonsick EM, Saunders WB: Symptoms of depression among community-dwelling elderly African-American and white older adults. Psychol Med 28: 1311–1320, 19989854272
        255. Sachs-Ericsson N, Burns AB, Gordon KH, Eckel LA, Wonderlich SA, Crosby RD, Blazer DG: Body mass index and depressive symptoms in older adults: the moderating roles of race, sex, and socioeconomic status. Am J Geriat Psychiat 15: 815–825, 2007
        256. House JS, Landis KR, Umberson D: Social relationships and health. Science 241: 540–545, 19883399889
        257. Clark S, Farrington K, Chilcot J: Nonadherence in dialysis patients: prevalence, measurement, outcome, and psychological determinants. Semin Dial 27: 42–49, 201424164416
        258. Plantinga LC, Fink NE, Harrington-Levey R, Finkelstein FO, Hebah N, Powe NR, Jaar BG: Association of social support with outcomes in incident dialysis patients. Clin J Am Soc Nephrol 5: 1480–1488, 201020430940
        259. Kovac JA, Patel SS, Peterson RA, Kimmel PL: Patient satisfaction with care and behavioral compliance in end-stage renal disease patients treated with hemodialysis. Am J Kidney Dis 39: 1236–1244, 200212046037
        260. Porter A, Fischer MJ, Brooks D, Bruce M, Charleston J, Cleveland WH, Dowie D, Faulkner M, Gassman J, Greene T, Hiremath L, Kendrick C, Kusek JW, Thornley-Brown D, Wang X, Norris K, Unruh M, Lash J: Quality of life and psychosocial factors in African Americans with hypertensive chronic kidney disease. Transl Res 159: 4–11, 201222153804
        261. Thong MS, Kaptein AA, Krediet RT, Boeschoten EW, Dekker FW: Social support predicts survival in dialysis patients. Nephrol Dial Transplant 22: 845–850, 200717164318
        262. Christensen AJ, Wiebe JS, Smith TW, Turner CW: Predictors of survival among hemodialysis patients: effect of perceived family support. Health Psychol 13: 521–525, 1994
        263. Patel SS, Shah VS, Peterson RA, Kimmel PL: Psychosocial variables, quality of life, and religious beliefs in ESRD patients treated with hemodialysis. Am J Kidney Dis 40: 1013–1022, 200212407647
        264. Cohen SD, Sharma T, Acquaviva K, Peterson RA, Patel SS, Kimmel PL: Social support and chronic kidney disease: an update. Adv Chronic Kidney Dis 14: 335–344, 200717904500
        265. Williams DR, Neighbors H: Racism, discrimination and hypertension: evidence and needed research. Ethn Dis 11: 800–816, 200111763305
        266. Barnes LL, Mendes de Leon CF, Bienias JL, Evans DA: A longitudinal study of black-white differences in social resources. J Gerontol B Psychol Sci Soc Sci 59: S146–S153, 200415118020
        267. Sloan MM, Evenson Newhouse RJ, Thompson AB: Counting on Coworkers: Race, Social Support, and Emotional Experiences on the Job. Soc Psychol Q 76: 343–372, 2013
        268. Rees CA, Karter AJ, Young BA: Race/ethnicity, social support, and associations with diabetes self-care and clinical outcomes in NHANES. Diabetes Educ 36: 435–445, 201020332281
        269. Dixon P: Marriage Among African Americans: What Does the Research Reveal? J Afr Am Stud 13: 29–46, 2009
        270. James S: Longitudinal Patterns of Women’s Marital Quality: The Case of Divorce, Cohabitation, and Race-Ethnicity. Marriage Fam Rev 50: 738–763, 2014
        271. Broman CL: Marital Quality in Black and White Marriages. J Fam Issues 26: 431–441, 2005
        272. Bulanda JR, Brown SL: Race-ethnic differences in marital quality and divorce. Soc Sci Res 36: 945–967, 2007
        273. Kiecolt-Glaser JK, Loving TJ, Stowell JR, Malarkey WB, Lemeshow S, Dickinson SL, Glaser R: Hostile marital interactions, proinflammatory cytokine production, and wound healing. Arch Gen Psychiatry 62: 1377–1384, 200516330726
        274. Burman B, Margolin G: Analysis of the association between marital relationships and health problems: an interactional perspective. Psychol Bull 112: 39–63, 19921529039
        275. Johnson NJ, Backlund E, Sorlie PD, Loveless CA: Marital status and mortality: the national longitudinal mortality study. Ann Epidemiol 10: 224–238, 200010854957
        276. Kulik JA, Mahler HI. Marital quality predicts hospital stay following coronary artery bypass surgery for women but not men. Soc Sci Med 63: 2031–2040, 2006
          277. Robles TF, Kiecolt-Glaser JK: The physiology of marriage: pathways to health. Physiol Behav 79: 409–416, 200312954435
          278. Kimmel PL, Peterson RA, Weihs KL, Shidler N, Simmens SJ, Alleyne S, Cruz I, Yanovski JA, Veis JH, Phillips TM: Dyadic relationship conflict, gender, and mortality in urban hemodialysis patients. J Am Soc Nephrol 11: 1518–1525, 200010906166
          279. Finkelstein FO, Finkelstein SH, Steele TE: Assessment of marital relationships of hemodialysis patients. Am J Med Sci 271: 21–28, 1976943937
          280. Steele TE, Finkelstein SH, Finkelstein FO: Marital discord, sexual problems, and depression. J Nerv Ment Dis 162: 225–237, 19761255152
          281. Khaira A, Mahajan S, Khatri P, Bhowmik D, Gupta S, Agarwal SK: Depression and marital dissatisfaction among Indian hemodialysis patients and their spouses: a cross-sectional Study. Ren Fail 34: 316–322, 201222263897
          282. Daneker B, Kimmel PL, Ranich T, Peterson RA: Depression and marital dissatisfaction in patients with end-stage renal disease and in their spouses. Am J Kidney Dis 38: 839–846, 200111576888
          283. Turner-Musa J, Leidner D, Simmens S, Reiss D, Kimmel PL, Holder B: Family structure and patient survival in an African-American end-stage renal disease population: a preliminary investigation. Soc Sci Med 48: 1333-1340, 1999
          284. Association of American Medical Colleges: Diversity in the Physician Workforce: Facts & Figures 2014. Washington, DC, 2014. Available at: Accessed December 4, 2015
          285. Onumah C, Kimmel PL, Rosenberg ME: Race disparities in U.S. nephrology fellowship training. Clin J Am Soc Nephrol 6: 390–394, 201121273375
          286. Paul-Emile K, Smith AK, Lo B, Fernández A: Dealing with Racist Patients. N Engl J Med 374: 708–711, 201626933847
          287. Agency for Healthcare Research and Quality: 2014 National Healthcare Quality and Disparities Report, Rockville, MD, US Department of Health and Human Services, 2015
          288. Ray KN, Chari AV, Engberg J, Bertolet M, Mehrotra A: Disparities in Time Spent Seeking Medical Care in the United States. JAMA Intern Med 175: 1983–1986, 201526437386
          289. Gaskin DJ, Price A, Brandon DT, Laveist TA: Segregation and disparities in health services use. Med Care Res Rev 66: 578–589, 200919460811
          290. Perneger TV, Whelton PK, Klag MJ: Race and end-stage renal disease. Socioeconomic status and access to health care as mediating factors. Arch Intern Med 155: 1201–1208, 19957763126
          291. Jurkovitz CT, Li S, Norris KC, Saab G, Bomback AS, Whaley-Connell AT, McCullough PA; KEEP Investigators: Association between lack of health insurance and risk of death and ESRD: results from the Kidney Early Evaluation Program (KEEP). Am J Kidney Dis 61[Suppl 2]: S24–S32, 201323507267
          292. Evans K, Coresh J, Bash LD, Gary-Webb T, Köttgen A, Carson K, Boulware LE: Race differences in access to health care and disparities in incident chronic kidney disease in the US. Nephrol Dial Transplant 26: 899–908, 201120688771
          293. Office of Disease Prevention and Health Promotion: Healthy People 2020 Chronic Kidney Disease Objectives Washington, DC: U.S. Department of Health and Human Services; 2014. Available from: Accessed November 16, 2015
          294. Sealy-Jefferson S, Vickers J, Elam A, Wilson MR: Racial and Ethnic Health Disparities and the Affordable Care Act: a Status Update. J Racial Ethn Health Disparities 2: 583–588, 201526668787
          295. Abdus S, Mistry KB, Selden TM: Racial and Ethnic Disparities in Services and the Patient Protection and Affordable Care Act. Am J Public Health 105[Suppl 5]: S668–S675, 201526447920
          296. Chen J, Vargas-Bustamante A, Mortensen K, Ortega AN: Racial and Ethnic Disparities in Health Care Access and Utilization Under the Affordable Care Act. Med Care 54: 140–146, 201626595227
          297. Martinez ME, Ward BW, Adams PF: Health Care Access and Utilization Among Adults Aged 18-64, by Race and Hispanic Origin: United States, 2013 and 2014. NCHS Data Brief 208: 1–8, 201526222388
          298. Sommers BD, Gunja MZ, Finegold K, Musco T: Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act. JAMA 314: 366–374, 201526219054
          299. Gornick ME, Eggers PW, Reilly TW, Mentnech RM, Fitterman LK, Kucken LE, Vladeck BC: Effects of race and income on mortality and use of services among Medicare beneficiaries. N Engl J Med 335: 791–799, 19968703185
          300. Saha S, Freeman M, Toure J, Tippens KM, Weeks C: Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review, Washington, DC, Department of Veterans Affairs, Veterans Health Administration, 2007
          301. Call KT, McAlpine DD, Garcia CM, Shippee N, Beebe T, Adeniyi TC, Shippee T: Barriers to care in an ethnically diverse publicly insured population: is health care reform enough? Med Care 52: 720–727, 201425023917
          302. Institute of Medicine Committee on Health Literacy: Health Literacy: A Prescription to End Confusion. In: Lynn Nielsen-Bohlman, Allison M. Panzer, edited by Kindig DA, Washington, DC, Institute of Medicine of the National Academies, 2004
          303. Golbeck AL, Ahlers-Schmidt CR, Paschal AM, Dismuke SE: A definition and operational framework for health numeracy. Am J Prev Med 29: 375–376, 200516242604
          304. Office of Disease Prevention and Health Promotion: America’s Health Literacy: Why We Need Accessible Health Information, Washington, DC, US Department of Health and Human Services, 2008
          305. Narva AS, Norton JM, Boulware LE: Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care. Clin J Am Soc Nephrol 11: 694–703, 2015.
          306. Wright JA, Wallston KA, Elasy TA, Ikizler TA, Cavanaugh KL: Development and results of a kidney disease knowledge survey given to patients with CKD. Am J Kidney Dis 57: 387–395, 201121168943
          307. Devraj R, Borrego M, Vilay AM, Gordon EJ, Pailden J, Horowitz B: Relationship between Health Literacy and Kidney Function. Nephrology (Carlton) 20: 360–367, 201525661456
          308. Ricardo AC, Yang W, Lora CM, Gordon EJ, Diamantidis CJ, Ford V, Kusek JW, Lopez A, Lustigova E, Nessel L, Rosas SE, Steigerwalt S, Theurer J, Zhang X, Fischer MJ, Lash JP; CRIC Investigators: Limited health literacy is associated with low glomerular filtration in the Chronic Renal Insufficiency Cohort (CRIC) study. Clin Nephrol 81: 30–37, 201424219913
          309. Kazley AS, Hund JJ, Simpson KN, Chavin K, Baliga P: Health literacy and kidney transplant outcomes. Prog Transplant 25: 85–90, 201525758806
          310. Adeseun GA, Bonney CC, Rosas SE: Health literacy associated with blood pressure but not other cardiovascular disease risk factors among dialysis patients. Am J Hypertens 25: 348–353, 201222237154
          311. Lai AY, Ishikawa H, Kiuchi T, Mooppil N, Griva K: Communicative and critical health literacy, and self-management behaviors in end-stage renal disease patients with diabetes on hemodialysis. Patient Educ Couns 91: 221–227, 201323357415
          312. Green JA, Mor MK, Shields AM, Sevick MA, Arnold RM, Palevsky PM, Fine MJ, Weisbord SD: Associations of health literacy with dialysis adherence and health resource utilization in patients receiving maintenance hemodialysis. Am J Kidney Dis 62: 73–80, 201323352380
          313. Cavanaugh KL, Wingard RL, Hakim RM, Eden S, Shintani A, Wallston KA, Huizinga MM, Elasy TA, Rothman RL, Ikizler TA: Low health literacy associates with increased mortality in ESRD. J Am Soc Nephrol 21: 1979–1985, 201020671215
          314. Abdel-Kader K, Dew MA, Bhatnagar M, Argyropoulos C, Karpov I, Switzer G, Unruh ML: Numeracy skills in CKD: correlates and outcomes. Clin J Am Soc Nephrol 5: 1566–1573, 201020507954
          315. Iceland J, Sharp G, Timberlake JM: Sun belt rising: regional population change and the decline in black residential segregation, 1970-2009. Demography 50: 97–123, 201322965374
          316. Logan JR, Stults BJ, Farley R: Segregation of minorities in the metropolis: two decades of change. Demography 41: 1–22, 200415074122
          317. The Annie E. Casey Foundation: The 2014 KIDS COUNT Data Book. Baltimore, MD, 2014. Available at: Accessed April 28, 2016.
          318. Kaplan GA, Pamuk ER, Lynch JW, Cohen RD, Balfour JL: Inequality in income and mortality in the United States: analysis of mortality and potential pathways. BMJ 312: 999–1003, 19968616393
          319. Wilkinson RG: Income distribution and life expectancy. BMJ 304: 165–168, 19921637372
          320. Nuru-Jeter AM, LaVeist TA: Racial segregation, income inequality, and mortality in US metropolitan areas. J Urban Health 88: 270–282, 2011
          321. Kramer MR, Hogue CR: Is segregation bad for your health? Epidemiol Rev 31: 178–194, 200919465747
          322. LaVeist TA: Racial segregation and longevity among African Americans: an individual-level analysis. Health Serv Res 38: 1719–1733, 200314727794
          323. Rodriguez RA, Sen S, Mehta K, Moody-Ayers S, Bacchetti P, O’Hare AM: Geography matters: relationships among urban residential segregation, dialysis facilities, and patient outcomes. Ann Intern Med 146: 493–501, 200717404351
          324. Patzer RE, Amaral S, Wasse H, Volkova N, Kleinbaum D, McClellan WM: Neighborhood poverty and racial disparities in kidney transplant waitlisting. J Am Soc Nephrol 20: 1333–1340, 200919339381
          325. Garg PP, Diener-West M, Powe NR: Income-based disparities in outcomes for patients with chronic kidney disease. Semin Nephrol 21: 377–385, 200111455526
          326. General Accounting Office: Siting of Hazardous Waste Landfills and Their Correlation with Racial and Economic Status of Surrounding Communities, Washington, DC, U.S. General Accounting Office, 1983. Available at: Accessed November 16, 2015
          327. Bell ML, Ebisu K: Environmental inequality in exposures to airborne particulate matter components in the United States. Environ Health Perspect 120: 1699–1704, 201222889745
          328. Clark LP, Millet DB, Marshall JD: National patterns in environmental injustice and inequality: outdoor NO2 air pollution in the United States. PLoS One 9: e94431, 201424736569
          329. Powell LM, Slater S, Chaloupka FJ, Harper D: Availability of physical activity-related facilities and neighborhood demographic and socioeconomic characteristics: a national study. Am J Public Health 96: 1676–1680, 200616873753
          330. Moore LV, Diez Roux AV, Evenson KR, McGinn AP, Brines SJ: Availability of recreational resources in minority and low socioeconomic status areas. Am J Prev Med 34: 16–22, 200818083446
          331. Walker RE, Keane CR, Burke JG: Disparities and access to healthy food in the United States: A review of food deserts literature. Health Place 16: 876–884, 201020462784
          332. Moore LV, Diez Roux AV: Associations of neighborhood characteristics with the location and type of food stores. Am J Public Health 96: 325–331, 200616380567
          333. Hilmers A, Hilmers DC, Dave J: Neighborhood disparities in access to healthy foods and their effects on environmental justice. Am J Public Health 102: 1644–1654, 201222813465
          334. Bower KM, Thorpe RJ Jr, Rohde C, Gaskin DJ: The intersection of neighborhood racial segregation, poverty, and urbanicity and its impact on food store availability in the United States. Prev Med 58: 33–39, 201424161713
          335. Said S, Hernandez GT: Environmental exposures, socioeconomics, disparities, and the kidneys. Adv Chronic Kidney Dis 22: 39–45, 201525573511
          336. Agency for Toxic Substances & Diseases Registry: Lead Toxicity: Who Is at Risk of Lead Exposure? Atlanta, GA: Center for Disease Control and Prevention; 2007 [Available from:
          337. Ekong EB, Jaar BG, Weaver VM: Lead-related nephrotoxicity: a review of the epidemiologic evidence. Kidney Int 70: 2074–2084, 200617063179
          338. Gutiérrez OM: Contextual poverty, nutrition, and chronic kidney disease. Adv Chronic Kidney Dis 22: 31–38, 201525573510
          339. Crews DC, Kuczmarski MF, Miller ER 3rd, Zonderman AB, Evans MK, Powe NR: Dietary habits, poverty, and chronic kidney disease in an urban population. J Renal Nutr 25: 103–110, 2015
          340. Gutiérrez OM, Muntner P, Rizk DV, McClellan WM, Warnock DG, Newby PK, Judd SE: Dietary patterns and risk of death and progression to ESRD in individuals with CKD: a cohort study. Am J Kidney Dis 64: 204–213, 201424679894
          341. Moser M, White K, Henry B, Oh S, Miller ER, Anderson CA, Benjamin J, Charleston J, Appel LJ, Chang AR: Phosphorus content of popular beverages. Am J Kidney Dis 65: 969–971, 201525863829
          342. Banerjee T, Crews DC, Wesson DE, Tilea A, Saran R, Rios Burrows N, Williams DE, Powe NR; Centers for Disease Control and Prevention Chronic Kidney Disease Surveillance Team: Dietary acid load and chronic kidney disease among adults in the United States. BMC Nephrol 15: 137, 201425151260
          343. Banerjee T, Crews DC, Wesson DE, Tilea AM, Saran R, Ríos-Burrows N, Williams DE, Powe NR; Centers for Disease Control and Prevention Chronic Kidney Disease Surveillance Team: High Dietary Acid Load Predicts ESRD among Adults with CKD. J Am Soc Nephrol 26: 1693–1700, 201525677388
          344. Leventhal T, Brooks-Gunn J: Moving to opportunity: an experimental study of neighborhood effects on mental health. Am J Public Health 93: 1576–1582, 200312948983
          345. Ludwig J, Sanbonmatsu L, Gennetian L, Adam E, Duncan GJ, Katz LF, Kessler RC, Kling JR, Lindau ST, Whitaker RC, McDade TW: Neighborhoods, obesity, and diabetes--a randomized social experiment. N Engl J Med 365: 1509–1519, 201122010917
          346. Anderson NB: Solving the puzzle of socioeconomic status and health: the need for integrated, multilevel, interdisciplinary research. Ann N Y Acad Sci 896: 302–312, 199910681906
          347. Anderson NB, Scott PA: Making the case for psychophysiology during the era of molecular biology. Psychophysiology 36: 1–13, 199910098375
          348. Narva AS: Reducing the burden of chronic kidney disease among American Indians. Adv Chronic Kidney Dis 15: 168–173, 200818334242
          349. Narva AS, Sequist TD: Reducing health disparities in American Indians with chronic kidney disease. Semin Nephrol 30: 19–25, 201020116644
          350. Walker AT, Smith PJ, Kolasa M; Centers for Disease Control and Prevention (CDC): Reduction of racial/ethnic disparities in vaccination coverage, 1995-2011. MMWR Morb Mortal Wkly Rep 63: 7–12, 201424743661
          351. Greenwald AG, McGhee DE, Schwartz JL: Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol 74: 1464–1480, 19989654756
          352. Greenwald T, Banaji M, Nosek B: Project Implicit. Cambridge, MA, Harvard University. Available from: Accessed December 1, 2015

          chronic kidney disease; social determinants; racial disparities; socioeconomic status; psychosocial factors; end stage kidney disease

          Copyright © 2016 by the American Society of Nephrology