Racial Disparities in the Optimal
Delivery of Chronic Kidney Disease Care
Neil R. Powe, MD, MPH, MBAa,b,c,*,
Michal L. Melamed, MDa,c
aDepartment of Medicine, Johns Hopkins School of Medicine,
2024 East Monument Street, Suite 2-600, Baltimore, MD 21205, USA
bDepartments of Epidemiology and Health Policy and Management,
Johns Hopkins Bloomberg School of Public Health, 2024 East Monument Street,
Suite 2-600, Baltimore, MD 21205, USA
cWelch Center for Prevention, Epidemiology, and Clinical Research,
Johns Hopkins Medical Institutions, 2024 East Monument Street, Suite 2-600,
Baltimore, MD 21205, USA
Ethnic minorities make up a disproportionate share of the end-stage
renal disease (ESRD) population in the United States. The reasons for this
are multifactorial including a concentration of biologic-clinical, sociodemo-
graphic, and behavioral risk factors for chronic kidney disease (CKD)
among certain racial and ethnic minorities. Behavioral factors including
patient and provider interactions are not yet fully explored and may be
central to the delivery of optimal care and prevention of ESRD in racial and
ethnic minorities. More attention to understanding the clustering and
reduction of these risk factors may help to arrest the continuing epidemic of
ESRD in racial and ethnic minorities in the United States.
Epidemiology of chronic kidney disease in racial groups
Racial minorities including African, Native, and Hispanic Americans
have a high risk of CKD and ESRD (Table 1). Currently, ethnic minorities
make up 38.5% of the ESRD population in the United States . The
United States Renal Data System estimates that by 2030 approximately
50% of the ESRD population will be composed of ethnic minorities .
Dr. Powe is supported by grant number K24 DK59616 and Dr. Melamed is supported by
grant numbers T32 DK007732 and F32 DK069017 from the National Institute of Diabetes,
Digestive and Kidney Disease, Bethesda, Maryland.
* Corresponding author.
E-mail address: firstname.lastname@example.org (N.R. Powe).
0025-7125/05/$ - see front matter ? 2005 Elsevier Inc. All rights reserved.
Med Clin N Am 89 (2005) 475–488
Before the 1990s, interest and attention on prevention of CKD was
nonexistent. Knowledge about the substantial burden of ESRD in
minorities and its human and economic cost to society has in part resulted
in prevention-oriented research performed in the last decade to understand
the reasons for the excess burden of CKD among racial and ethnic
minorities in the United States. Much of this research has focused on
African Americans, but Native Americans and Hispanics who also have an
increased risk of CKD present other significant challenges in the un-
derstanding of disparities. The work is beginning to point to many
responsible factors that cause kidney dysfunction or progression of pre-
existing kidney dysfunction. They include biologic and clinical factors (eg,
hypertension and diabetes) and sociodemographic factors (eg, health
insurance) (Fig. 1). New research is beginning to identify behavioral factors
that may influence the development and progression of CKD. This article
summarizes work that has been done to understand the reasons for a higher
burden of CKD in racial and ethnic minorities and indicates where more
focus needs to be placed, thereby providing a framework for the goal of
prevention of CKD and its progression in these high-risk groups.
Clinical and biologic risk factors
Among the most important clinical and biologic risk factors for CKD are
hypertension and diabetes. These risk factors for CKD are more prevalent
in many minority populations, possibly explaining some of the disparities in
ESRD risk (see Table 1).
According to the National Health and Nutrition Examination Survey
(NHANES) data, African Americans have a higher prevalence of
hypertension, 33.5% compared with 28.9% in non-Hispanic whites .
Klag et al  showed that African Americans who underwent screening for
the Multiple Risk Factor Intervention Trial had a relative risk of 1.87 (95%
confidence interval 1.47–2.39) of ESRD compared with whites with the same
blood pressure levels. They also used median income from zip code data as
Prevalence of incident end-stage renal disease and chronic kidney disease risk factors in different
Incident ESRD 
CKD risk factors
Per million 254988N/A
Abbreviations: DM, diabetes mellitus; HTN, hypertension; N/A, not available.
aAdjusted for age and sex.
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a surrogate for socioeconomic class and showed that the elevated risk for
African Americans was higher in this population independent of socioeco-
nomic class. Also using the Multiple Risk Factor Intervention Trial data,
Walker et al  showed that African Americans have a faster decline in their
renal function, based on serum creatinine measurements, than whites.
Diabetes mellitus, both type 1 and 2, leads to diabetic nephropathy, the
most common cause of ESRD in the United States. African Americans and
other racial minorities have been shown to be more prone to development of
type 2 diabetes mellitus. Brancati et al  showed that African American
women had 2.4 times the risk of white women and the risk in African
American men was 1.5 times higher than their white counterparts in the
Atherosclerosis Risk in Communities (ARIC) study. Data from the 2001
Behavioral Risk Factor Surveillance System, based on 163,584 patients,
evaluated associations between race, ethnicity, and prevalence of diabetes.
Adjusted for age, sex, body mass index, and health insurance status, in
comparison with white Americans, Asians Americans had an odds ratio for
diabetes of 1.6 (1.1–2.2); Native Americans of 1.8 (1.3–2.5); African
Americans of 1.9 (1.7–2.1); Hispanics of 1.9 (1.6–2.1); and Pacific Islanders
of 3 (1.4–6.7) .
African Americans with type 2 diabetes mellitus have a higher risk of
developing ESRD compared with whites with type 2 diabetes mellitus. In
a study comparing incidence of ESRD in Maryland, African Americans
were found to have a relative risk of 4.80 (3.09–7.46) compared with whites
health habits (e.g. smoking)
problem solving ability
-participatory decision making
-patient centeredness of visits
adherence to visits and therapy
locus of control
trust in providers & system
age, sex, education, income,
occupation, health insurance
BP, HbA1c, family hx, obesity, urine
protein (micro and macro albuminuria)
inflammation, genotype, nephron mass
HIV, systemic lupus erythematosis
Fig. 1. Interaction of factors that may be responsible for disparities in CKD at different
transitions in health and treatment. BP, blood pressure.
RACIAL DISPARITIES IN CKD CARE
after adjustment for age, prevalence of diabetes, prevalence of poorly
controlled hypertension, no college education, and lack of a regular source
of health care . Comparing ESRD rates in the Michigan Kidney Registry
with national data on the prevalence of diabetes showed that the incidence
of ESRD was 2.6-fold higher in African Americans than whites, adjusting
for the prevalence of diabetes . More recently, in a large population of
patients using the Kaiser Permanente health system, African Americans,
Latinos, and Asians had higher hazards of developing ESRD than their
white counterparts but had similar risks of myocardial infarction, stroke,
congestive heart failure, and lower extremity amputation .
CKD has been associated with obesity both through predisposition to
type 2 diabetes mellitus and through other renal pathologies. Obesity is
a health epidemic in the United States. It is particularly prevalent in the
African American population, especially among women. NHANES 1999 to
2000 data show that approximately 50% of African American women are
obese (defined as body mass index ? 30) compared with 30% of non-
Hispanic white women . A recent look at Framingham data revealed that
a higher body mass index was an independent predictor of developing kidney
disease controlling for diabetes at baseline . In a nationally representative
sample from NHANES, Stengel et al  found an association between
morbid obesity and CKD, which was explained by diabetes and hyperten-
sion. They also found a relative risk of 2.2 (1.3–3.8) for CKD among those
with low levels of physical activity compared with their counterparts with
higher levels of physical activity. Obesity-related focal segmental glomerulo-
sclerosis has been increasing in prevalence according to one biopsy series .
Other authors have noted modification of markers of kidney damage
(decreased proteinuria) in obese patients who lose weight [14,15], suggesting
that obesity plays a role in the pathogenesis of chronic kidney damage.
Familial clustering of ESRD among African Americans, including those
with type 2 diabetes, systemic lupus erythematosis, and HIV, has raised the
possibility of genetics playing a role in disparities in CKD occurrence or
progression . A great deal of work in gene identification has focused on
the renin-angiotensin-aldosterone system because of its importance in renal
physiology. Although genes that can account for a large number of ESRD
cases in African Americans have not yet been identified, more efficient
techniques for scanning of the human genome for candidate genes should
add to the knowledge in future years about the genetic control of CKD.
Another intriguing hypothesis is that lower nephron mass at birth resulting
from abnormalities in intrauterine growth is associated with chronic disease
including hypertension and chronic renal disease later in life [17,18]. Very
low birth weights (defined as \ 1500 g) and low birth weights (defined
as \ 2500 g) are more common among African Americans than whites and
are associated with lower nephron number and albuminuria, rendering
plausibility of this hypothesis as a contributor to the excess burden of CKD
in African Americans.
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Systemic lupus erythematosus and HIV infection are diseases responsible
for fewer cases of CKD than diabetes and hypertension, yet these diseases
when they affect the kidney also show racial differences, possibly because of
genetics. Proliferative lupus nephritis has been shown to have a worse
prognosis in patients who are of African American race . A more recent
report suggests that some of the racial differences can be explained by lower
socioeconomic status rather than genetic factors . HIV infection is
associated with several renal manifestations, the most common being HIV-
associated nephropathy. In a cohort of 2059 women with HIV followed
prospectively, African American race was associated with presence of
proteinuria . In a cohort of 3976 patients followed prospectively in an
inner city hospital, Lucas et al  showed that African American patients
had a relative risk of 9 for developing HIV-associated nephropathy
compared with their white counterparts.
There are other biologic risk factors that have been associated with CKD;
however, these do not seem to be more prevalent in racial and ethnic groups.
These include the metabolic syndrome, high serum triglycerides, and low
high-density lipoprotein [11,23–25]. Biologic and clinical factors among
other factors probably contribute substantially to the excess burden of CKD
in racial minorities; however, they are unlikely to explain all of it.
Sociodemographic risk factors
Demographic and socioeconomic factors contributing to early pro-
gression may include age, sex, lower education, income, or health insurance
leading to poor access to appropriate therapies for patients with CKD.
Studies have shown the importance of sociodemographic characteristics,
such as income, in renal disease progression. Klag et al  showed that lower
income was associated with a higher risk of ESRD in African Americans.
This was true also among whites. Different authors have tried to explain the
mechanisms behind these disparities evaluating different steps in the
continuum of health care, including availability of insurance. In diabetic
participants of NHANES III there was a difference in insurance coverage
with non-Hispanic whites and non-Hispanic blacks having approximately
90% insurance coverage, whereas only 66% of Mexican Americans
had health insurance. More non-Hispanic whites had private health
insurance (81%) than non-Hispanic blacks (56%) and Mexican Americans
National, population-based cohort studies from NHANES II and the
ARIC study suggest that 10% to 12% of the excess risk of CKD in African
Americans compared with whites is explained by socioeconomic factors,
such as education, household income, and insurance status [27,28]. Kinchen
et al  show that lack of health insurance is an important predictor of the
timing of referral for CKD to a nephrologist.
RACIAL DISPARITIES IN CKD CARE
Behavioral risk factors
It is increasingly recognized that there is interplay of biologic, clinical,
sociodemographic, and behavioral factors in chronic disease progression
and that fundamental research is needed to understand what behaviors can
prevent complications and maintain health. With the excess prevalence of
biologic, clinical, and sociodemographic risk factors, racial and ethnic
minorities should be targeted for prevention and treatment of risk factors
but studies show that risk factors may actually be undermanaged compared
with their white counterparts. The reasons for undermanagement are
complex, involving behaviors of patients, behaviors of providers, and
interactions between patients and health care providers. Chronic disease
care can be viewed on the continuum of awareness of the disease, treatment
of the condition, and control of the condition. This paradigm has been used
to assess hypertension treatment and can be applied to other chronic
diseases. Having a regular health care provider could promote awareness of
an asymptomatic disease, taking appropriate medications, and finally
control of disease.
The full scope of behavioral factors that could impact on chronic disease
is health knowledge and awareness of disease, beliefs, and attitudes
including locus of control ; dietary or lifestyle habits; language and
health literacy; patient-physician communication ; participatory decision
making by providers [32,33]; trust in physicians and the health care system
[34,35]; patient perceptions of respectful treatment by health care pro-
viders ; and patient adherence to recommended therapies [37,38]. Few of
these factors have been explored for their contribution to disparities in
In addition, progression of disease can be influenced by a patient’s health-
related problem-solving ability, especially managing the sometimes complex
regimens needed to control hypertension and diabetes [39–41]. Patients with
CKD must monitor their disease (eg, blood pressure, glucose, cholesterol);
make decisions about diet and physical activity; adjust their medication;
engage their physicians; and prioritize activities in their life to achieve
control of their disease. Effective problem solving to do this requires
knowledge, the ability to apply it, effective transfer of past learning to new
problem situations, positive problem-solving orientation and self-efficacy,
and rational systematic problem-solving skills and processes. Research in
patients with diabetes mellitus suggests that problem-solving ability and
patient-physician communication impact on complications of the disease
Locus of control refers to an individual’s perception of what causes
a health event . An internal control orientation includes beliefs about
whether the health outcomes of a person’s actions are contingent on what
they do, whereas an external control orientation includes beliefs about
whether the health outcomes of a person’s actions are contingent on events
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outside their personal control. Such learned orientations could impact on
whether patients adhere to providers’ advice and treatment regimens.
Persons from minority groups have been shown to have less trust in
providers . Many believe this stems from experiences of discrimination
in health care and history of inappropriate research experimentation in
minority groups. In addition, participatory decision making, whereby
physicians encourage patients to be more involved in treatment decisions
and to take greater responsibility for their care, has been shown to be
lacking in some patient-physician relationships among racial and ethnic
minorities . Studies indicate that increased patient involvement and
greater patient control have a favorable impact on health status, patient
satisfaction, and remaining under the care of a specific health care provider
[46–48]. This could contribute to the early progression of CKD in
underserved patients, but it is relatively understudied.
The content and quality of patient-physician discussions regarding CKD
(eg, measured using techniques that group observed communication be-
haviors into categories of content, affect, and process) may be important in
effecting behaviors [31,49]. One study of patient-physician communication,
however, could not demonstrate that differences in patient-reported out-
comes among minority groups were explained by patient-physician commu-
nication . Health literacy of patients could have important impacts on
patient-provider communication, but is understudied in CKD.
A few studies have begun to address behavioral factors in development
and progression of CKD. These are worthy of comment. Awareness of
having risk factors for CKD is still lacking in many populations. NHANES
1999 to 2000, using a representative national sample of noninstitutionalized
adults, asked participants if they ‘‘have ever been told by a doctor or health
care professional of weak or failing kidneys.’’ Using results from this
question and estimated glomerular filtration rate (GFR) and albuminuria
collected as part of NHANES, Nickolas et al  showed that only 39.5%
of participants with stage 1 and 2 CKD were aware of their kidney
problems, whereas only 23.1% of participants with stage 3 and 4 CKD had
similar awareness. In multivariate regression, factors associated with lack of
awareness about the diagnosis of kidney disease for early CKD were male
sex, non-Hispanic black race-ethnicity, and a history of hypertension. This
study did not find any difference in health care access between participants
who were aware or unaware of their kidney disease. Among patients with
diabetes, hemoglobin A1clevels were significantly higher in the unaware
group (8.3% versus 7.4%). This study suggests that there are racial
disparities in awareness of kidney disease and that unawareness of kidney
disease is associated with less adequate control of comorbidities, such as
To promote awareness of kidney disease the National Kidney Foun-
dation initiated the Kidney Early Evaluation Program. This program
screened 6071 high-risk participants in 33 states for CKD and its risk
RACIAL DISPARITIES IN CKD CARE
factors. Screening in this population with first-degree relatives having
diabetes, hypertension, CKD, or a personal history of diabetes or hy-
pertension revealed 82 participants with elevated blood sugars, 1014
participants with undiagnosed high blood pressure, and 839 participants
with reduced kidney function based on estimated GFR. Eighty-six percent
of these participants had health insurance coverage suggesting that they
had the ability to seek medical care and yet were not previously diagnosed.
In this volunteer population with health insurance there was a high
prevalence of undiagnosed risk factors. This raises extreme concern about
the other population that does not come for screening and does not have
health insurance in which risk factors for kidney disease are not being
The amount of attribution of behavioral factors to racial and ethnic
disparities in CKD compared with biologic and demographic factors is
largely understudied. Data from a national population cohort study of 9082
adults in NHANES II suggest that 12% of the excess risk of progression of
CKD among African Americans may be attributable to lifestyle factors,
such as physical activity, body mass index, alcohol use, and cigarette
smoking . Among 1434 persons with diabetes enrolled in the ARIC
study, 15% of the excess risk among African Americans in CKD
progression could be attributed to health behaviors .
Data about racial disparities in the process and outcomes care of patients
with diabetes mellitus exist but are inconsistent. Although diabetes mellitus
is an important risk factor for CKD, there is evidence to suggest that it is
not being adequately controlled to prevent diabetic complications. In
nationally representative data from NHANES III, the mean hemoglobin
A1c for all patients with type 2 diabetes mellitus was 7.6%, above the
recommended 7%. Non-Hispanic black women and Mexican American
men had significantly higher mean hemoglobin A1clevels (8.3% and 8.2%,
There are data that reveal less routine screenings for minority patients
with diabetes for low-density lipoprotein and dilated eye examinations 
and hemoglobin A1c. Some of these effects disappeared after adjustment
for age, sex, and insurance type, suggesting that the type of insurance may
explain some of the differences. Another study of diabetics revealed that
African Americans and Hispanics were equally as likely to receive treatment
for diabetes but they had higher hemoglobin A1cand blood pressures .
National data from NHANES III reveal that minority patients are less
likely to self-monitor their blood sugar, have higher hemoglobin A1cand
blood pressure, but that non-Hispanic whites were also not at the goals set
by national guidelines . A precise understanding of the relative con-
tribution of behavioral, clinical, biologic, and sociodemographic factors and
their interactions in progression of CKD could help identify targets for
future interventions aimed at slowing the early progression of CKD in
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Optimal delivery of care for conditions associated with and treatment of
chronic kidney disease
Racial and ethnic disparities are also evident in the early care of
complications of CKD including anemia management and calcium-
phosphate metabolism management and the treatment for ESRD, such as
placement of vascular access, renal replacement therapy choice, and listing
for transplantation. This article is not complete without mention of some of
this work that has been also discussed elsewhere . Early referral to
a nephrologist has been shown to be associated with lower mortality in
selected cohorts and population-based studies [29,59–62] and differs by race.
A nephrologist’s role in the care of pre-ESRD patients includes preparing
patients for renal replacement therapy and treating complications of
decreased renal function. Because the number of cases of CKD vastly
exceeds the capacity of the nephrologist workforce, exemplary models of
integrative comanagement of CKD between specialists and primary care
physicians are needed.
Anemia is common in people with chronic kidney disease. NHANES III
data show a 44.1% prevalence of anemia in people with estimated GFR of
15 to 29 and 5.2% prevalence in those with an estimated GFR of 30 to 59
. In addition, non-Hispanic blacks in the NHANES survey have
a significantly higher prevalence of anemia at all levels of estimated GFR
compared with non-Hispanic whites. Erythropoietin use in chronic kidney
disease care correlates with an early referral to a nephrologist. In the
CHOICE cohort only 12.7% of patients with late evaluation by a ne-
phrologist were on erythropoietin therapy compared with 25.3% of those
with an early referral . Using Center for Medicare and Medicaid Studies
data, Obrador et al  found that non-Hispanic blacks had lower
hematocrits at the initiation of dialysis and were less likely to have received
erythropoietin as part of their chronic kidney disease care.
Disorders of bone metabolism are common in patients with ESRD, but
there has been little attention to disparities in this complication .
Measurement of metabolic bone disease parameters, including serum
calcium, phosphate, and parathyroid hormone level, should begin when
the GFR decreases below 60 mL/min/1.73 m2. Management of pre-
ESRD bone disease is not common. In one study only 3.4% of incident
ESRD patients in New Jersey had their parathyroid hormone assessed
before initiation of renal replacement therapy, whereas 12% were on
a vitamin D formulation and 16% were on calcium-containing phosphate
binders. This study compared the 1-year mortality of patients who had had
bone disease addressed in pre-ESRD care with those who had not and found
a 35% decreased likelihood of death in the first year of renal replacement
therapy . This study suggests both that metabolic bone disease is
undermanaged in CKD care and that perhaps it is an area where
intervention may increase patient survival.
RACIAL DISPARITIES IN CKD CARE
Recent evidence shows that ESRD patients treated with peritoneal
dialysis report a higher quality of life . The choice of dialysis modality is
influenced by racial factors. There are fewer non-Hispanic blacks who
choose peritoneal dialysis. The difference persists after adjustment for age,
education, social support, home ownership, functional status, albumin level,
and comorbid diseases .
The type of vascular access for hemodialysis can influence a patient’s
mortality on dialysis. Initiating dialysis with a vascular catheter is associated
with a higher mortality than dialysis with an arteriovenous fistula . In
a study of Medicare patients, initiating dialysis with a catheter was asso-
ciated with a hazard ratio of death of 1.7 (95% confidence interval 1.59–
1.81) compared with initiation with an arteriovenous fistula . Predictors
of dialysis with a catheter in 7497 prevalent ESRD patients were African
American race, younger age, female sex, short duration since initiation of
dialysis, and impaired functional status . In another study of 356 in-
cident ESRD patients, late referral to a nephrologist was predictive of using
a dialysis catheter for a longer period of time . These studies emphasize
the fact that obtaining an arteriovenous fistula or graft is an important
predictor of survival and that ethnic disparities exist in vascular access
placement. More studies are needed to clarify mechanisms (ie, sociodemo-
graphic, biologic, behavioral) behind these disparities.
Kidney transplantation is the preferred renal replacement solution for
those who qualify to be placed on the waiting list because of improved
survival and decreased costs over time . Several studies have shown that
African American patients are not activated on the renal transplant list at
the same rates as their white counterparts. Garg et al  showed that in
a nationally representative sample of over 7000 patients the most striking
disparity between African American and white patients’ activation was in
the youngest, healthiest group of patients. In this group that benefits most
from renal transplantation, African Americans had 50% less chance of
being activated on the waiting list than whites.
Various barriers have been shown to contribute to disparities in kidney
transplantation. Using dialysis records Alexander and Sehgal  identified
four steps in the process to be listed for a kidney transplant: (1) being
medically suitable and possibly interested, (2) being definitely interested, (3)
completing the pretransplant evaluation, and (4) waiting on the waiting list
to receive a transplant. African Americans in their study were less likely to
finish the last three steps . To explore reasons for differences further,
Klassen et al  evaluated racial discrimination and attitudes by patients.
They found that 49 African Americans who had experienced racial dis-
crimination were less likely to be on the transplant waiting list than those
who had not experienced discrimination. To explore physician barriers,
Ayanian et al  surveyed 278 nephrologists and 606 patients and found
that fewer physicians thought that kidney transplantation improved survival
in African Americans than in whites. More physicians thought patient
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factors were responsible for disparities in transplantation than physician
factors, such as patient-physician communication and trust and physician
bias. The true reasons behind racial disparities in renal transplantation and
other CKD care are probably numerous and include patient, physician, and
system factors, including those mentioned previously.
This article provides evidence that the current and growing burden of
CKD in racial and ethnic minority populations is likely to be multifactorial
involving the interplay of biologic, clinical, social, and behavioral
determinants. To eliminate these disparities, crafting successful solutions
requires more attention to the constellation of contributing factors not only
by specialists, primary care physicians, and other health care providers
involved in CKD care, but also by clinical and behavioral scientists, payers
of health care, and patients.
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