Minority Kidney Patients at Increased Risk for COVID-19 Due to Longstanding Structural Inequities

The statistics are startling. As of April 20, African Americans were far more likely than whites to become infected with SARS-CoV-2 and die from COVID-19. More recent data paint a similarly bleak picture of COVID-19’s impact in Hispanic and Native-American communities.


The statistics are startling. As of April 20, African Americans were far more likely than whites to become infected with SARS-CoV-2 and die from COVID-19. More recent data paint a similarly bleak picture of COVID-19’s impact in Hispanic and Native-American communities.

These populations share several social vulnerabilities due to longstanding structural inequities. They disproportionately live in crowded or congregate housing , work in low-wage jobs that must be done on site, rely on public transportation , and have inadequate access to clean water. All these factors increase their risk of exposure to SARS-CoV-2.

“Minority groups also often face challenges around access to health care and everything that flows from that,” says nephrologist Deidra Crews, MD, ScM, FASN, associate professor at Johns Hopkins University School of Medicine in Baltimore, MD. Among those consequences: “Later recognition and poor control of some of the clinical risk factors being highlighted during the pandemic: diabetes, high blood pressure, and obesity. Racial and ethnic minorities bear a disproportionate burden of those chronic conditions, so they are doubly at risk for poor outcomes from the infection,” she says.

Minority populations also make up a disproportionate share of people with kidney disease, which has emerged as a risk factor for severe COVID-19. A majority of people with end-stage kidney disease are reliant on in-center hemodialysis. For many, this requires using public transportation, then sitting in close proximity with other patients and staff several times a week—a recipe for potential exposure to infection. Patients who have received kidney transplants may be even more vulnerable to COVID-19 by virtue of the immunosuppressant drugs they take. And remarkably, COVID-19 can trigger acute kidney injury , even in patients with no previously diagnosed kidney disease.

“It’s a multifaceted problem that is laying bare some of the holes in our public health and healthcare infrastructures,” says O. N. Ray Bignall II, MD, FAAP, director of kidney health advocacy and community engagement at Nationwide Children’s Hospital in Columbus, OH, and assistant professor of pediatrics at The Ohio State University College of Medicine. “When there are already disparities in care and disparities in access, anything that stresses the system, like a global pandemic, will only serve to exacerbate those disparities.”

While Bignall, who sits on ASN’s Policy and Advocacy Committee, is concerned about those health disparities, he wants researchers to stop looking at race alone as a risk factor for disease. “The American Public Health Association data suggest 70% to 80% of health outcomes have to do with factors outside of our biology—the built environment, access to care, education, income, food access, housing, and the stress we experience. We will be best served as a community of healthcare providers when we begin to view the world through that lens,” he believes.

What can policymakers do?

On May 27, Crews, who formerly chaired the ASN Diversity and Inclusion Committee, spoke about these issues during a virtual Congressional briefing organized by the National Kidney Foundation (NKF) and the National Association for the Advancement of Colored People.

“There are things that could be done for the general population that would also help those with kidney disease. States could expand Medicaid and the number of entities that can enroll people based on presumptive eligibility,” she says. “They could also expand the Supplemental Nutrition Assistance Program and extend moratoria on evictions. These steps could reduce food insecurity and housing instability —both risk factors for kidney disease.”

Crews would also like to see support for sufficient personal protective equipment (PPE) and safe transportation options for those receiving and delivering in-center dialysis, greater investment in promoting home dialysis, Medicare authorization for longer supplies of medicine for transplant recipients, and a recognition that vascular access surgery is an essential procedure. She would also welcome a federal mandate that states collect and share data disaggregated by race, ethnicity, gender, and zip code or census tract—a priority articulated by NKF during the briefing, and one that aligns with ASN’s policy goals.

In the meantime, Crews and Bignall are working at the local level to combat misinformation, which they say is also endangering minority communities. “Early on there was a rumor that black people couldn’t get COVID-19,” says Bignall, who had to correct this misperception among some of his patients’ family members. He points out that everybody cites the Tuskegee experiment as the root of African Americans’ distrust of the medical community, but contemporary examples of poor treatment abound. “You’d be hard-pressed to find an African American individual in this country who does not have a story about how their family member’s concerns were ignored or brushed aside,” he says. “I do, and I am a physician.”

One way to address the problem, says Crews, is to partner with trusted community and faith leaders and help them disseminate accurate information within socially disadvantaged communities. Building such bridges of trust will be important for reducing the long-term impact of COVID-19 on minority communities once a safe and effective vaccine becomes available. “It’s a really fraught situation,” Bignall says, “and I don’t know if people appreciate how challenging it’s going to be for people of color to come around to vaccination for this disease.”