Social determinants of health (SDOH) and structural racism are key drivers of disparities in blood pressure control and cardiovascular risk in patients with chronic kidney disease (CKD), said Dinushika Mohottige, MD, MPH, assistant professor in the Institute for Health Equity Research at the Icahn School of Medicine at Mount Sinai in New York City, at Kidney Week 2023. In an effort to improve kidney care for those in underserved communities, Mohottige introduced a session reviewing how SDOH contribute to inequities in cardiovascular disease (CVD) prevention in patients with CKD.
The conditions in which people live, work, play, and pray shape their experience in terms of health outcomes, said Anika Hines, PhD, MPH, assistant professor of health behavior and policy at Virginia Commonwealth University School of Medicine in Richmond. This includes factors such as the wealth of local communities and related quality of schools, availability of healthy food and green spaces, noise, stress, and access to health care.
In one example, a recent study (1) found that factors such physician environment, safety and social cohesion of neighborhoods, plus perceived stress and discrimination on cardiovascular health all had influence on the difference in cardiovascular health factors like blood pressure and on behavior like cigarette smoking between Black and White participants, Hines said.
There are several steps clinicians can take to work to address SDOH, Hines posited:
Acknowledge the role of structural factors. Remember that the patient you see represents not just themself but the broad, lived experience of their family or community. “These societal structures may impact the way that they make decisions…or their health behaviors,” Hines said. “We should not treat behaviors as just individuals’ ‘moral defects’ but think about broader levers that can impact an individual's health or their healthy decision-making.”
Engage with patients in equipoised discussions about navigating barriers. Strive to engage with patients in a way that allows them to tell their lived experiences that could illuminate opportunities as well as barriers to implementing changes you might ask them to make in terms of their health.
Provide proper referral to resources. Be aware of organizations and agencies providing accessible services for patients in need in your area, so you can direct patients appropriately.
SDOH in the Hispanic community
Hispanic individuals represent the largest ethnic minority in the United States, with approximately 63.6 million people recorded in 2022 census data (2), said Tali Elfassy, MSPH, PhD, a research assistant professor at the University of Miami Leonard M. Miller School of Medicine, FL. Hispanic individuals have a lower prevalence of hypertension (34%) than do those who are non-Hispanic Asian, non-Hispanic Black, and non-Hispanic White, according to data from the National Health and Nutrition Examination Survey used in a 2018 study (3). However, that study sampled predominantly people of Mexican origin, Elfassy said.
“The Hispanic population has actually been very heterogeneous so it's not necessarily reflective of the health of all US Hispanics,” she said. Data from the Hispanic Community Health Study/Study of Latinos (4), which recruited over 16,000 Hispanic individuals from diverse backgrounds, found prevalence of hypertension to be 25% across the board but varied by country of origin, with people from Cuba, the Dominican Republic, and Puerto Rico having higher rates (5).
SDOH impact changes in blood pressure among US Hispanic individuals, Elfassy said. For example:
Economic stability. Women earning above $30,000 had lower rates of hypertension; however, that effect was not statistically significant in men (5).
Education. Having less than a high school education was associated with a lower rate of hypertension among men but a higher rate of hypertension among women (5).
Health care access. Having health insurance was associated with a lower rate of hypertension but only in women (5).
Built environment. Having 1 standard deviation of neighborhood socioeconomic deprivation was associated with 49% greater odds of having hypertension (6).
The role of biomarkers
Black adults experience a higher burden of cardiovascular risk factors and are 32% more likely to die from CVD than members of other racial and ethnic groups (7), said Susanne Nicholas, MD, PhD, MPH, professor of medicine and hypertension specialist at University of California Los Angeles Health, citing data from the National Center for Health Statistics. They also have the highest incidence of kidney failure compared with other groups (8), she said.
However, there is a survival paradox in that Black patients on dialysis actually have lower mortality compared with White patients on dialysis, Nicholas added. Research looking to explain this phenomenon has found that Black patients have lower levels of C-reactive protein (9) and genetic variation in levels of apolipoprotein L1 (10). This survival advantage begins even before dialysis, research has found (11). “It begs the question: What's contributing to this, and also, are there markers that we can potentially identify in individuals?” Nicholas said.
Several major pathophysiological mechanisms link CKD and CVD outcomes, she said, such as anemia, inflammation, and increased oxidative stress and accumulation of uremic toxins (12). The two conditions also are impacted by many similar biomarkers as well as SDOH, she noted.
Studies from Nicholas’ group confirmed that African American patients with diabetes had higher levels of C-reactive protein, whereas Hispanic patients had higher levels of urine albumin excretion (13). C-reaction protein levels could be detected in Black patients with metabolic syndrome even before the development of diabetes, she noted, and could predict the development of cardiovascular parameters (14).
Nicholas’ group also studied levels of vitamin D (15), which is deficient in approximately 80% of African Americans and thought to contribute to CVD. In a clinical trial, they repleted patients with 100,000 units of vitamin D3 every 4 weeks for 12 weeks and found that it was significantly correlated with pulse wave velocity, a measure of arterial stiffness.
The identification and validation of additional race-specific biomarkers could allow clinicians to stratify patients based on risk to delay progression of CVD and CKD, identify strategies to provide precision-directed therapies based on biomarker values to potentially predict clinical outcomes, monitor response to therapy, and educate patients on potential risks for disease progression, Nicholas said.
References
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Hines AL, et al. Neighborhood factors, individual stressors, and cardiovascular health among Black and White adults in the US: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. JAMA Netw Open 2023; 6:e2336207. doi: 10.1001/jamanetworkopen.2023.36207
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Krogstad JM, et al. Key facts about Latinos U.S. for National Hispanic Heritage Month. Pew Research Center. September 22, 2023. Accessed November 10, 2023. https://www.pewresearch.org/short-reads/2023/09/22/key-facts-about-us-latinos-for-national-hispanic-heritage-month/
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Muntner P, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018; 71:109–118. doi: 10.1161/CIRCULATIONAHA.117.032582
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Elfassy T, et al. Incidence of hypertension among US Hispanics/Latinos: The Hispanic Community Health Study/Study of Latinos, 2008 to 2017. J Am Heart Assoc 2020; 9:e015031. doi: 10.1161/JAHA.119.015031
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Savin KL, et al. Social and built neighborhood environments and blood pressure 6 years later: Results from the Hispanic Community Health Study/Study of Latinos and the SOL CASAS ancillary study. Soc Sci Med 2022; 292:114496. doi: 10.1016/j.socscimed.2021.114496
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American Heart Association. Heart Attack and Stroke Symptoms. Age-adjusted total CVD mortality rates by race/ethnicity. November 11, 2020. Accessed November 10, 2023. https://www.heart.org/en/about-us/2024-health-equity-impact-goal/age-adjusted-total-cvd-mortality-rates-by-race-ethnicity
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Norton J, et al. Social determinants of racial disparities in CKD. J Am Soc Nephr 2016; 27:2576–2595. doi: 10.1681/ASN.2016010027
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Crews DC, et al. Inflammation and the paradox of racial differences in dialysis survival. J Am Soc Nephr 2011; 22:2279–2286. doi: 10.1681/ASN.2011030305
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Lertdumrongluk P, et al. Survival advantage of African American dialysis patients with end-stage renal disease causes related to APOL1. Cardiorenal Med 2019; 9:212–221. doi: 10.1159/000496472
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Newsome BB, et al. Survival advantage of Black patients with kidney disease after acute myocardial infarction. Clin J Am Soc Nephr 2006; 1:993–999. doi: 10.2215/CJN.01251005
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Matsushita K, et al. Epidemiology and risk of cardiovascular disease in populations with chronic kidney disease. Nat Rev Nephrol 2022; 18:696–707. doi: 10.1038/s41581-022-00616-6
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Sinha SK, et al. Association of race/ethnicity, inflammation, and albuminuria in patients with diabetes and early chronic kidney disease. Diabetes Care 2014; 37:1060–1068. doi: 10.2337/dc13-0013
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Sinha SK, et al. How clinically relevant is C-reactive protein for Blacks with metabolic syndrome to predict microalbuminuria? Metab Syndr Relat Disord 2021; 19:39–47. doi: 10.1089/met.2019.0121
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Sinha SK, et al. Vitamin D3 repletion improves vascular function, as measured by cardiorenal biomarkers in a high-risk African American cohort. Nutrients 2022; 14:3331. doi: 10.3390/nu14163331