This Month in AJKD

Article Outline

• Socioeconomic Status and ESRD
• Attitudes and Behavior of African Americans About Early Detection of Kidney Disease
• Effect of Home-Based Education on Living Donor Kidney Transplantation
• Detecting Access Stenosis Using Ultrasound Monitoring

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Socioeconomic Status and ESRD 

See Ward, pages 563-572 and Merkin, pages 539-541.

Individuals of lower socioeconomic status (SES) appear to be at increased risk of ESRD, but the reason for this association is not clear. In this issue, Ward et al examine the hypothesis that the discrepancy is related to treatment differences among individuals with lower SES. Because the development, progression, and complications of kidney disease in diabetes mellitus, systemic lupus erythematosus, and polycystic kidney disease may vary in their responsiveness to treatment, the authors test this hypothesis by comparing the association between SES and ESRD incidence rates in these 3 disease states. They examined records of all adult patients in the United States with incident ESRD from 1996 to 2004 (N = 747,556), using zip code of residence to approximate socioeconomic status. They found that, regardless of sex or race, the incidence of ESRD was highest among those with the lowest socioeconomic status score quartile and decreased progressively with increasing SES. Socioeconomic status and ESRD were more highly associated in individuals with diabetes than in lupus nephritis and polycystic kidney disease, suggesting that access to and participation in care may explain the association between SES and ESRD. In an accompanying editorial, Dr Merkin discusses the public health impact of these findings.

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Attitudes and Behavior of African Americans About Early Detection of Kidney Disease 

See Waterman et al, pages 554-562 and Boulware, pages 535-538.

African Americans are 4 times more likely than whites to develop kidney failure requiring treatment by dialysis or transplantation and have a far higher prevalence of common risk factors for developing chronic kidney disease (CKD), including diabetes and hypertension. Previous research has shown that African Americans’ knowledge of diabetes and hypertension and the treatment of these chronic conditions are incongruent with clinical recommendations and diagnoses; however, no large study of African Americans’ awareness and attitudes about kidney disease has ever been conducted. In this issue, Waterman et al evaluate awareness of and attitudes about CKD through a telephone survey of 2,017 African Americans in 7 states to determine their perception of CKD as a top health concern, perceived risk of getting kidney disease, and knowledge of CKD and its prevention. While nearly half of the survey participants (43.7%) had a CKD risk factor, only 23.5% of African Americans stated that they were screened for kidney disease during the preceding year and only 2.8% reported that CKD was a top health concern. In an accompanying editorial, Dr Boulware commends recent initiatives in CKD education, but suggests that there is a tremendous effort still needed to increase knowledge of CKD among African Americans. She stresses that, for public programs to be successful, they need to both educate the public about CKD and provide patients information that can enhance their individual perceptions of risk, and notes that this will require a sustained and diligent effort at across the public health system.

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Effect of Home-Based Education on Living Donor Kidney Transplantation 

See Rodrigue et al, pages 663-670 and Becker, pages 542-544.

Although African Americans are more susceptible to chronic kidney disease (CKD) than whites, African Americans are less likely than whites to undergo live donor kidney transplantation (LDKT). Previously, Rodrigue et al conducted a clinical trial testing whether a home-based educational program about LDKT can increase the number of LDKTs as compared to a clinic-based program. In this issue, Rodrigue et al expand on a prior report of the benefits of a home-based versus clinic-based educational program, and investigate the differential impact of a home-based education on kidney donation by African Americans and whites. After 12 months, there were more living donor inquiries, more donors evaluated and more LDKTs performed in the home-based education group than in the clinic-based group. The effect of home-based education on the number of donor evaluations and the number of LDKTs performed was significantly greater among African Americans than among whites. An editorial by Dr Becker stresses the importance of this study to promote the development of educational initiatives that incorporate home-based initiatives to best meet specific needs of various racial and ethnic groups.

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• Figure reproduced with permission from United States Renal Data System 2006 Annual Data Report Atlas of Chronic Kidney Disease & End-Stage Renal Disease in the United States.

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Detecting Access Stenosis Using Ultrasound Monitoring 

See Tonelli et al, pages 630-640 and Maya and Allon, pages 702-708.

Observational studies have shown that monitoring hemodialysis arteriovenous access patency and subsequent intervention could potentially improve vascular access outcomes in hemodialysis patients; however, randomized trials have proven inconclusive. In this issue, Tonelli et al perform a systematic review and meta-analysis of randomized trials that examined the clinical utility of monitoring using blood flow or ultrasound. They found 12 trials including 1,164 participants that met their criteria. In the 4 trials that studied arteriovenous fistulas, monitoring significantly decreased the risk of access thrombosis but had no effect on the risk of fistula loss or overall resource use. Conversely, there was no decrease in risk of thrombosis or access loss identified in the 8 clinical trials that studied access monitoring in arteriovenous grafts. From these findings, Tonelli et al conclude that there is no evidence that monitoring using access blood flow measurements or Doppler ultrasound is beneficial to patients with grafts. A core curriculum in vascular access by Drs Maya and Allon describes several methods used to monitor vascular access patency.

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