American Journal of Kidney Diseases

Racial and Ethnic Disparities in Acute Care Utilization Among Patients With Glomerular Disease

Published:September 30, 2022DOI:

      Rationale & Objective

      The effects of race, ethnicity, socioeconomic status (SES), and disease severity on acute care utilization in patients with glomerular disease are unknown.

      Study Design

      Prospective cohort study.

      Setting & Participants

      1,456 adults and 768 children with biopsy-proven glomerular disease enrolled in the Cure Glomerulonephropathy (CureGN) cohort.


      Race and ethnicity as a participant-reported social factor.


      Acute care utilization defined as hospitalizations or emergency department visits.

      Analytical Approach

      Multivariable recurrent event proportional rate models were used to estimate associations between race and ethnicity and acute care utilization.


      Black or Hispanic participants had lower SES and more severe glomerular disease than White or Asian participants. Acute care utilization rates were 45.6, 29.5, 25.8, and 19.2 per 100 person-years in Black, Hispanic, White, and Asian adults, respectively, and 55.8, 42.5, 40.8, and 13.0, respectively, for children. Compared with the White race (reference group), Black race was significantly associated with acute care utilization in adults (rate ratio [RR], 1.76 [95% CI, 1.37-2.27]), although this finding was attenuated after multivariable adjustment (RR, 1.31 [95% CI, 1.03-1.68]). Black race was not significantly associated with acute care utilization in children; Asian race was significantly associated with lower acute care utilization in children (RR, 0.32 [95% CI 0.14-0.70]); no significant associations between Hispanic ethnicity and acute care utilization were identified.


      We used proxies for SES and lacked direct information on income, household unemployment, or disability.


      Significant differences in acute care utilization rates were observed across racial and ethnic groups in persons with prevalent glomerular disease, although many of these difference were explained by differences in SES and disease severity. Measures to combat socioeconomic disadvantage in Black patients and to more effectively prevent and treat glomerular disease are needed to reduce disparities in acute care utilization, improve patient wellbeing, and reduce health care costs.

      Graphical abstract

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Siddall E.C.
        • Radhakrishnan J.
        The pathophysiology of edema formation in the nephrotic syndrome.
        Kidney Int. 2012; 82: 635-642
        • Gulati S.
        • Kher V.
        • Gupta A.
        • Arora P.
        • Rai P.K.
        • Sharma R.K.
        Spectrum of infections in Indian children with nephrotic syndrome.
        Pediatr Nephrol Berl Ger. 1995; 9: 431-434
        • Rheault M.N.
        • Wei C.C.
        • Hains D.S.
        • Wang W.
        • Kerlin B.A.
        • Smoyer W.E.
        Increasing frequency of acute kidney injury amongst children hospitalized with nephrotic syndrome.
        Pediatr Nephrol Berl Ger. 2014; 29: 139-147
        • Kerlin B.A.
        • Haworth K.
        • Smoyer W.E.
        Venous thromboembolism in pediatric nephrotic syndrome.
        Pediatr Nephrol Berl Ger. 2014; 29: 989-997
        • Sethna C.B.
        • Merchant K.
        • Reyes A.
        Cardiovascular disease risk in children with kidney disease.
        Semin Nephrol. 2018; 38: 298-313
        • Glenn D.A.
        • Henderson C.D.
        • O’Shaughnessy M.
        • et al.
        Infection-related acute care events among patients with glomerular disease.
        Clin J Am Soc Nephrol. 2020; 15: 1749-1761
        • Gipson D.S.
        • Messer K.L.
        • Tran C.L.
        • et al.
        Inpatient health care utilization in the United States among children, adolescents, and young adults with nephrotic syndrome.
        Am J Kidney Dis. 2013; 61: 910-917
        • Rheault M.N.
        • Zhang L.
        • Selewski D.T.
        • et al.
        AKI in children hospitalized with nephrotic syndrome.
        Clin J Am Soc Nephrol. 2015; 10: 2110-2118
        • Wang C.S.
        • Yan J.
        • Palmer R.
        • Bost J.
        • Wolf M.F.
        • Greenbaum L.A.
        Childhood nephrotic syndrome management and outcome: a single center retrospective analysis.
        Int J Nephrol. 2017; 20172029583
        • Ayoob R.M.
        • Hains D.S.
        • Smoyer W.E.
        Trends in hospitalization characteristics for pediatric nephrotic syndrome in the USA.
        Clin Nephrol. 2012; 78: 106-111
        • Fenton A.
        • Smith S.W.
        • Hewins P.
        Adult minimal-change disease: observational data from a UK centre on patient characteristics, therapies, and outcomes.
        BMC Nephrol. 2018; 19: 207
        • Mariani L.H.
        • Bomback A.S.
        • Canetta P.A.
        • et al.
        CureGN study rationale, design, and methods: establishing a large prospective observational study of glomerular disease.
        Am J Kidney Dis. 2019; 73: 218-229
        • Flynn J.T.
        • Kaelber D.C.
        • Baker-Smith C.M.
        • et al.
        Clinical practice guideline for screening and management of high blood pressure in children and adolescents.
        Pediatrics. 2017; 140e20171904
        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/AphA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        J Am Coll Cardiol. 2018; 71: e127-e248
        • Levey A.S.
        • Stevens L.A.
        • Schmid C.H.
        • et al.
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2009; 150: 604-612
        • Schwartz G.J.
        • Muñoz A.
        • Schneider M.F.
        • et al.
        New equations to estimate GFR in children with CKD.
        J Am Soc Nephrol. 2009; 20: 629-637
        • Ng D.K.
        • Schwartz G.J.
        • Schneider M.F.
        • Furth S.L.
        • Warady B.A.
        Combination of pediatric and adult formulas yield valid glomerular filtration rate estimates in young adults with a history of pediatric chronic kidney disease.
        Kidney Int. 2018; 94: 170-177
        • Raghunathan T.
        • Lepkowski J.
        • Hoewyk J.V.
        • Solenberger P.
        A multivariate technique for multiply imputing missing values using a sequence of regression models.
        Surv Methodol. 2001; 27: 85-89
        • Lin D.
        • Wei L.
        • Yang I.
        • Ying Z.
        Semiparametric regression for the mean and rate functions of recurrent events.
        J R Stat Soc B. 2000; 62: 711-730
        • Rubin D. Frontmatter
        Multiple Imputation for Nonresponse in Surveys. John Wiley & Sons, 1987: i-xxix
        • Feehally J.
        • Kendell N.P.
        • Swift P.G.
        • Walls J.
        High incidence of minimal change nephrotic syndrome in Asians.
        Arch Dis Child. 1985; 60: 1018-1020
        • Banh T.H.M.
        • Hussain-Shamsy N.
        • Patel V.
        • et al.
        Ethnic differences in incidence and outcomes of childhood nephrotic syndrome.
        Clin J Am Soc Nephrol. 2016; 11: 1760-1768
        • Kim J.S.
        • Bellew C.A.
        • Silverstein D.M.
        • Aviles D.H.
        • Boineau F.G.
        • Vehaskari V.M.
        High incidence of initial and late steroid resistance in childhood nephrotic syndrome.
        Kidney Int. 2005; 68: 1275-1281
        • Freedman B.I.
        • Limou S.
        • Ma L.
        • Kopp J.B.
        APOL1-associated nephropathy: a key contributor to racial disparities in CKD.
        Am J Kidney Dis. 2018; 72: S8-S16
        • Gharavi A.G.
        • Kiryluk K.
        • Choi M.
        • et al.
        Genome-wide association study identifies susceptibility loci for IgA nephropathy.
        Nat Genet. 2011; 43: 321-327
        • Mohottige D.
        • Gibson K.
        Staying on track to achieve racial justice in kidney care.
        Nat Rev Nephrol. 2022; 18: 72-73
        • Bignall O.N.R.
        • Drews D.C.
        Stony the road we trod: towards racial justice in kiney care.
        Nat Rev Nephrol. 2021; 17: 79-80
        • Bodenheimer T.
        • Wagner E.H.
        • Grumbach K.
        Improving primary care for patients with chronic illness.
        JAMA. 2002; 288: 1775-1779