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ORIGINAL ARTICLE | KIDNEY DISEASE
2025
:9;
e012
doi:
10.25259/IJTMRPH_88_2024

Trends and Socioeconomic, Demographic, and Behavioral Determinants of Kidney Disease Prevalence among African Americans in the United States, 1997–2021

The Center for Global Health and Health Policy, Global Health and Education Projects, Inc., Riverdale, United States
Formerly with Department of Public Policy and Public Affairs, University of Massachusetts Boston, Boston, United States
Department of Population and Public Health Sciences, University of Southern California, Keck School of Medicine, Los Angeles, United States
Author image

*Corresponding author: Gopal K. Singh, The Center for Global Health and Health Policy, Global Health and Education Projects, Inc., Riverdale, United States. gsingh@mchandaids.org

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Singh GK, Lee H, Azuine RE. Trends and socioeconomic, demographic, and behavioral determinants of kidney disease prevalence among African Americans in the United States, 1997– 2021. Int J Transl Med Res Public Health. 2025;09:e012. doi: 10.25259/IJTMRPH_88_2024

Abstract

Background and Objective:

Both race and socioeconomic status (SES) have been associated with the development and progression of chronic kidney disease (CKD), with African Americans/Blacks and low-SES individuals experiencing substantially increased risks of the disease. However, SES and behavioral determinants of kidney disease among Black Americans are not well studied. This study examines the prevalence and socioeconomic, demographic, and behavioral correlates of severe kidney disease among Black adults in the United States.

Methods:

Using 1997–2000 (n = 130,497), 2012–2018 (n = 224,444), and 2020–2021 (n = 60,894) National Health Interview Surveys, racial/ethnic and SES disparities in kidney disease (weak/failing kidneys) were analyzed by multivariate logistic regression and trend analyses.

Results:

During 2012–2018, the prevalence of severe CKD was 2.4% for the Black population aged ≥18, compared with 1.8% for non-Hispanic Whites, 3.5% for American Indians/Alaska Natives, 1.1% for Asian/Pacific Islanders, and 1.7% for Hispanics. Even after controlling for socioeconomic and demographic factors, Blacks had 19% higher odds of severe CKD than non-Hispanic Whites and 47% higher odds than Asian/Pacific Islanders. Education, income, occupation, nativity/immigrant status, physical inactivity, body mass index, hypertension, and diabetes were strong predictors of kidney disease in Blacks. In the adjusted models, Black immigrants had 47% lower odds of severe CKD than US-born Blacks; Blacks with <12 years of education and income below the poverty level had 1.7- and 3.0-times higher odds than Blacks with a college degree and income ≥400% of the poverty threshold, respectively. Physical inactivity, diabetes, and hypertension were associated with 1.9-, 2.9-, and 4.4-times higher odds of severe CKD, respectively, controlling for other factors. CKD effects of diabetes and hypertension were greater among adults aged 18–64 than those aged ≥65. Trend analyses show persistent SES disparities in prevalence between 1997 and 2021.

Conclusion and Implications for Translation:

SES and health-risk factors are independent and powerful predictors of kidney disease among Black Americans. Socioeconomic influences on kidney disease are greater for Blacks than for non-Hispanic Whites. Policies aimed at prevention, management, and treatment of kidney disease need to monitor the socioeconomically disadvantaged segments of the Black population.

Keywords

African American
Black American
Chronic Kidney Disease
Disparities
Health Behaviors
Kidney Disease
Race
Socioeconomic Status
Trend

INTRODUCTION

As the prevalence of obesity, diabetes, and hypertension in the United States (US) has risen markedly over the past several decades,[1] there has been a concomitant rise in chronic kidney disease (CKD) prevalence and mortality over time.[2-4] The prevalence of CKD, including stages 3 and 4 defined as estimated glomerular filtration rate 30– 59 and 15–29 mL/min/1.73 m2, rose from about 4.7% in 1988–1994 to about 6.7% in 1999–2006, and the trend has been more or less stable since then.[5] The overall prevalence of CKD (stages 1–5) among US adults aged ≥18 years was 13.9% in 2017–2020 compared with 12.9% in 2001–2004, with higher rates among Blacks, people aged ≥65, and those with diabetes or hypertension.[5,6] Kidney disease (nephritis) was the 9th leading cause of death in the US, with 57,386 deaths reported in 2022.[1] African Americans/Blacks have the highest mortality rate from kidney disease, followed by American Indians/Alaska Natives (AIANs), Hispanics, non-Hispanic Whites, and Asian/Pacific Islanders (APIs).[3] Kidney disease mortality rates have remained stable but high for the past two decades; however, people aged 25– 64 in all racial/ethnic groups, including Blacks, experienced consistently increasing mortality rates between 2011 and 2022.[1,3]

High rates of CKD prevalence and mortality among Black Americans are not only explained by their higher obesity, diabetes, and hypertension prevalence, but also by their social environment.[7] Both race and socioeconomic status (SES) have been associated with the development and progression of chronic kidney disease, with Black Americans and lowSES individuals experiencing substantially increased risks of the disease.[8-12] However, socioeconomic and behavioral determinants of kidney disease among Black Americans are not well studied, particularly social inequalities over time, using large population-based surveys. This study (1) examines trends in prevalence and socioeconomic, demographic, and behavioral correlates of kidney disease among Black adults in the US and (2) compares patterns with other racial/ethnic groups, using trend and cross-sectional data from a large, nationally representative survey.

METHODS

Data: National Health Interview Survey

We derived data on kidney disease and selected socioeconomic, demographic, and behavioral characteristics for the entire US population and Black population aged ≥18 from the 1997 to 2000, 2012 to 2018, and 2020 to 2021 National Health Interview Surveys (NHIS).[13] The NHIS is a national sample household survey that collects data on sociodemographic, behavioral, morbidity, health, and healthcare characteristics through personal household interviews. The information collected in the survey is based on self-reports. The NHIS employs a complex, multistage probability design and is representative of the US civilian non-institutionalized population.[1,13,14]

We pooled four years of NHIS data from 1997 to 2000 (n = 130,497), seven years of data from 2012 to 2018 (n = 224,638), and two years of data from 2020 to 2021 (n = 60,894) to ensure sufficient sample sizes for analyzing kidney disease patterns among Black Americans and other racial/ethnic groups by various characteristics over time. Kidney disease data were not available for the 2019, 2022, and 2023 NHIS and were available only for the third and fourth quarters of the 2020 survey. While data from all three periods were used to analyze time trends in racial/ethnic and socioeconomic disparities in kidney disease, more in-depth multivariate analyses were conducted for the 2012–2018 period because of a larger sample size and more detailed information on race, ethnicity, SES, and behavioral and health status characteristics.

Dependent or Outcome Variable: Severe Kidney Disease

The dichotomous outcome variable of severe kidney disease was based on the question: “During the past 12 months, have you been told by a doctor or other health professional that you had weak/failing kidneys? Do not include kidney stones, bladder infections, or incontinence.”[13] During 2012–2018, 194 or 0.086% of the cases with missing data on kidney disease were excluded from the analysis. This resulted in a pooled sample size of 224,444 for the total population and a sample of 29,590 Black adults aged ≥18.

Independent or Predictor Variables: Socioeconomic, Demographic, and Behavioral Characteristics

Based on prior research, we considered the following covariates for analysis: survey year, age, gender, race/ethnicity, nativity/immigrant status, marital status, region of residence, educational attainment, family income/poverty status, occupation, hypertension, diabetes, physical activity, and body mass index (BMI).[5,6,8,9,11,15-18] Race/ethnicity was grouped into five categories: non-Hispanic Whites, non-Hispanic Blacks/African Americans, AIANs, APIs, and Hispanics. Individuals born in one of the 50 US states or Washington, DC, were considered US-born. Individuals born outside the mainland US were considered immigrants or foreign-born. Educational attainment was measured by five categories: <9, 9–11, 12, 13–15, ≥16 years of completed schooling. Income/poverty level, measured as a ratio of annual family income to the federal poverty threshold, was defined by five categories, ranging from <100% to ≥400% of the poverty level. Occupational class consisted of five broad categories: professional and managerial occupations, sales/clerical and technical support occupations, service, craft and repair, laborers, all other occupations, and those outside the labor force.[13,14]

Survey respondents were considered as having hypertension if they had ever been told by a doctor or other health professional that they had hypertension or high blood pressure.[13,14] Diagnosed diabetes (yes, no) was a dichotomous variable. Respondents were considered as having diabetes if they had ever been told by a doctor or other health professional that they had diabetes.[13,14] BMI was classified into three categories: normal weight (BMI < 25), overweight (25≥BMI < 30), and obesity (BMI ≥ 30). Leisure time physical activity, measured by the number of times per week of vigorous, moderate, or light activities of specific duration, consisted of three categories: inactive, engaged in some activity, and regular activity.[13,14] Physical inactivity included adults who did not engage in any sessions of light or moderate (causing light sweating or a slight to moderate increase in breathing or heart rate) or vigorous (causing heavy sweating or a large increase in breathing or heart rate) leisure-time physical activity of at least 10 min duration or were unable to perform leisure-time physical activity. Regular physical activity included adults who engaged in at least three sessions per week of vigorous leisure-time physical activity lasting at least 20 min in duration or at least five sessions per week of light or moderate leisure-time physical activity lasting at least 30 min in duration.[1,13,14] All other covariates were measured as shown in Table 1.

Table 1: Descriptive characteristics for African Americans/Blacks Aged 18+ with and without severe CKD: The US National Health Interview Survey, 2012–2018 (N=29,590).
Covariates Total Sample CKD (n=946) Without CKD (n=28,644)
Weighted % SE Weighted % SE Weighted % SE
Age (years)
  18–34 34.96 0.47 5.59 1.10 35.70 0.47
  35–44 17.26 0.33 5.52 0.92 17.56 0.34
  45–54 17.90 0.33 15.53 1.66 17.93 0.33
  55–64 15.74 0.27 27.07 2.01 15.45 0.27
  65+ 14.14 0.28 45.29 2.04 13.35 0.28
Gender
  Male 45.16 0.42 46.53 2.12 45.13 0.43
  Female 54.84 0.42 53.47 2.12 54.87 0.43
Nativity/immigrant status
  US-born 87.03 0.48 94.79 1.25 86.83 0.48
  Foreign-born 12.97 0.98 5.21 1.25 13.17 0.48
Marital status
  Married 40.51 0.43 36.88 2.19 40.60 0.44
  Widowed 6.10 0.17 18.08 1.49 5.80 0.17
  Divorced/separated 15.48 0.27 21.28 1.57 15.33 0.27
  Single 37.92 0.44 23.76 1.84 38.27 0.44
Geographic region
  Northeast 16.13 0.68 12.64 1.59 16.22 0.68
  Midwest 16.82 0.68 17.32 1.79 16.81 0.68
  South 58.66 1.13 62.26 2.37 58.57 1.13
  West 8.39 0.39 7.78 1.39 8.41 0.39
Education (years of school completed)
  0–8 2.74 0.12 8.81 1.15 2.59 0.12
  9–11 12.19 0.30 18.20 1.61 12.04 0.30
  12 29.74 0.41 33.80 2.22 29.64 0.42
  13–15 33.81 0.44 27.92 1.89 33.96 0.45
  16+ 21.52 0.47 11.27 1.52 21.77 0.48
Poverty status (ratio of family income to poverty threshold)
  <100% 21.20 0.44 29.87 1.91 20.99 0.44
  100–199% 21.48 0.39 27.47 1.91 21.33 0.39
  200–299% 16.50 0.31 15.28 1.69 16.53 0.31
  300–399% 9.52 0.26 5.98 0.93 9.61 0.27
  ≥400% 22.38 0.56 11.37 1.41 22.66 0.57
  Unknown 8.91 0.28 10.04 1.38 8.89 0.28
Occupation
  Professional/managerial 19.83 0.41 15.37 1.68 19.95 0.41
  Sales/clerical/technical support 29.99 0.37 22.63 1.69 30.17 0.37
  Service 19.25 0.33 24.34 1.75 19.12 0.34
  Craft and repair 12.25 0.33 17.99 1.69 12.11 0.33
  Laborers 8.50 0.23 9.93 1.35 8.46 0.23
  All other occupations 2.91 0.14 1.93 0.46 2.93 0.15
  Unemployed/not in labor force 7.28 0.26 7.81 1.29 7.26 0.27
Hypertension
  Yes 37.72 0.45 87.12 1.64 36.48 0.44
  No 62.28 0.45 12.88 1.64 63.52 0.44
Diabetes
  Yes 12.17 0.25 48.59 2.07 11.26 0.24
  No 87.83 0.25 51.41 2.07 88.74 0.24
Leisure-time physical activity
  Inactive 36.72 0.51 61.86 2.11 36.08 0.51
  Engaged in some activity 29.86 0.46 21.66 1.83 30.07 0.46
  Regular activity 33.42 0.44 16.48 1.57 33.85 0.44
BMI/weight status
  Normal weight (BMI <25) 28.59 0.40 25.04 2.00 28.68 0.41
  Overweight (25 ≤BMI <30) 32.33 0.39 27.86 1.82 32.44 0.40
  Obese (BMI ≥30) 39.08 0.44 47.10 2.25 38.88 0.45

SE: Standard error, CKD: Chronic kidney disease , BMI: Body mass index, Chi-square statistics for testing the compositional differences between Black adults with and without CKD were statistically significant at P<0.01, except for gender (p=0.52) and region (p=0.09)

Statistical Methods

We used multivariate logistic regression to examine the association between kidney disease prevalence and selected sociodemographic and behavioral characteristics among Black Americans. We used the Chi-square (χ2) statistic to test for compositional differences between Black adults with and without CKD and differences in kidney disease prevalence by education or income/poverty level. We applied t-tests to test for race-specific differences in socioeconomic gradients over time. To account for the complex sample design of the NHIS, we used SUDAAN software to conduct all statistical analyses, including the logistic modeling procedure RLOGIST.[19]

RESULTS

Descriptive Characteristics of the Pooled Sample

For the large 2012–2018 pooled sample, approximately 35.0% of the Black sample consisted of individuals aged 18–34, and 14.1% of the sample were adults aged ≥65 years [Table 1]. Age-compositional differences differed substantially among Black adults with and without CKD. Only 5.6% of the adults with CKD were aged 18–34, compared with 35.7% of those without CKD. Approximately 45.3% of Black adults with CKD were aged ≥65 years, compared with 13.4% of those without CKD. Compared to adults without CKD, those with CKD were more likely to be US-born, widowed/divorced/separated, Southern residents, had lower educational attainment and income, higher likelihood of being employed in blue-collar occupations, and higher prevalence of hypertension, diabetes, physical inactivity, and obesity.

Disparities in CKD Prevalence and Odds by Socioeconomic, Demographic, and Behavioral Risk Factors

Disparities presented here refer to the large 2012–2018 pooled sample containing detailed information on race, ethnicity, SES, and behavioral and health status covariates. In 2018, 6.0 million adults aged ≥18, including 0.9 million Black adults, reported being diagnosed with severe kidney disease – an increase of 2.1 million total kidney disease patients and 269,538 Black kidney disease patients since 2012. During 2012–2018, the prevalence of severe kidney disease was 2.4% for the Black population aged ≥18 years, compared with 1.8% for non-Hispanic Whites, 3.5% for AIANs, 1.1% for APIs, and 1.7% for Hispanics. Even after controlling for socioeconomic and demographic factors, Blacks had 19% higher odds (odds ratio [OR] = 1.19; 95% confidence interval [CI] = 1.07–1.32) of kidney disease than non-Hispanic Whites and 47% higher odds than APIs (OR = 1.47; 95% CI = 1.32–1.66) [data not shown].

Education, income, occupation, nativity/immigrant status, physical inactivity, BMI, hypertension, and diabetes were strong predictors of kidney disease in Black Americans [Table 2]. The unadjusted prevalence of CKD for Black adults with <9 years of education was 7.9%, 6.2 times higher than that for Black adults with a college degree (≥16 years of education). Consistent income gradients in kidney disease prevalence were found. Black adults with incomes below the poverty level had 2.8 times higher prevalence than those with incomes at ≥400% of the poverty level (3.5% vs. 1.3%). Blacks employed in service, craft/repair, and manual labor occupations had 51 to 89% higher prevalence of CKD than those in professional and managerial occupations. Black immigrants had a CKD prevalence of 1.0%, 63% lower than the prevalence of 2.7% for US-born Blacks. Black adults with hypertension, diabetes, physical inactivity, and obesity had, respectively, 11.1-, 6.8-, 3.4-, and 1.4-times higher prevalence of CKD than those without these behavioral risk factors [Table 2].

Table 2: Unadjusted and covariate-adjusted prevalence and odds of severe kidney disease among African Americans/Blacks Aged ≥18 by socioeconomic, demographic, and behavioral characteristics: The US National Health Interview Survey, 2012–2018 (n=29,590).
Covariates Unadjusted Model 11 Model 22 Model 33 Adjusted3
Prevalence SE OR 95% CI AOR 95% CI AOR 95% CI Prevalence SE
Age (years)
  18–34 0.39 0.08 1.00 Reference 1.00 Reference 1.00 Reference 0.75 0.16
  35–44 0.78 0.13 2.01 1.20 3.36 2.53 1.51 4.21 1.53 0.89 2.63 1.13 0.20
  45–54 2.26 0.25 5.89 3.73 9.30 7.56 4.73 12.10 3.05 1.83 5.08 2.19 0.25
  55–64 4.22 0.36 11.19 7.19 17.42 13.63 8.73 21.27 3.97 2.42 6.51 2.80 0.24
  65+ 7.85 0.44 21.67 14.35 32.71 25.45 16.38 39.54 6.17 3.73 10.20 4.18 0.33
Gender
  Male 2.52 0.16 1.06 0.89 1.26 1.32 1.09 1.59 1.48 1.23 1.80 3.00 0.19
  Female 2.39 0.14 1.00 Reference 1.00 Reference 1.00 Reference 2.11 0.12
Nativity/immigrant status
  US-born 2.67 0.11 1.00 Reference 1.00 Reference 1.00 Reference 1.42 0.32
  Foreign-born 0.98 0.24 0.36 0.22 0.58 0.44 0.28 0.71 0.53 0.33 0.84 2.55 0.11
Marital status
  Married 2.23 0.18 1.00 Reference 1.00 Reference 1.00 Reference 2.29 0.19
  Widowed 7.26 0.61 3.43 2.69 4.38 1.11 0.84 1.47 1.12 0.83 1.5 2.53 0.25
  Divorced/separated 3.37 0.27 1.53 1.22 1.91 0.99 0.79 1.25 1.02 0.80 1.29 2.32 0.18
  Single 1.54 0.14 0.68 0.54 0.87 1.21 0.93 1.57 1.26 0.97 1.66 2.83 0.25
Geographic region
  Northeast 1.92 0.24 1.00 Reference 1.00 Reference 1.00 Reference 2.35 0.27
  Midwest 2.52 0.25 1.32 0.96 1.82 1.12 0.82 1.53 1.07 0.77 1.46 2.49 0.24
  South 2.60 0.14 1.36 1.04 1.79 1.11 0.85 1.44 1.05 0.80 1.37 2.45 0.13
  West 2.27 0.42 1.19 0.76 1.86 1.07 0.68 1.69 1.10 0.69 1.76 2.56 0.46
Education (years of school completed)
  0–8 7.88 1.02 6.57 4.43 9.76 1.71 1.05 2.79 1.40 0.84 2.31 2.91 0.42
  9–11 3.66 0.34 2.92 2.07 4.11 1.29 0.85 1.95 1.05 0.68 1.61 2.25 0.22
  12 2.79 0.22 2.20 1.60 3.04 1.41 0.97 2.06 1.21 0.83 1.78 2.56 0.20
  13–15 2.02 0.15 1.59 1.14 2.20 1.34 0.93 1.91 1.19 0.83 1.71 2.52 0.19
  16+ 1.28 0.18 1.00 Reference 1.00 Reference 1.00 Reference 2.15 0.34
Poverty status (ratio of family income to poverty threshold)
  <100% 3.45 0.25 2.84 2.07 3.88 3.02 2.05 4.47 2.39 1.61 3.57 3.35 0.30
  100–199% 3.13 0.24 2.57 1.89 3.49 2.21 1.57 3.12 1.86 1.32 2.63 2.68 0.21
  200–299% 2.27 0.27 1.84 1.28 2.65 1.78 1.21 2.6 1.59 1.09 2.34 2.32 0.27
  300–399% 1.54 0.25 1.24 0.82 1.88 1.27 0.83 1.93 1.19 0.77 1.82 1.77 0.28
  ≥400% 1.25 0.17 1.00 Reference 1.00 Reference 1.00 Reference 1.51 0.22
  Unknown 2.76 0.39 2.25 1.53 3.31 1.82 1.22 2.72 1.70 1.14 2.55 2.47 0.33
Occupation
  Professional/managerial 1.90 0.22 1.00 Reference 1.00 Reference 1.00 Reference 2.79 0.36
  Sales/clerical/technical support 1.85 0.16 0.97 0.73 1.3 0.86 0.62 1.20 0.82 0.58 1.16 2.34 0.21
  Service 3.10 0.25 1.65 1.25 2.19 0.99 0.70 1.41 0.94 0.66 1.36 2.65 0.22
  Craft and repair 3.60 0.37 1.93 1.41 2.64 0.87 0.60 1.25 0.80 0.55 1.17 2.29 0.24
  Laborers 2.86 0.41 1.52 1.05 2.21 0.91 0.61 1.36 0.78 0.51 1.19 2.23 0.31
  All other occupations 1.62 0.41 0.85 0.49 1.48 0.54 0.31 0.97 0.54 0.30 0.97 1.59 0.38
  Unemployed/not in labor force 2.63 0.45 1.39 0.92 2.11 1.10 0.68 1.79 0.96 0.58 1.59 2.68 0.46
Hypertension
  Yes 5.66 0.25 11.78 8.85 15.67 4.42 3.12 6.25 3.47 0.20
  No 0.51 0.07 1.00 Reference 1.00 Reference 0.85 0.13
Diabetes
  Yes 9.78 0.54 7.45 6.29 8.84 2.86 2.38 3.43 4.50 0.28
  No 1.43 0.09 1.00 Reference 1.00 Reference 1.72 0.10
Leisure-time physical activity
  Inactive 4.19 0.22 3.52 2.80 4.43 1.85 1.45 2.35 3.15 0.17
  Engaged in some activity 1.81 0.17 1.48 1.12 1.96 1.07 0.80 1.41 1.91 0.18
  Regular activity 1.23 0.13 1.00 Reference 1.00 Reference 1.80 0.18
BMI/weight status
  Normal weight
(BMI <25)
2.17 0.20 1.00 Reference 1.00 Reference 3.13 0.28
  Overweight
(25 ≤BMI <30)
2.14 0.16 0.98 0.78 1.25 0.69 0.54 0.88 2.24 0.17
  Obese (BMI ≥30) 2.99 0.19 1.39 1.10 1.75 0.72 0.57 0.92 2.34 0.15

SE: Standard error, OR: Odds ratio, CI: Confidence interval, BMI: Body mass index. 1Unadjusted for the effects of other covariates. 2This logistic regression model includes survey year, age, gender, nativity, marital status, region of residence, education, poverty status, and occupation as covariates. 3This logistic model includes all covariates of Model 2 plus hypertension, diabetes, physical activity, and BMI. Chi-square statistics for testing the overall association between each covariate and kidney disease prevalence were statistically significant at p<0.01 except for gender (p=0.52) and region (p=0.09)

In the fully adjusted Model 3 that controlled for various socioeconomic, demographic, and behavioral risk factors, disparities in prevalence and odds of CKD were substantially reduced, compared with unadjusted Model 1 and SES-adjusted Model 2. However, Black immigrants had 53% lower adjusted odds of kidney disease than US-born Black. Blacks with incomes below the poverty level had 2.4 times higher adjusted odds of having CKD than Blacks with incomes at ≥400% of the poverty level. Physical inactivity, diabetes, and hypertension were associated with 1.9, 2.9, and 4.4 times higher adjusted odds of CKD among Black adults, respectively, controlling for other factors [Table 2].

Trends in SES Inequalities in Kidney Disease and Interaction Effects by Race, SES, and Age

Educational and income inequalities in kidney disease prevalence were substantial and consistent for the total population, Blacks, non-Hispanic Whites, and APIs in 1997– 2000, 2012–2018, and 2020–2021, with educational and income gradients persisting over time [Figure 1 and Table 3]. During these time periods between 1997 and 2021, Blacks, non-Hispanic Whites, APIs, and the total US population with <12 years of education had 3–5 times higher risk of kidney disease than their counterparts with a college degree [Figure 1]. The prevalence of severe CKD increased significantly over time, particularly between 2012–2018 and 2020–2021, among Blacks and for the total US population at each education and income level. For example, the prevalence of severe CKD among Blacks with <12 years of education increased from 4.2% in 1997–2000 to 4.4% in 2012–2018 and 6.4% in 2020–2021. The prevalence of severe CKD among Blacks with incomes below the poverty level increased from 3.4% in 1997–2000 to 3.5% in 2012–2018 and 6.4% in 2020– 2021 [Figure 1].

(a-f) Prevalence (%) of severe kidney disease by race/ethnicity, education, and income/poverty level, United States, 1997–2000, 2012–2018, and 2020–2021. (a) Educational inequalities, 1997–2000, (b) Educational inequalities, 2012–2018, (c) Educational inequalities, 2020–2021, (d) Income/poverty level inequalities, 1997–2000, (e) Income/poverty level inequalities, 2012–2018, (f) Income/poverty level inequalities, 2020–2021 Source: Data derived from the 1997 to 2000, 2012 to 2018, and 2020 to 2021 NHIS. Notes: Chi-square statistics for testing the overall association between education and severe kidney disease prevalence were statistically significant at p < 0.01 for all groups except for American Indians/Alaska Natives in 2012–2018 (p = 0.20). The association between income/poverty level and kidney severe disease prevalence was statistically significant at p < 0.01 for all groups except for American Indians/Alaska Natives (p = 0.02) and Asian/Pacific Islanders (p = 0.38) in 1997–2000 and for American Indians/Alaska Natives (p = 0.09) in 2012–2018. Kidney disease prevalence estimates for American Indians/Alaska Natives were shown for <12 and ≥12 years of education and for <100% and ≥100% of poverty level in 1997–2000 and for <100%, 100-199%, and ≥200% of poverty level in 2012–2018. Kidney disease prevalence estimates for Asian/Pacific Islanders were shown for <200% and ≥200% of the poverty level in 1997–2000.
Figure 1:
(a-f) Prevalence (%) of severe kidney disease by race/ethnicity, education, and income/poverty level, United States, 1997–2000, 2012–2018, and 2020–2021. (a) Educational inequalities, 1997–2000, (b) Educational inequalities, 2012–2018, (c) Educational inequalities, 2020–2021, (d) Income/poverty level inequalities, 1997–2000, (e) Income/poverty level inequalities, 2012–2018, (f) Income/poverty level inequalities, 2020–2021 Source: Data derived from the 1997 to 2000, 2012 to 2018, and 2020 to 2021 NHIS. Notes: Chi-square statistics for testing the overall association between education and severe kidney disease prevalence were statistically significant at p < 0.01 for all groups except for American Indians/Alaska Natives in 2012–2018 (p = 0.20). The association between income/poverty level and kidney severe disease prevalence was statistically significant at p < 0.01 for all groups except for American Indians/Alaska Natives (p = 0.02) and Asian/Pacific Islanders (p = 0.38) in 1997–2000 and for American Indians/Alaska Natives (p = 0.09) in 2012–2018. Kidney disease prevalence estimates for American Indians/Alaska Natives were shown for <12 and ≥12 years of education and for <100% and ≥100% of poverty level in 1997–2000 and for <100%, 100-199%, and ≥200% of poverty level in 2012–2018. Kidney disease prevalence estimates for Asian/Pacific Islanders were shown for <200% and ≥200% of the poverty level in 1997–2000.
Table 3: Socioeconomic gradients in severe kidney disease prevalence by race/ethnicity, 1997–2000, 2012–2018, and 2020–2021 US National Health Interview Survey.
Covariates 1997–2000 2012–2018 2020–2021
Logistic coefficient (β) SE OR Prevalence (%) Logistic coefficient (β) SE OR 95% CI Logistic coefficient (β) SE OR Prevalence (%)
Education (ordinal scale from low to high)
  All races −0.53 0.03 0.59 0.55 0.62 −0.35 0.02 0.71 0.68 0.73 −0.34 0.03 0.71 0.67 0.75
  Non-Hispanic White −0.54 0.04 0.58 0.54 0.62 −0.41 0.02 0.66 0.63 0.69 −0.37 0.04 0.69 0.64 0.74
  Non-Hispanic Black −0.63 0.08 0.54 0.46 0.63 −0.41 0.04 0.66 0.61 0.72 −0.32 0.08 0.73 0.62 0.86
  American Indian/Alaska Native −1.25 0.43 0.29 0.12 0.67 −0.21 0.14 0.81 0.62 1.07 −0.54 0.24 0.58 0.36 0.94
  Asian/Pacific Islander −0.58 0.17 0.56 0.40 0.78 −0.38 0.09 0.68 0.58 0.81 −0.30 0.15 0.74 0.55 0.99
  Hispanic −0.30 0.07 0.74 0.64 0.86 −0.17 0.06 0.84 0.75 0.95 −0.41 0.10 0.66 0.54 0.81
Income/poverty level (ordinal scale from low to high income)
  All races −0.40 0.02 0.67 0.64 0.69 −0.27 0.01 0.75 0.74 0.78 −0.29 0.02 0.75 0.72 0.78
  Non-Hispanic White −0.44 0.03 0.65 0.61 0.68 −0.29 0.02 0.75 0.72 0.77 −0.31 0.03 0.73 0.70 0.77
  Non-Hispanic Black −0.38 0.06 0.69 0.61 0.77 −0.27 0.03 0.77 0.72 0.82 −0.35 0.06 0.70 0.62 0.79
  American Indian/Alaska Native −1.25 0.52 0.29 0.10 0.79 −0.21 0.11 0.81 0.65 1.02 −0.41 0.24 0.66 0.41 1.05
  Asian/Pacific Islander −0.35 0.40 0.70 0.32 1.54 −0.37 0.07 0.69 0.60 0.79 −0.26 0.13 0.77 0.60 0.99
  Hispanic −0.27 0.07 0.76 0.66 0.88 −0.25 0.04 0.78 0.72 0.85 −0.27 0.07 0.77 0.67 0.87

SE: Standard error, OR: Odds ratio; CI: Confidence interval. Logistic coefficients and odds ratios were estimated by logistic regression model of kidney disease as a function of either education or income/poverty level

To examine possible differential effects of each covariate on kidney disease by age,[10,20] we conducted a sensitivity analysis and estimated various interaction models of age (18–64, ≥65) with other covariates, for example, age*diabetes and age*hypertension. None of the interactions, except for hypertension and diabetes, were statistically significant, and the socioeconomic, demographic, and behavioral patterns in kidney disease prevalence and odds were generally similar for adults aged 18–64 and those aged ≥65 (data not shown). For statistically significant interaction terms, age*hypertension and age*diabetes, we separately estimated the odds of having CKD by hypertension or diabetes after restricting the sample by age group (18-64 vs. 65+). Black adults aged 18–64 with hypertension had 11.9 times higher unadjusted odds (OR = 11.87; 95% CI = 8.51–16.55) of CKD and 5.4 times higher adjusted odds (OR = 5.40; 95% CI = 3.47–8.18) of CKD than their counterparts without hypertension. Black adults aged ≥65 with hypertension had 3.2 times higher unadjusted odds (OR = 3.17; 95% CI = 1.86–5.39) of CKD and 2.8 times higher adjusted odds (OR = 2.78; 95% CI = 1.66–4.66) of CKD than their counterparts without hypertension.

Black adults aged 18–64 with diabetes had 8.7 times higher unadjusted odds (OR = 8.66; 95% CI = 6.77–11.07) of CKD and 3.2 times higher adjusted odds (OR = 3.15; 95% CI = 2.40–4.12) of CKD than their counterparts without diabetes. Black adults aged ≥65 with diabetes had 2.8 times higher unadjusted odds (OR = 2.81; 95% CI = 2.19–3.61) of CKD and 2.6 times higher adjusted odds (OR = 2.57; 95% CI = 1.98–3.34) of CKD than their counterparts without diabetes.

DISCUSSION

We found that SES and health-risk factors are independent, powerful predictors of severe kidney disease among Black Americans, who saw a marked increase in disease prevalence between 1997 and 2021, along with other major racial/ethnic groups. Between 2012 and 2021, there was an increase of 3.3 million total patients and 303,059 Black patients with severe kidney disease. Blacks with incomes below the poverty level, physical inactivity, diabetes, and hypertension had higher adjusted odds of CKD, compared with each counterfactual. Socioeconomic influences, including education and poverty effects, on kidney disease were greater for Blacks than for non-Hispanic Whites.

Our findings are consistent with previous studies that Black adults with low SES had a higher prevalence of CKD than those with high SES in the US. Bruce et al. found that the odds of having CKD were 41% higher for African Americans aged 35–84 years with low income (<100% poverty level), compared to those with high income (>350% poverty level) after adjusting for demographic characteristics, healthcare access, and health status including CVD, hypertension, diabetes, and BMI.[8] Crews et al. also found a 91% higher CKD prevalence for African Americans aged 30–64 years with low income (<125% poverty level) than those with higher income (>125% poverty level) after adjusting for demographic characteristics, education, health insurance, comorbidities, tobacco, and drug use.[9] Shoham et al. found that working-class Black adults had 40–80% higher CKD prevalence compared to non-working-class adults, with higher SES impacts on CKD among the younger than the older age groups.[10] However, White et al., using the third National Health and Nutrition Examination Survey III data among adults aged 35 years and older, did not find an association between CKD prevalence and education or income. However, they did find a significant association for employment status in the full model.[12] These mixed findings might have been due to differences in the use of model covariates, measures of SES, and age groups.

Our study has provided evidence of a strong association between sociodemographic characteristics and CKD, but it does not quite explain the pathways through which socioeconomic risk factors influence CKD. Individuals’ race/ethnicity, sex, and SES could affect their social environments such as economic deprivation, poor residential conditions, discrimination through structural racism, and psychological and behavioral factors, healthcare access, as well as more proximate risk factors such as hypertension, diabetes, and obesity, resulting in poor CKD-related health outcomes.[7,20,21] Given higher levels of area deprivation[22] and residential segregation[23] among African-Americans, future studies need to estimate the contextual effects of area socioeconomic measures on CKD.[10,24] Policies aimed at prevention, management, and treatment of kidney disease need to monitor the socioeconomically disadvantaged segments of the Black population. Blacks are disproportionately affected by acute and chronic kidney disease, resulting in end-stage organ disease or requiring organ transplantation. For example, Blacks comprised 29% of those on the waiting list for kidney transplants in 2019.[25] Such future studies would shed light on addressing underrepresented racial/ethnic populations requiring organ transplantation by emphasizing fundamental risk factors of CKD among African Americans.

Limitations of the study

NHIS is a cross-sectional survey; causality cannot be inferred, especially for SES and health-risk factors, and CKD. However, education and racial/ethnic disparities in CKD are less likely to be affected by reverse causality as formal education is generally attained by age 25 by most individuals and is stable over the life course, and CKD is more likely to develop at more advanced ages. Second, our measure of CKD is based on self-report and likely captures stages 3 and 4 of the disease. The self-reported CKD has been shown to be substantially underestimated when compared with clinical measures of CKD, especially among older patients, males, those at early stages of the disease, and those with less access to and use of health services.[18] Third, NHIS does not collect data on CKD by stage. As a result, we were not able to estimate overall or stage-specific CKD prevalence for Black, other racial/ethnic, and sociodemographic groups. Such information is important to understand the overall kidney disease burden, risk factors, disease progression, and to design better public health interventions, including treatment programs.[5]

CONCLUSION AND IMPLICATIONS FOR TRANSLATION

Kidney disease is a significant public health problem in the US, particularly among Black Americans and other racial and ethnic minorities. Nearly 37 million or 14% of US adults have the disease, with Medicare expenditures for CKD patients exceeding $130 billion annually.[5,6,17] SES and health-risk factors are independent, powerful predictors of severe kidney disease among Black Americans. Socioeconomic influences on kidney disease are greater for Blacks than for non-Hispanic Whites. Policies aimed at prevention, management, and treatment of kidney disease need to monitor the socioeconomically disadvantaged segments of the Black population. Reducing the prevalence of CKD and improving access to quality health care, especially kidney disease care, among Black Americans and other racial/ethnic minorities will have a substantial impact on reducing mortality from kidney disease and resultant health disparities in the US.[6,17]

Key Messages

1) During 2012–2018, the prevalence of severe kidney disease (weak and failing kidneys) in the US was 2.4% for the Black population aged ≥18 years, compared with 1.8% for non-Hispanic Whites, 3.5% for AIANs, 1.1% for APIs, and 1.7% for Hispanics. 2) In 2021, 7.2 million US adults aged ≥18, including 0.98 million Black adults, reported being diagnosed with severe kidney disease – an increase of 3.3 million total patients and 303,059 Black patients with severe kidney disease since 2012. 3) Education, income, occupation, nativity/immigrant status, physical inactivity, BMI, hypertension, and diabetes were strong predictors of kidney disease in US Blacks. 4) Controlling for other risk factors, US Blacks aged 18–64 with diabetes and hypertension experienced 3.2- and 5.4-times increased risk of CKD, respectively. 5) Policies aimed at prevention, management, and treatment of kidney disease in the United States need to monitor the socioeconomically disadvantaged segments of the Black population.

Acknowledgments

None.

COMPLIANCE WITH ETHICAL STANDARDS

Conflicts of Interest: The authors declare no competing interests. Financial Disclosure: Nothing to declare. Funding/Support: There was no funding for this study. Ethics Approval: Institutional Review Board approval was not required for this study, as it is based on the secondary analysis of a public-use federal database. Declaration of Patient Consent: Patient’s consent is not required, as there are no patients in this study. Use of Artificial Intelligence (AI)-Assisted Technology for Manuscript Preparation: The authors confirm that there was no use of Artificial Intelligence (AI)-Assisted Technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI. Disclaimer: The views expressed are the authors’ and not necessarily those of their institutions.

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