key: cord-355001-audh5qa7
authors: Novick, Tessa K.; Rizzolo, Katherine; Cervantes, Lilia
title: COVID-19 and Kidney Disease Disparities in the United States
date: 2020-06-23
journal: Adv Chronic Kidney Dis
DOI: 10.1053/j.ackd.2020.06.005
sha: 
doc_id: 355001
cord_uid: audh5qa7

Abstract Racial, ethnic, socioeconomic, age, and sex-related health disparities in kidney disease are prominent in the United States. The Coronavirus Disease 2019 (COVID-19) pandemic has disproportionately affected marginalized populations. Older adults, people experiencing unstable housing, racial and ethnic minorities and immigrants are potentially at increased risk for infection and severe complications from COVID-19. The direct and societal effects of the pandemic may increase risk of incident kidney disease and lead to worse outcomes for those with kidney disease. The rapid transition to telemedicine potentially limits access to care for older adults, immigrants, and people experiencing unstable housing. The economic impact of the pandemic has had a disproportionate effect on women, minorities and immigrants, which may limit their ability to manage kidney disease, and lead to complications or kidney disease progression. We describe the impact of COVID-19 on marginalized populations and highlight how the pandemic may exacerbate existing disparities in kidney disease.

Racial and ethnic minorities experience a disproportionate and complex burden of medical, mental health, and social needs. The Coronavirus Disease 2019 (COVID-19) pandemic has exacerbated a particularly critical one-disparities in marginalized patients with kidney disease. Latinx, Blacks, and Native Americans/Pacific Islanders already make up nearly 50% of the population with kidney failure and compared to non-Latino whites, these same groups are also more heavily impacted with COVID-19. Further, many with COVID-19 develop multiorgan failure, including kidney failure, and subsequently require kidney replacement therapy. In the context of the viral pandemic, here we describe many disparities and additional struggles of patient populations with kidney disease, including those faced by the aging and homeless, and among racial and ethnic minorities, immigrants, and refugees. The impacts from COVID-19 on these populations as well as recommendations are summarized in Table 1 .

Older adults have been disproportionately affected by COVID-19, with greater risk for infection, 1,2 severe complications, 3 and death. 4, 5 Among 393 patients with COVID-19 in New York City, the median age was 62 years, and older, compared with younger patients, were more likely to require invasive mechanical ventilation, kidney replacement therapy, and die. 6 This pattern is consistent worldwide. For example, among 1591patients with COVID-19 admitted to intensive care units in Italy, the median age was 63 years, and older versus younger patients experienced more severe acute respiratory distress syndrome and higher mortality (36% versus 15%). 3 Drivers of the variability in infection risk and severity with age are poorly understood and likely multifactorial. Older adults are more likely to have underlying medical conditions like chronic kidney disease, which have been associated with COVID-19 infection and

complications. An estimated 44% of adults over age 70 have chronic kidney disease, compared to 9.2% of adults aged 40-59 years. 7 Among 701 hospitalized patients with COVID-19 in Wuhan, older adults were more likely to have elevated creatinine on presentation, which was associated with 3 times higher risk for in-hospital death. 8 The relationship between age, immune response to SARS-CoV-2 infection, and chronic diseases remains poorly understood. 9 The physical environment and limitations in the ability to self-isolate may also impact COVID-19 risks for older adults. Many older adults live in long-term care facilities, which are high-risk settings for COVID-19 outbreaks. A confirmed COVID-19 case was identified on February 28, 2020 at a skilled nursing facility in King County, Washington. 10 10 Even if older adults live alone, many rely on visiting caregivers. Many older adults cannot drive and rely on public transportation, which was theorized to be a primary driver in COVID-19 propagation early in the pandemic. 11 The impact of COVID-19 on frailty and depression among older adults with kidney disease has not been studied. However, shelter-in-place rules have forced older adults to stay inside and remain inactive, and higher levels of inactivity exacerbate frailty and depression.

Frailty has been associated with increased risk of hospitalization and mortality among people with chronic kidney disease 12 and kidney failure, 13 and allograft loss among transplant recipients. 14 A survey of older adults with cognitive impairment found that individuals who live alone were more likely to experience negative feelings. 15 Depression may have long-term effects on medication adherence and treatment engagement, and in people with kidney disease has been associated with lower quality of life 16 and higher mortality. 14 While nephrology practices are using telemedicine to limit SARS-CoV-2 transmission in clinical settings, older adults may also not have access to required technology for videoconferencing. Further, hearing loss and low health-literacy may compound the already poor communication during telephone visits, or might lead to skipped visits altogether due to the elderly being unable to participate. However, the impact of telemedicine on older adults with kidney disease has not been studied, and research is needed to understand how to effectively deliver telemedicine to this population.

The impact of COVID-19 is especially prominent among unstably housed populations.

Living in shelters and frequent moves makes social distancing impossible, and limits the ability to comply with hand washing and other hygiene measures to prevent infection. 17, 18 SARS-CoV-2 transmission in shelters has led to clusters of COVID-19 in large cities. 19 People experiencing homelessness are more likely to have chronic medical conditions than the general population, and if infected, are at increased risk for severe complications. 20 Mortality among unsheltered homeless adults is 10 times higher than the general population, and whether COVID-19 will inflate relative risks over time is unknown. 20 Having kidney disease may intensify risk for COVID-19 infection for people experiencing unstable housing. A study in San Francisco found that chronic kidney disease patients experiencing homelessness have higher acute care utilization than stably housed counterparts, and greater exposure to hospitals increases COVID-19 exposure. 21 In Boston, 146

out of 397 asymptomatic people tested at a homeless shelter were positive for COVID-19, indicating high rates of asymptomatic transmission. 22 Similarly, homeless dialysis patients might have increased risk for exposure and infection due to inability to attend dialysis and increased reliance on emergency departments for treatment. 23, 24 How the COVID-19 pandemic will impact kidney disease outcomes for patients experiencing unstable housing is unknown. Prior to the COVID-19 pandemic, a study in Baltimore found that chronic kidney disease patients experiencing housing insecurity were 59% more likely to post-pone needed medical care. 25 This population may not be able to participate in needed telemedicine visits due to lack of required technology, and be even more likely to postpone needed treatment during COVID-19 than before. Untreated chronic kidney disease and comorbidities may lead to progression, and ultimately exacerbate existing socioeconomic disparities in kidney failure. 26, 27 Sex Differences Clinical and socioeconomic gender-specific consequences of COVID-19 will be likely to have ripple effects across the kidney failure community. Though the prevalence of chronic kidney disease is more common in women, men have higher rates of kidney failure progression and mortality. 28 Early COVID-19 data shows a similar trend: in New York City, 42.9 men per 100,000 have died, compared with 23.1 per 100,000 women, with almost twice the number of hospitalizations among men compared with women with 29 similar trends observed in China and Italy. 30 31 A recent meta-analysis of 29 reports representing 206,128 cases demonstrated no differences in cases between men and women, but did show an increase in intensive treatment and mortality in men compared with women 32 . Though the etiology explaining this difference still remained unclear, differences in immune response may play a role. Male patients with kidney failure are thus at a unique disadvantage given increased risk of morbidity and mortality both from kidney failure and COVID-19. Further research will be needed to demonstrate sex as a determinant of adverse sequelae from COVID-19.

Conversely, the socioeconomic effects of the COVID-19 pandemic will have a inequitable effect on women. One in three jobs held by women are essential, with the highest proportion in the healthcare industry. As such, women account for 73% of US health care worker COVID-19

infections. 33 The employment losses related to social distancing are in predominantly female employment sectors, 34 in addition to the pressing need of child care at home largely falling to women. 35 Incidence of domestic abuse cases may rise, as additional time at home means more time around an abusive partner. Further, complications with pregnancy, or unintended pregnancy, may be a consequence of restricted access to care. 36 Women with chronic kidney disease are more likely to belong to a racial or ethnic minority group, be a single mother, and have a low income and low-level education 37 , placing this community at higher risk of exposure and economic challenges due to lost employment and childcare needs. As such, existing and future community services and social policies should continue to support women throughout the pandemic-especially those in disadvantaged and resource-poor communities.

The COVID-19 pandemic exposes the systemic interplay of race, social determinants of health, and comorbidities. The incidence of kidney failure is 3.5 times higher for Blacks, and 1.5 times greater for Latinx, with higher rates of progression to kidney failure in both communities. 38 39 The etiology for this disturbing finding is multifactorial in the setting of structural racism and individual factors, including undertreated metabolic conditions and cardiovascular disease as well as poor access to care, and socioeconomic factors such as living conditions, education, and health literacy. 40 Notably, these same factors are exposed in the COVID-19 pandemic. Though data collection by race and ethnicity on the COVID-19 pandemic is sparse and incomplete, limited data shows Black, Latinx, and Native Americans make up a disproportionate number of COVID-19 related deaths and cases across the United States. 41,42 43 In New York City, the age adjusted mortality rate from COVID-19 for Blacks is double that of white and Asian residents, and age adjusted case rate is highest in the Latinx and Black community. 44 Among the Navajo nation, the infection rate has surpassed the state of New York. 45 Health disparities are primarily driven by structural racism, defined as "the ways in which historical and contemporary racial inequities in outcomes are perpetuated by social, economic, and political systems, including mutually reinforcing systems of health care, education, housing, employment, the media, and criminal justice." 46 Racial and ethnic minorities, for example, are more likely to live in crowded living conditions such as densely populated urban areas, and multigenerational households. They are over represented in homeless shelters and prisons, and are more likely to live in poverty. 40 Blacks make up a majority of those living in poverty in urban areas. 40 . Furthermore, racial and ethnic minorities are disproportionately essential workers: 25% of Latinx or Black workers are employed in service industry jobs, compared with 16% of whites. 47 Further, access to care may be out of reach in states that have not expanded Medicaid; it should be of no surprise these areas are associated with higher mortality and lower life expectancies. 48 In the COVID-19 era, there will likely be further evidence of racial disparities in health care access due to loss of insurance, poor quality of care, and disproportionate distribution of testing and resources. Moreover, language barriers in some minority communities limits contact tracing and preventative outreach. 49 Thus, the aggregate of kidney failure and COVID-19 in minorities portends a potentially lethal combination. In the wave of the pandemic, myriad health disparities will disproportionately affect minorities with kidney failure and therefore must be fully considered when evaluating actionable prevention strategies.

The impact of COVID-19 on immigrant populations has been profound. Undocumented immigrants are disproportionately essential workers, risking daily exposure to Many immigrants work low-wage jobs in the service and hotel industries and are among the millions in America out of work. 51 The $1 trillion economic relief package will not reach the undocumented population as they face unemployment and mounting financial resource strain. 52 Many support large families, and will have little to spend on medications, healthy food, and other health-related social needs. 52 Increasing financial resource strain increases risk for incident albuminuria and rapid kidney function decline, and the economic impact of COVID-19 alone may result in a higher prevalence of kidney disease and kidney disease progression in this population. 53 Undocumented immigrants are not eligible for the Affordable Care Act, and there are an estimated 7.1 million without health insurance. 54 Without insurance, undocumented immigrants do not have consistent access to primary care, and undiagnosed or poorly controlled chronic conditions increase their risk for severe complications from COVID-19 if infected. Without primary care undocumented immigrants do not have a place to call for guidance or testing if they experience symptoms, and many rely instead on emergency services. 52 Increased reliance on acute care increases their changes for exposure to COVID-19, and unnecessarily contributes to overwhelmed hospital systems if they could otherwise be managed at home. 52 The rapid transition to telemedicine during COVID-19 has potentially increased the number of immigrants without nephrology care, and led to suboptimal care for those connected to nephrology. Undocumented immigrants may not seek care or testing due to fear of the public charge rule and repercussions from the U.S. Immigration and Customs Enforcement Agency. This rule, which went into effect in February 2020, states that "aliens are inadmissible if they are unable to care for themselves," and discourages them from seeking assistance. 52 This population often faces fear and mistrust of the medical system, which might be worse if they cannot see the clinical staff or environment. 52, 55 For those who do seek care, the technology needed for telemedicine visits complicates clinical encounters that are already threatened by low health literacy and language barriers. Undocumented immigrants attempting to establish care might not know where to call, or if they will be understood when they call.

Additionally, providers are forced to have nuanced discussions over the phone, with translators, and without assistance from facial cues, about complex kidney management issues and dialysis planning. Pre-dialysis nephrology care is an established predictor of early mortality among incident dialysis patients. 56 There are 57.5 million Latinx in the US as of 2017, and that number is expected to double in the next twenty years. 57 The prevalence of kidney failure among Latinx populations is 2-fold higher than whites. 58 Research is needed to determine whether the lack of, or flawed, nephrology encounters during COVID-19 will exacerbate existing disparities in kidney failure among Latinx populations.

There are an estimated 5,500-8,857 uninsured immigrants with kidney failure in the U.S. 59 In most states, this population relies on hospitals for emergency-only dialysis. 59 The Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to treat anyone who enters with an emergency medical condition. These individuals do not have funding for outpatient dialysis, and EMTALA enables them to receive treatment when they present with emergency indications for dialysis. 60 Emergency-only dialysis is associated with worse morbidity 55 and mortality 61, 62 for patients, promotes burnout and emotional exhaustion for providers, 63 and is extremely costly to the medical system. 64 Individuals who receive emergency-only dialysis have high acute care utilization and spend less time in the outpatient setting than those who receive standard dialysis. In one study, patients receiving emergency-only dialysis presented to the emergency room 6 times in a 30-day period, on average. 61 This population is at increased risk for severe complications and death if they are infected with SARS-CoV-2, but they repeatedly risk exposure for themselves and their families every time they present for dialysis. Fear of exposure to COVID-19 may also promote waiting longer to present for dialysis and increase risk of out-of-hospital death. They are also unnecessarily utilizing emergency, inpatient and dialysis resources that could otherwise be used for patients with COVID-19 during a time when resources are limited.

The COVID-19 pandemic is re-exposing an underlying and long-standing set of critical weaknesses in our nation's health care system, especially relevant to the stark burdens already faced by many underserved populations. Numerous complications and struggles with kidney disease have unfortunately intensified in patient groups, and have risen to the forefront during a time of great patient need and distress. The risk for the elderly, the homeless, differences between sexes, and overwhelming threats to racial, ethnic, and underserved minorities and immigrants are compounding. All together, the broad and complex set of inter-connected disparities, both nationally and globally, will require a similarly broad and complex set of solutions. As the nation pulls together during these times of great uncertainty, it will be our continued responsibility to move the needle forward on the inequities faced by marginalized populations that have been unheeded far too long. 

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• Males have higher risk of progression of kidney failure and mortality from kidney failure • Women with CKD are more likely to be a minority, low education and low income • Higher burden of caregiving on women