Anemia of CKD: Strategies to Erase Health Disparities in the Most Vulnerable Populations

Key Takeaways

• Patients with anemia of CKD and health disparities (eg, racial differences, low health literacy, low socioeconomic status) have worse clinical and patient-level outcomes.
• Strategies for healthcare professionals to mitigate health disparities include increasing awareness of implicit bias, using interpreter services, and improving communication with all patients.
• Societal and health system changes, such as improving access to care and the number of insured patients, are imperative to erase health disparities.

Chronic kidney disease (CKD) is a condition that disproportionately affects racial and ethnic minoritized groups. In early-stage CKD, the prevalence is roughly equal among racial and ethnic minority populations when compared to White patients. In later-stage CKD, including end-stage kidney disease (ESKD), racial and ethnic minoritized groups have a prevalence that is 1.3-4.0 times greater than that of White patients.

Recognizing Anemia of CKD

Prevalence
One important complication of CKD is CKD-related anemia, which is underdiagnosed and undertreated. Approximately 1 in 7 people with CKD have anemia, but the numbers increase with patient age, CKD stage, and comorbidities. Across all estimated glomerular filtration rate categories, patients with diabetes have higher rates of anemia. Many racial and ethnic minoritized groups also have higher rates of CKD complications, including anemia. Anemia is more common and more severe in Black patients with CKD. In prior studies, Black patients with CKD have a 1.5-2.0 times greater prevalence of CKD-related anemia than White patients.

Anemia of CKD Is Associated With Poor Outcomes
CKD-related anemia is associated with negative clinical, patient, and societal outcomes. Patients with CKD-related anemia have a faster progression to ESKD and greater cardiovascular morbidity and mortality. Patients also report reduced quality of life and reduced physical and cognitive function. These clinical and patient-centered outcomes also have increased health system and societal costs. Patients are less able to work and require more assistance with activities of daily living. In addition, patients with untreated anemia have more hospitalizations and greater lengths of stay. Finally, faster CKD progression leads to increased ESKD prevalence and healthcare costs due to the high cost of dialysis care.

Risk Factors and Health Disparities
There are patient-level risk factors for CKD-related anemia. Patients with diabetic nephropathy and polycystic kidney disease have higher rates of CKD. Patients with lab abnormalities such as higher C-reactive protein and phosphate also were more likely to have low hemoglobin. Premenopausal women also have a higher prevalence of anemia due to blood loss during menstruation.

Black patients with CKD often have lower baseline hemoglobin and higher rates of CKD anemia. Black patients may have hemoglobinopathies that lead to lower hemoglobin. Black patients with CKD also may need higher doses of erythropoiesis-stimulating agents for the same hemoglobin response. In addition, race is a social construct associated with ancestry that groups individuals according to presumed physical and social characteristics. Thus, many of the observed associations with Black race and increased anemia are related to social position rather than an inherent difference in biology. Anemia rates are higher in individuals with low health literacy and high poverty. These disparities may be due to nutritional deficiencies and higher rates of inflammation due to stress, comorbidities, or environmental toxins. In addition, patients with lower income or racial and ethnic minority patients also may have reduced access to healthcare or receive lower-quality healthcare.

Improving the Management of Anemia of CKD by Addressing Health Disparities

Acknowledging Biases
Healthcare professionals (HCPs) can play an important role in perpetuating or mitigating disparities in CKD-related anemia. Primary care physicians may delay treatment of anemia due to being overburdened with other medical conditions, uncertainty about treatment, or thinking CKD-related anemia is the domain of the nephrologist. HCP bias also can play a role in underrecognition or undertreatment. HCPs, even well-meaning ones, may make assumptions about a patient’s desire or ability to treat their CKD and its complications. For HCPs, other ways to ensure equitable CKD care for racial and ethnic minority patients are being aware of their own implicit bias and, once aware, actively working to overcome that bias. One can monitor bias by reviewing processes of care (eg, screening, referral) and outcomes by patient race and ethnicity, insurance, or HCP.

Improving Communication With Patients
Another important aspect of reducing anemia disparities is improved patient–HCP communication. Racial and ethnic minority patients may be less likely to receive clear communication with their HCPs due to low health literacy, language barriers, or limited HCP explanation. HCPs should talk to all patients in plain language about their diagnosis, potential harms, and treatment options. This should include a discussion on treatment benefits, costs, and potential adverse events. HCPs can use their clinical expertise to make a recommendation, but they also should be able to alter their treatment plan according to patient goals and concerns. Shared decision-making can empower patients to ask questions about their health and to adhere to treatment plans. Interpreter services also help improve patient–HCP communication. A recent national study reported that only 25% of physicians reported using professional interpreters with patients with low English proficiency. Less desirable alternatives include using bilingual staff or the patient’s family, or “getting by” in English.

Increasing Access to Care
Although HCPs are at the front line for reducing anemia disparities, health system and societal interventions also are needed. Many patients with CKD, even advanced CKD, may not be well-connected to healthcare. Racial and ethnic minority patients are more likely to lack a usual source of care due to lack of insurance, difficulties obtaining a physician due to type of insurance, or location. An important intervention would be to expand eligibility to insurance or improve the safety net for non–employer-based insurance. Although there have been recent reductions in the number of uninsured patients due to the Affordable Care Act, many remain uninsured or underinsured. Some people do not have insurance that is accepted by many HCPs or have limited acceptance among subspecialists. Other insurance policies restrict pharmacy access with limited formularies or high co-pays. Limited subspecialist and drug access may limit the recognition and treatment of CKD-related anemia, particularly among patients with low income or racial and ethnic minority patients. Another important intervention is to monitor CKD-related quality outcomes and ensure that programs are structured to both improve quality of life and reduce disparities. Quality improvement and pay-for-performance programs must monitor outcomes so that they do not penalize doctors and clinics in disadvantaged communities, but they also should not accept lower-quality care for patients because of their race, insurance, or community.

We currently have safe, effective treatments to treat CKD-related anemia, but they are not equitably distributed. HCP-level interventions are necessary but are not sufficient to mitigate these disparities entirely.

Your Thoughts?
In your practice, how do you address health disparities when caring for your patients with anemia of CKD? Please answer the polling question and join the conversation by posting a comment in the discussion section below.