Social Determinants of Health and ESKD among Survivors of Critical Illness and Acute Kidney Injury.

KEY POINTS: During follow-up, 326 (1%) critical illness survivors with AKI developed ESKD; 2723 (9%) died. Black race and lack of health insurance were independently associated with higher risk of developing ESKD. Residence in a socioeconomically deprived neighborhood was independently associated with higher risk of ESKD.

BACKGROUND

Adverse social determinants of health (SDOHs) are associated with higher risk of AKI. This study evaluated the association of individual- and neighborhood-level SDOHs with incident ESKD among intensive care unit (ICU) survivors of AKI.

METHODS

Thirty thousand four hundred ninety-eight adult ICU survivors of AKI at a major academic medical center between January 1, 2012, and December 31, 2022, were included. Individual-level SDOHs (race, ethnicity, and insurance status) were obtained from the hospital electronic health record, whereas neighborhood-level SDOHs (Area Deprivation Index among others) were derived from census-based indices. ESKD was defined by kidney failure with an eGFR <15 ml/min per 1.73 m 2 or the initiation of KRT, including maintenance dialysis or kidney transplantation. Association of individual- and neighborhood-level SDOHs with incident ESKD was evaluated using multivariable cause-specific Cox proportional hazards models adjusting for clinical factors.

RESULTS

The median age was 58 years, 40% were women, 31% were Black, and 12% were uninsured. The median follow-up time was 730 days, during which 326 (1%) patients developed ESKD and 2723 (9%) died. In adjusted models, Black race was associated with a higher hazard of ESKD compared with White race (adjusted hazard ratio [aHR], 1.43, 95% confidence interval [CI], 1.05 to 1.94), whereas having health insurance was associated with a lower hazard of ESKD (aHR, 0.60; 95% CI, 0.39 to 0.92). Higher neighborhood-level socioeconomic disadvantage was also independently associated with higher risk of ESKD (Area Deprivation Index tertile 2: aHR, 1.42; 95% CI, 1.01 to 2.00; tertile 3: aHR, 1.58; 95% CI, 1.08 to 2.33).

CONCLUSIONS

Black race, lack of health insurance, and residence in socioeconomically deprived neighborhoods were independently associated with a higher hazard of incident ESKD among ICU survivors of AKI. Standardized SDOHs assessment in clinical practice may improve risk stratification of ESKD and identify AKI survivors most likely to benefit from postdischarge interventions.