Healthcare Disparities across the Continuum of Kidney Care

Updated on September 7, 2023

What is a Health Disparity 

Health disparities are preventable differences in rates of illness, injuries, or opportunities to achieve optimal health in one group compared to another.  Many factors contribute to health disparities.  This article focuses on health disparities associated with race, lower socioeconomic status, and rural residency due to their association with lower quality of health care and higher rates of illness and death in the U.S., representing significant inequities across many diseases, including kidney disease.1 

Thirty-seven million individuals in the U.S. are estimated to have chronic kidney disease (CKD), with more than half unaware of their condition.  According to the 2019 National Institute of Health (NIH) report, over 800,000 individuals have end-stage kidney disease (ESKD), a recognized public health issue2, with >50% of those individuals belonging to a minority group.2 African Americans make up <14% of the U.S. population but represent nearly 35% of individuals with ESKD.  They are almost five times more likely to develop ESKD than their Caucasian counterparts.  Similarly, the Hispanic population is <20% but has drastically higher ESKD rates and is approximately 1.5 times more likely to develop ESKD than Caucasians.3  Native Americans represent only 1.5 percent of the U.S. population, yet ESKD rates are six times higher than non-Native Americans, one of the highest rates globally.4 

Kidney Disease

Kidney disease is a detrimental progressive illness; if not addressed, it can advance over time, leading to kidney failure or death.   There are numerous causes of kidney disease, but hypertension and type two diabetes are the most common contributing factors in the U.S.

Modifiable risk factors such as unhealthy eating and physical inactivity also contribute largely.  Individuals with mild kidney disease can display no symptoms initially but progress to more advanced stages of kidney disease without warning signs.  Once an individual progresses to ESKD, life-sustaining medical management, dialysis (hemodialysis or peritoneal; H.D., P.D.), and kidney transplantation are necessary.5

Patients undergoing H.D. are 100 times more likely to develop a bloodstream infection (BSI) because a patient’s circulatory system must be accessed, which can introduce bacteria, causing infection resulting in severe illness or death.  In 2020, there were more than 140,000 bloodstream infections reported in H.D. patients.6 BSI rates are highest for black and Hispanic patients than white patients.3 

In addition to health consequences, there are substantial costs associated with kidney disease.  In 2019 the cost for Medicare patients with kidney failure treatment, dialysis, or kidney transplant was $125 billion.  This represents a substantial portion of Medicare funding.5 

Influencing Factors

Social determinants of health (SDOH) are economical and social circumstances that drastically impact an individual’s health status and offer insights into why health disparities exist.  There are five components of SDOH, economic stability, neighborhood, education access, and quality, healthcare access and quality, and community environment.  Examples of SDOH are safe housing, transportation, education, income, literacy skills, and safe drinking water Individuals lacking the five components are at increased risk for inadequate healthcare and outcomes7

Transportation, limited access to healthy food, lack of health insurance, and financial issues contribute to health disparities.  Rural residents, Hispanic and black individuals have higher rates of food shortages and frequently have limited access to healthy food options, with fewer supermarkets that require traveling long distances or financial inability to purchase healthy food.8.  Individuals in lower socioeconomic groups often lack health insurance and have limited income to purchase healthy food or medications contributing to suboptimal health outcomes.9 Lack of health insurance is greater among rural residents compared to suburban and urban area residents, and an additional access obstacle to attaining healthcare.11 

These barriers to a healthy lifestyle increase the risk of developing and worsening disease and decrease life expectancy.Lower socioeconomic status correlates to worse health outcomes compared to higher socioeconomic statuses, including kidney disease.  For example, the rate of ESKD is greater among individuals with worse social deprivation index (SDI) scores, a tool for measuring economic inequality based on geographic location for all groups.  Rates of ESKD in African Americans were 40% greater than Caucasians in the lowest SDI category and were more than fifty percent higher in Hispanic individuals.1.  

Provider Disparities

Among many contributors to health disparities is the critical shortage of health professionals and health services in rural areas, creating substantial barriers to obtaining appropriate medical care.9 According to the National Rural Health Association, only 12% of primary care physicians practice in rural areas, with fewer than 30 health specialists per 100,000 compared to 263 per 100,000 in urban areas.10  

Non-medical and Medical Improvement and Mitigation Strategies

Addressing and eliminating health disparities requires a multidimensional approach based on SDOH.  Increasing public and clinician awareness of health disparities can influence policy and practice changes.  Expanding health insurance coverage to underrepresented individuals can provide improved access to medical care and can increase the number of health professionals in underserved areas through multicultural recruitment and incentives along with telehealth services.  12 Multicultural training for health professionals strengthens relationships and builds trust between patients and clinicians from different backgrounds.  Utilizing health information to identify and track high-risk groups and patterns of disparity can enable and inform health improvement strategies.13

The first step to combat this issue in kidney disease is clinician, patient, and public awareness.  Patients and families need education regarding healthy lifestyle choices, including nutrition, physical activity, and medication self-management.  Educational initiatives for health professionals to heighten their focus on health disparities and current evidence-based guidelines to improve prevention, screening, diagnosis, and early treatment are crucial.14 Clinicians should be urged to improve screening of at-risk patient groups with and for diabetes, hypertension, kidney, and cardiovascular disease, making earlier interventions like medication management to slow disease progression and prevent associated complications to improve quality of life and health outcomes.13


1. The Centers for Disease Control and Prevention, (2017).  About rural health.

2. The Centers for Disease Control and Prevention, (2023).  “Black and Hispanic patients” on dialysis have higher rates of Staph bloodstream infections. 

3. The Centers for Disease Control and Prevention, (2022).  “Chronic” kidney disease basics.

4. The Centers for Disease Control and Prevention, (2023).  Preventing bloodstream infections in people on dialysis.

5. The Centers for Disease Control and Prevention [CDC] (2022), Social determinants of health at the CDC.

6. The Centers for Medicare and Medicaid Services [CMS], (2023).  Addressing Rural Health Inequities in Medicare. 

7. The National Institute of Health [NIH], U.S. Renal Data System, (2021).  Incidence, prevalence, patient characteristics, and treatment modalities.

8. The National Kidney Foundation [NKF], (n.d.).  Chronic Kidney Disease Change Package.

The National Kidney Foundation [NKF], (2023).  Disparities.

The National Kidney Foundation, (2023).  “Priorities” for the 118th Congress.

The National Kidney Foundation, (2020).  Race, ethnicity, and kidney disease.

Seshamani, M., Jacobs, D., Moody-Williams, J., Fleisher, L., (2023).  The Centers for Medicare and Medicaid Services.  Addressing rural health inequities in Medicare.

The United States Census Bureau [USCB], (2018).  Supplemental Nutrition Assistance Program (SNAP) Receipt for Households: 2018. 

United States Department of Health and Human Services, National Institute of Health, (2021).  Racial and Ethnic Disparities.

Betsy Graham-Moeller

Betsy Graham-Moeller, APRN-CNP, MBA is Senior Medical Science Liaison with CorMedix, Inc.