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This study examined dimensions of young-adulthood development in lived experience reported by young persons (19 women, 18 men) with the disabling condition of kidney failure requiring chronic dialysis or kidney transplantation. In semistructured phone interviews, participants (ages 23–37) described their family/living situation, employment and community activity, current situation, and experience. Participants' qualitative responses about “the way you see things, do things, feel about things” and “how you feel about yourself” were examined to identify themes. Limited achievement of proposed “successful” dimensions of young adulthood characterized the study cohort, based on indicators included in the interview. In qualitative data, the theme of perceived stigma and spoiled identity (Goffman, 1963) was reflected in comments offered by participants regarding their self-confidence and motivation to pursue goals. A second theme in participants' qualitative responses was a sense of isolation from age peers who shared their condition, and participants expressed frustration around having an age-inappropriate condition (“why me?”). Perceived stigma and spoiled identity impact social ties and life goals and are understudied influences in the life course trajectory of young persons with kidney failure and the challenges inherent in navigating health status and developmental life course transitions.

Disparities in transplant rates across social categories provide limited information about gatekeeping processes in access to kidney transplantation. We hypothesized that early opportunities for discussion of kidney transplantation potentially generate social capital that serves as a resource for patients as they navigate the transplantation pathway.

A national sample of first-year dialysis patients was surveyed and asked if kidney transplantation had been discussed with them before and after starting dialysis treatment. Associations between reported discussion and patient-specific clinical and nonclinical (sociodemographic) indicators of attributed utility for transplantation were investigated, and the association of reported transplant discussion with subsequent transplant waitlisting was analyzed.

Time to placement on the kidney transplant waiting list was significantly shorter for patients who reported that transplantation had been discussed with them before, as well as after, starting dialysis. Likelihood of reported discussion varied by patient age, employment and insurance status, cardiovascular comorbidity burden, and perceived health status; in addition, women were less likely to report early discussion.

It would be valuable to know more about the nature of the transplant discussions recalled by patients to better understand how social capital may be fostered through these discussions.

Indicators of attributed utility for successful transplantation were associated with transplant discussion both before and after starting dialysis, potentially contributing to observed disparities in access to kidney transplantation.

Predialysis nephrology care and patient participation in discussion of kidney transplantation may foster social capital that facilitates navigating the transplantation pathway.

In the context of US kidney disease care in 2020, this chapter highlights challenges of managing COVID-19–related acute pathology, sustaining safe chronic dialysis treatment for individuals with kidney failure during a pandemic, and identifying ways to effectively address intersections of race/ethnicity, SES, and health.

Medical literature and American Society of Nephrology (ASN) online member forum review, and Emory School of Medicine Renal Grand Rounds participant observation: April 2020–March 2021.

Among persons infected with COVID-19, especially persons of African descent, acute kidney injury (AKI) risk was elevated and associated with need for long-term dialysis. Dialysis-dependent chronic kidney disease patients constituted a high-risk group for COVID-19 infection and hospitalization, due to underlying chronic conditions as well as required travel to clinics for multiple weekly dialysis treatments with exposure to possibly infected staff and other patients.

Findings that are discussed are based on a limited time frame. The longer-term impact of COVID-19 for patient outcomes and for the structure of kidney disease care is a fertile area for continued study, especially in relation to broad health equity goals.

Racial justice activism in 2020 highlighted the imperative to address socioeconomic and racially structured inequities in the United States, and health equity goals and strategies that target kidney disease care have been outlined. The acute/chronic continuum of kidney disease care is a fertile area for research that is informed by the COVID-19 experience and population health inequity challenges.

Health promotion and rehabilitation models of care are valuable for persons with chronic health conditions, but when these individuals are dependent on a life-maintaining technology, such as kidney dialysis, a cure-oriented model may dominate the system within which they receive care. Providers can preserve their monopoly over expert treatment knowledge by defining the key care issues, by limiting patients’ access to expert knowledge, and by discrediting the patient as a responsible actor. Multiple care paradigms can benefit patients with chronic conditions, however, empowering the patient-actor to collaborate with the clinician to maximize functioning and well-being as well as patient survival.

Socioeconomic status (SES) is a fundamental social cause of disease. The association of SES with chronic renal failure has received limited study. Older persons and blacks are at significantly increased risk for this health condition, which is also known as end-stage renal disease (ESRD). Among ESRD cases and controls aged 56-88, we investigated whether SES was predictive of ESRD, independent of subjects' race, sex, age, and history of diabetes. Our SES measure combined information about individuals' education and occupation. In race-specific logistic regression models, there was a trend for higher SES to be protective against ESRD. In a combined model, controlling for the effects of race, sex, age, and diabetes, the SES effect was statistically significant. Diabetes and hypertension, important ESRD risk factors, are also related to SES. The adverse “effect” of black race on a health outcome like ESRD may be expressed preferentially among economically disadvantaged persons. Improved understanding of race, SES, and age vis-à-vis a chronic condition such as ESRD requires studies in which cohort changes in health, resources, access to care, and service utilization are monitored longitudinally and analyzed using a life course perspective.