Impact of Social Determinants of Health on Chronic Kidney Disease: A Review of Disparities in Renal Transplantation

Socioeconomic Impact on Kidney Transplant


  • Conner V. Lombardi 1. University of Toledo College of Medicine and Life Sciences
  • Logan D. Glosser University of Toledo College of Medicine and Life Sciences
  • Hanna M. Knauss 1. University of Toledo College of Medicine and Life Sciences
  • Teanya Norwood Promedica Toledo Hospital, Department of Care Navigation
  • Julia T. Berry 1. University of Toledo College of Medicine and Life Sciences
  • Obinna O. Ekwenna 3. University of Toledo Medical Center, Department of Urology



End Stage Renal Disease, Kidney Failure, Dialysis, Socioeconomic Factors, Health care and access, Kidney Transplantation


Background: Striking disparity exists in the incidence and treatment of chronic kidney disease (CKD) secondary to individual social determinants of health.  Additionally, the uninsured, minority racial-ethnic groups, and Medicaid enrollees receive less nephrology care prior to being diagnosed with end-stage renal disease (ESRD). The most effective treatment for the management of kidney failure is kidney transplantation. This review addresses how social determinants of health impact the workup for patients with ESRD, with emphasis on the kidney transplant process.


Methods: A search was conducted via multiple online databases (MedLine, PubMed, etc.) for articles that addressed the interplay between CKD, ESRD and kidney transplantation with the social determinants of health.


Findings: The impact of the social determinants of health on CKD, ESRD, and the kidney transplantation process can be qualitatively and quantitatively measured using the five categories of education, health care and access, economic stability, neighborhood and built environment, and social and community context.


Conclusion: Social determinants of health impact outcomes in CKD, ESRD, and kidney transplantation. Public and private initiatives aimed at reducing social disparities among patients with kidney disease must include emphasis on education, health care and access, economic stability, neighborhood and built environment, and social and community context. This initiative is necessary to prevent progression to ESRD and to ensure quality care in the kidney transplantation process.


Myers OB, Pankratz VS, Norris KC, Vassalotti JA, Unruh ML, Argyropoulos C. Surveillance of CKD epidemiology in the US - a joint analysis of NHANES and KEEP. Sci Rep. 2018;8(1):15900. Epub 2018/10/28. doi: 10.1038/s41598-018-34233-w. PubMed PMID: 30367154; PubMed Central PMCID: PMCPMC6203800.

Johansen KL, Chertow GM, Foley RN, Gilbertson DT, Herzog CA, Ishani A, et al. US Renal Data System 2020 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2021;77(4 Suppl 1):A7-A8. Epub 2021/03/24. doi: 10.1053/j.ajkd.2021.01.002. PubMed PMID: 33752804; PubMed Central PMCID: PMCPMC8148988.

Ahmed O, Patel K, Rabei R, Patel MV, Ginsburg M, Clayton B, et al. Hemodialysis Access Maintenance in the Medicare Population: An Analysis Over a Decade of Trends by Provider Specialty and Site of Service. J Vasc Interv Radiol. 2018;29(2):159-69. Epub 2017/12/24. doi: 10.1016/j.jvir.2017.09.028. PubMed PMID: 29273282.

Richard A RN. Institute of Medicine (US) Committee for the Study of Medicare End-Stage Renal Disease Program. Washington (DC): National Academies Pressu (US). 1991.

Axelrod DA, Dzebisashvili N, Schnitzler MA, Salvalaggio PR, Segev DL, Gentry SE, et al. The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes. Clin J Am Soc Nephrol. 2010;5(12):2276-88. Epub 2010/08/28. doi: 10.2215/CJN.04940610. PubMed PMID: 20798250; PubMed Central PMCID: PMCPMC2994090.

Patzer RE, Perryman JP, Schrager JD, Pastan S, Amaral S, Gazmararian JA, et al. The role of race and poverty on steps to kidney transplantation in the Southeastern United States. Am J Transplant. 2012;12(2):358-68. Epub 2012/01/12. doi: 10.1111/j.1600-6143.2011.03927.x. PubMed PMID: 22233181; PubMed Central PMCID: PMCPMC3950902.

Ladin K, Hanto DW. Understanding disparities in transplantation: do social networks provide the missing clue? Am J Transplant. 2010;10(3):472-6. Epub 2010/01/09. doi: 10.1111/j.1600-6143.2009.02963.x. PubMed PMID: 20055801.

Saran R, Robinson B, Abbott KC, Agodoa LY, Albertus P, Ayanian J, et al. US Renal Data System 2016 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2017;69(3 Suppl 1):A7-A8. Epub 2017/02/27. doi: 10.1053/j.ajkd.2016.12.004. PubMed PMID: 28236831; PubMed Central PMCID: PMCPMC6605045.

Emma Aitken RS, Faisal Hanif, Diana Raj, Karen Stevenson, David Kingsmore. Renal Transplantation: An update for Anaesthetists. International Journal of Anesthetics and Anesthesiology. 2016;3(4). Epub October 01, 2016.

Chronic Kidney Disease Health.gov2020 [cited 2021 May 31]. Available from:

Kucirka LM, Grams ME, Balhara KS, Jaar BG, Segev DL. Disparities in provision of transplant information affect access to kidney transplantation. Am J Transplant. 2012;12(2):351-7. Epub 2011/12/14. doi: 10.1111/j.1600-6143.2011.03865.x. PubMed PMID: 22151011.

Batabyal P, Chapman JR, Wong G, Craig JC, Tong A. Clinical practice guidelines on wait-listing for kidney transplantation: consistent and equitable? Transplantation. 2012;94(7):703-13. Epub 2012/09/06. doi: 10.1097/TP.0b013e3182637078. PubMed PMID: 22948443.

Kulkarni S, Ladin K, Haakinson D, Greene E, Li L, Deng Y. Association of Racial Disparities With Access to Kidney Transplant After the Implementation of the New Kidney Allocation System. JAMA Surg. 2019;154(7):618-25. Epub 2019/04/04. doi: 10.1001/jamasurg.2019.0512. PubMed PMID: 30942882; PubMed Central PMCID: PMCPMC6583835.

Kiberd BA, AlBugami MM, Panek R, Tennankore K. Contraindications to kidney transplantation: uneven grounds? Transplant Res. 2015;4:2. Epub 2015/07/24. doi: 10.1186/s13737-015-0024-x. PubMed PMID: 26203355; PubMed Central PMCID: PMCPMC4509772.

Bond M, Pitt M, Akoh J, Moxham T, Hoyle M, Anderson R. The effectiveness and cost-effectiveness of methods of storing donated kidneys from deceased donors: a systematic review and economic model. Health Technol Assess. 2009;13(38):iii-iv, xi-xiv, 1-156. Epub 2009/08/14. doi: 10.3310/hta13380. PubMed PMID: 19674537.

Mirowsky J, Ross CE. Education, Health, and the Default American Lifestyle. J Health Soc Behav. 2015;56(3):297-306. Epub 2015/08/15. doi: 10.1177/0022146515594814. PubMed PMID: 26272989.

Patzer RE, Perryman JP, Pastan S, Amaral S, Gazmararian JA, Klein M, et al. Impact of a patient education program on disparities in kidney transplant evaluation. Clin J Am Soc Nephrol. 2012;7(4):648-55. Epub 2012/02/22. doi: 10.2215/CJN.10071011. PubMed PMID: 22344515; PubMed Central PMCID: PMCPMC6314035.

Schaeffner ES, Mehta J, Winkelmayer WC. Educational level as a determinant of access to and outcomes after kidney transplantation in the United States. Am J Kidney Dis. 2008;51(5):811-8. Epub 2008/04/26. doi: 10.1053/j.ajkd.2008.01.019. PubMed PMID: 18436092.

Goldfarb-Rumyantzev AS, Koford JK, Baird BC, Chelamcharla M, Habib AN, Wang BJ, et al. Role of socioeconomic status in kidney transplant outcome. Clin J Am Soc Nephrol. 2006;1(2):313-22. Epub 2007/08/21. doi: 10.2215/CJN.00630805. PubMed PMID: 17699222.

Russell CL. Culturally responsive interventions to enhance immunosuppressive medication adherence in older African American kidney transplant recipients. Prog Transplant. 2006;16(3):187-95; quiz 96. Epub 2006/09/30. PubMed PMID: 17007152.

Fraser SD, Blakeman T. Chronic kidney disease: identification and management in primary care. Pragmat Obs Res. 2016;7:21-32. Epub 2016/11/09. doi: 10.2147/POR.S97310. PubMed PMID: 27822135; PubMed Central PMCID: PMCPMC5087766.

Bello AK, Nwankwo E, El Nahas AM. Prevention of chronic kidney disease: a global challenge. Kidney Int Suppl. 2005(98):S11-7. Epub 2005/08/20. doi: 10.1111/j.1523-1755.2005.09802.x. PubMed PMID: 16108964.

Olomu AB, Gourineni V, Huang JL, Pandya N, Efeovbokhan N, Samaraweera J, et al. Rate and predictors of blood pressure control in a federal qualified health center in Michigan: a huge concern? J Clin Hypertens (Greenwich). 2013;15(4):254-63. Epub 2013/04/05. doi: 10.1111/jch.12067. PubMed PMID: 23551725.

Hall YN, Rodriguez RA, Boyko EJ, Chertow GM, O'Hare AM. Characteristics of uninsured Americans with chronic kidney disease. J Gen Intern Med. 2009;24(8):917-22. Epub 2009/06/10. doi: 10.1007/s11606-009-1028-3. PubMed PMID: 19506974; PubMed Central PMCID: PMCPMC2710472.

Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012;367(11):1025-34. Epub 2012/07/27. doi: 10.1056/NEJMsa1202099. PubMed PMID: 22830435.

Schold JD, Miller CM, Henry ML, Buccini LD, Flechner SM, Goldfarb DA, et al. Evaluation of Flagging Criteria of United States Kidney Transplant Center Performance: How to Best Define Outliers? Transplantation. 2017;101(6):1373-80. Epub 2016/08/03. doi: 10.1097/TP.0000000000001373. PubMed PMID: 27482960.

Schold JD, Buccini LD, Goldfarb DA, Flechner SM, Poggio ED, Sehgal AR. Association between kidney transplant center performance and the survival benefit of transplantation versus dialysis. Clin J Am Soc Nephrol. 2014;9(10):1773-80. Epub 2014/09/23. doi: 10.2215/CJN.02380314. PubMed PMID: 25237071; PubMed Central PMCID: PMCPMC4186511.

Hippen BE, Maddux FW. Integrating kidney transplantation into value-based care for people with renal failure. Am J Transplant. 2018;18(1):43-52. Epub 2017/09/13. doi: 10.1111/ajt.14454. PubMed PMID: 28898574.

Transplants in the U.S. by Recipient Ethnicity 2020 [cited 2020 October 15]. Available from:

Phelan JC, Link BG, Tehranifar P. Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010;51 Suppl:S28-40. Epub 2010/12/22. doi: 10.1177/0022146510383498. PubMed PMID: 20943581.

Hall YN. Social Determinants of Health: Addressing Unmet Needs in Nephrology. Am J Kidney Dis. 2018;72(4):582-91. Epub 2018/03/20. doi: 10.1053/j.ajkd.2017.12.016. PubMed PMID: 29548780.

Volkova N, McClellan W, Klein M, Flanders D, Kleinbaum D, Soucie JM, et al. Neighborhood poverty and racial differences in ESRD incidence. J Am Soc Nephrol. 2008;19(2):356-64. Epub 2007/12/07. doi: 10.1681/ASN.2006080934. PubMed PMID: 18057219; PubMed Central PMCID: PMCPMC2396744.

Gordon EJ, Ladner DP, Caicedo JC, Franklin J. Disparities in kidney transplant outcomes: a review. Semin Nephrol. 2010;30(1):81-9. Epub 2010/02/02. doi: 10.1016/j.semnephrol.2009.10.009. PubMed PMID: 20116652; PubMed Central PMCID: PMCPMC2818243.

Press R, Carrasquillo O, Nickolas T, Radhakrishnan J, Shea S, Barr RG. Race/ethnicity, poverty status, and renal transplant outcomes. Transplantation. 2005;80(7):917-24. Epub 2005/10/27. doi: 10.1097/ PubMed PMID: 16249739.

Patzer RE, Plantinga LC, Paul S, Gander J, Krisher J, Sauls L, et al. Variation in Dialysis Facility Referral for Kidney Transplantation Among Patients With End-Stage Renal Disease in Georgia. JAMA. 2015;314(6):582-94. Epub 2015/08/12. doi: 10.1001/jama.2015.8897. PubMed PMID: 26262796; PubMed Central PMCID: PMCPMC4571496.

Schold JD, Gregg JA, Harman JS, Hall AG, Patton PR, Meier-Kriesche HU. Barriers to evaluation and wait listing for kidney transplantation. Clin J Am Soc Nephrol. 2011;6(7):1760-7. Epub 2011/05/21. doi: 10.2215/CJN.08620910. PubMed PMID: 21597030.

Keith D, Ashby VB, Port FK, Leichtman AB. Insurance type and minority status associated with large disparities in prelisting dialysis among candidates for kidney transplantation. Clin J Am Soc Nephrol. 2008;3(2):463-70. Epub 2008/01/18. doi: 10.2215/CJN.02220507. PubMed PMID: 18199847; PubMed Central PMCID: PMCPMC2390941.

Kazley AS, Simpson KN, Chavin KD, Baliga P. Barriers facing patients referred for kidney transplant cause loss to follow-up. Kidney Int. 2012;82(9):1018-23. Epub 2012/07/27. doi: 10.1038/ki.2012.255. PubMed PMID: 22832516; PubMed Central PMCID: PMCPMC3472088.

Browne T, Amamoo A, Patzer RE, Krisher J, Well H, Gander J, et al. Everybody needs a cheerleader to get a kidney transplant: a qualitative study of the patient barriers and facilitators to kidney transplantation in the Southeastern United States. BMC Nephrol. 2016;17(1):108. Epub 2016/08/01. doi: 10.1186/s12882-016-0326-3. PubMed PMID: 27476111; PubMed Central PMCID: PMCPMC4967312.

Fielding JE, Teutsch S, Koh H. Health reform and Healthy People initiative. Am J Public Health. 2012;102(1):30-3. Epub 2011/11/19. doi: 10.2105/AJPH.2011.300312. PubMed PMID: 22095359; PubMed Central PMCID: PMCPMC3490564.

Stewart JA. The detrimental effects of allostasis: allostatic load as a measure of cumulative stress. J Physiol Anthropol. 2006;25(1):133-45. Epub 2006/04/18. doi: 10.2114/jpa2.25.133. PubMed PMID: 16617218.

Ludwig J, Sanbonmatsu L, Gennetian L, Adam E, Duncan GJ, Katz LF, et al. Neighborhoods, obesity, and diabetes--a randomized social experiment. N Engl J Med. 2011;365(16):1509-19. Epub 2011/10/21. doi: 10.1056/NEJMsa1103216. PubMed PMID: 22010917; PubMed Central PMCID: PMCPMC3410541.

Saunders MR, Cagney KA, Ross LF, Alexander GC. Neighborhood poverty, racial composition and renal transplant waitlist. Am J Transplant. 2010;10(8):1912-7. Epub 2010/07/28. doi: 10.1111/j.1600-6143.2010.03206.x. PubMed PMID: 20659097.

Said S, Hernandez GT. Environmental exposures, socioeconomics, disparities, and the kidneys. Adv Chronic Kidney Dis. 2015;22(1):39-45. Epub 2015/01/13. doi: 10.1053/j.ackd.2014.09.003. PubMed PMID: 25573511.

Norton JM, Moxey-Mims MM, Eggers PW, Narva AS, Star RA, Kimmel PL, et al. Social Determinants of Racial Disparities in CKD. J Am Soc Nephrol. 2016;27(9):2576-95. Epub 2016/05/15. doi: 10.1681/ASN.2016010027. PubMed PMID: 27178804; PubMed Central PMCID: PMCPMC5004663.

Ladin K, Emerson J, Butt Z, Gordon EJ, Hanto DW, Perloff J, et al. How important is social support in determining patients' suitability for transplantation? Results from a National Survey of Transplant Clinicians. J Med Ethics. 2018;44(10):666-74. Epub 2018/06/30. doi: 10.1136/medethics-2017-104695. PubMed PMID: 29954874; PubMed Central PMCID: PMCPMC6425471.

Plantinga LC, Pastan SO, Wilk AS, Krisher J, Mulloy L, Gibney EM, et al. Referral for Kidney Transplantation and Indicators of Quality of Dialysis Care: A Cross-sectional Study. Am J Kidney Dis. 2017;69(2):257-65. Epub 2016/11/25. doi: 10.1053/j.ajkd.2016.08.038. PubMed PMID: 27881246; PubMed Central PMCID: PMCPMC5263049.

Joshi S, Gaynor JJ, Bayers S, Guerra G, Eldefrawy A, Chediak Z, et al. Disparities among Blacks, Hispanics, and Whites in time from starting dialysis to kidney transplant waitlisting. Transplantation. 2013;95(2):309-18. Epub 2013/01/18. doi: 10.1097/TP.0b013e31827191d4. PubMed PMID: 23325005.

Kutner NG, Zhang R, Huang Y, Johansen KL. Impact of race on predialysis discussions and kidney transplant preemptive wait-listing. Am J Nephrol. 2012;35(4):305-11. Epub 2012/03/15. doi: 10.1159/000336891. PubMed PMID: 22414927; PubMed Central PMCID: PMCPMC3362182.

Myaskovsky L, Almario Doebler D, Posluszny DM, Dew MA, Unruh M, Fried LF, et al. Perceived discrimination predicts longer time to be accepted for kidney transplant. Transplantation. 2012;93(4):423-9. Epub 2012/01/10. doi: 10.1097/TP.0b013e318241d0cd. PubMed PMID: 22228417; PubMed Central PMCID: PMCPMC3275654.

Ayanian JZ, Cleary PD, Keogh JH, Noonan SJ, David-Kasdan JA, Epstein AM. Physicians' beliefs about racial differences in referral for renal transplantation. Am J Kidney Dis. 2004;43(2):350-7. Epub 2004/01/30. doi: 10.1053/j.ajkd.2003.10.022. PubMed PMID: 14750101.

van Ryn M, Fu SS. Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health? Am J Public Health. 2003;93(2):248-55. Epub 2003/01/30. doi: 10.2105/ajph.93.2.248. PubMed PMID: 12554578; PubMed Central PMCID: PMCPMC1447725.




How to Cite

Lombardi, C., Glosser, L., Knauss, H., Norwood, T., Berry, J., & Ekwenna, O. (2021). Impact of Social Determinants of Health on Chronic Kidney Disease: A Review of Disparities in Renal Transplantation: Socioeconomic Impact on Kidney Transplant. Translation: The University of Toledo Journal of Medical Sciences, 9(1).