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Racial and health insurance disparities in pediatric acute kidney injury in the USA

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Abstract

Background

Acute kidney injury (AKI) significantly increases morbidity and mortality for hospitalized children, yet sociodemographic risk factors for pediatric AKI are poorly described. We examined sociodemographic differences in pediatric AKI amongst a national cohort of hospitalized children.

Methods

Secondary analysis of the most recent (2012) Kids’ Inpatient Database (KID) from the Agency for Healthcare Research and Quality. Study sample weights were used to obtain national estimates of AKI (defined by administrative data). KID is a nationally representative sample of pediatric discharges throughout the USA. Linear risk regression models were used to assess the relationship between our primary exposures (race/ethnicity, health insurance, household urbanization, gender, and age) and the diagnosis of AKI, adjusting for comorbidities.

Results

A total of 1,699,841 hospitalizations met our study criteria. In 2012, AKI occurred in approximately 12.3/1000 pediatric hospitalizations, which translates to almost 30,000 children nationally. Asian/Pacific Islander, African-American, and Hispanic children were at slightly increased risk for AKI compared to Caucasian children (adjusted risk difference (RD) 4.5 per 1000 hospitalizations, 95% confidence interval (CI) 2.9–6.0; 2.5/1000 hospitalizations, 95% CI 1.7–3.3; and 1.7/1000 hospitalizations, 95% CI 0.9–2.5, respectively). Uninsured children were more likely to suffer AKI compared to children with any health insurance (e.g., no insurance versus Medicaid: adjusted RD 14.4/1000 hospitalizations, 95% CI 12.7–16.2). Based on these national estimates, one episode of AKI might be prevented if 70 (95% CI 62–79) hospitalized children without insurance were provided with Medicaid.

Conclusions

Pediatric AKI occurs more frequently in racial minority and uninsured children, factors linked to lower socioeconomic status.

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References

  1. Sutherland SM, Ji J, Sheikhi FH et al (2013) AKI in hospitalized children: epidemiology and clinical associations in a national cohort. Clin J Am Soc Nephrol. https://doi.org/10.2215/CJN.00270113

  2. Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL (2017) Epidemiology of acute kidney injury in critically ill children and young adults. N Engl J Med. https://doi.org/10.1056/NEJMoa1611391

  3. McGregor TL, Jones DP, Wang L et al (2016) Acute kidney injury incidence in noncritically ill hospitalized children, adolescents, and young adults: a retrospective observational study. Am J Kidney Dis. https://doi.org/10.1053/j.ajkd.2015.07.019

  4. Alkandari O, Eddington KA, Hyder A et al (2011) Acute kidney injury is an independent risk factor for pediatric intensive care unit mortality, longer length of stay and prolonged mechanical ventilation in critically ill children: a two-center retrospective cohort study. Crit Care. https://doi.org/10.1186/cc10269

  5. Hessey E, Morissette G, Lacroix J et al (2018) Healthcare utilization after acute kidney injury in the pediatric intensive care unit. Clin J Am Soc Nephrol 13(5):685–692

    Article  Google Scholar 

  6. Greenberg JH, Coca S, Parikh CR (2014) Long-term risk of chronic kidney disease and mortality in children after acute kidney injury: a systematic review. BMC Nephrol. https://doi.org/10.1186/1471-2369-15-184

  7. Park S-K, Hur M, Kim E et al (2016) Risk factors for acute kidney injury after congenital cardiac surgery in infants and children: a retrospective observational study. PLoS One. https://doi.org/10.1371/journal.pone.0166328

  8. Rheault MN, Zhang L, Selewski DT et al (2015) AKI in children hospitalized with nephrotic syndrome. Clin J Am Soc Nephrol. https://doi.org/10.2215/CJN.06620615

  9. Nicholas SB, Kalantar-Zadeh K, Norris KC (2015) Socioeconomic disparities in chronic kidney disease. Adv Chronic Kidney Dis. https://doi.org/10.1053/j.ackd.2014.07.002

  10. Shoham DA, Vupputuri S, Kaufman JS et al (2008) Kidney disease and the cumulative burden of life course socioeconomic conditions: the Atherosclerosis Risk in Communities (ARIC) study. Soc Sci Med. https://doi.org/10.1016/j.socscimed.2008.06.007

  11. Vart P, Gansevoort RT, Joosten MM, Bültmann U, Reijneveld SA (2015) Socioeconomic disparities in chronic kidney disease: a systematic review and meta-analysis. Am J Prev Med. https://doi.org/10.1016/j.amepre.2014.11.004

  12. HCUP Kids’ Inpatient Database (KID). Healthcare Cost and Utilization Project (HCUP). 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/kidoverview.org. Published 2012. Accessed August 1, 2018

  13. Mehta RL, Burdmann EA, Cerdá J et al (2016) Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 global snapshot: a multinational cross-sectional study. Lancet. https://doi.org/10.1016/S0140-6736(16)30240-9

  14. HCUP Chronic Condition Indicator (CCI). Healthcare Cost and Utilization Project (HCUP). 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/toolssoftware/chronic/chronic.jsp. Published 2012. Accessed May 1, 2018

  15. Hwang W, Weller W, Ireys H, Anderson G (2001) Out-of-pocket medical spending for care of chronic conditions. Health Aff. https://doi.org/10.1377/hlthaff.20.6.267

  16. Staplin N, Herrington WG, Judge PK et al (2017) Use of causal diagrams to inform the design and interpretation of observational studies: an example from the study of heart and renal protection (SHARP). Clin J Am Soc Nephrol. https://doi.org/10.2215/CJN.02430316

  17. Greenland S, Pearl J, Robins JM (1999) Causal diagrams for epidemiologic research. Epidemiology. https://doi.org/10.1097/00001648-199901000-00008

  18. Hernán MA, Hernández-Díaz S, Robins JM (2004) A structural approach to selection bias. Epidemiology. https://doi.org/10.1097/01.ede.0000135174.63482.43

  19. United States Census Bureau. Quick Facts United States. https://census.gov/quickfacts/fact/table/US/pst045218. Accessed December 2, 2019

  20. National Center for Education Statistics. Estimates of resident population, by race/ethnicity and age group: selected years, 1980 through 2016. https://nces.ed.gov/programs/digest/d16/tables/dt16_101.20.asp?referer=raceindicators. Accessed December 2, 2019

  21. Abdullah F, Zhang Y, Lardaro T et al (2010) Analysis of 23 million US hospitalizations: uninsured children have higher all-cause in-hospital mortality. J Public Health (Bangkok) 32(2):236–244. https://doi.org/10.1093/pubmed/fdp099

    Article  Google Scholar 

  22. Office of Disease Prevention and Health Promotion. Social Determinants of Health | Healthy People 2020. Healthy People 2020 Topics and Objectives. https://www.healthypeople.gov. Published 2015

  23. Centers for Medicare & Medicaid Services. Medicaid.gov. https://www.medicaid.gov. Published 2018. Accessed August 7, 2018

  24. Centers for Medicare & Medicaid Services. Healthcare.gov. https://www.healthcare.gov/medicaid-chip/. Published 2018. Accessed August 7, 2018

  25. Benefits.gov. State Children’s Health Insurance Program. https://benefits.gov/benefits/benefit-details/607. Published 2018. Accessed August 8, 2018

  26. Hidalgo G, Ng DK, Moxey-Mims M et al (2013) Association of income level with kidney disease severity and progression among children and adolescents with CKD: a report from the chronic kidney disease in children (CKiD) study. Am J Kidney Dis. https://doi.org/10.1053/j.ajkd.2013.06.013

  27. Shone LP, Dick AW, Brach C et al (2003) The role of race and ethnicity in the state Children’s health insurance program (SCHIP) in four states: are there baseline disparities, and what do they mean for SCHIP? Pediatrics. https://doi.org/10.1542/peds.112.6.SE1.521

  28. Scott JW, Rose JA, Tsai TC et al (2016) Impact of ACA insurance coverage expansion on perforated appendix rates among young adults. Med Care. https://doi.org/10.1097/MLR.0000000000000586

  29. Olabisi OA, Heneghan JF (2017) APOL1 nephrotoxicity: what does ion transport have to do with it? Semin Nephrol. https://doi.org/10.1016/j.semnephrol.2017.07.008

  30. Ng DK, Robertson CC, Woroniecki RP et al (2017) APOL1-associated glomerular disease among African-American children: a collaboration of the chronic kidney disease in children (CKiD) and nephrotic syndrome study network (NEPTUNE) cohorts. Nephrol Dial Transplant. https://doi.org/10.1093/ndt/gfw061

  31. Woroniecki RP, Ng DK, Limou S et al (2016) Renal and cardiovascular morbidities associated with APOL1 status among African-American and non-African-American children with focal segmental glomerulosclerosis. Front Pediatr. https://doi.org/10.3389/fped.2016.00122

  32. Parsa A, Kao WHL, Xie D et al (2013) APOL1 risk variants, race, and progression of chronic kidney disease. N Engl J Med. https://doi.org/10.1056/NEJMoa1310345

  33. Friedman DJ (2017) A brief history of APOL1: a gene evolving. Semin Nephrol. https://doi.org/10.1016/j.semnephrol.2017.07.003

  34. Grams ME, Matsushita K, Sang Y et al (2014) Explaining the racial difference in AKI incidence. J Am Soc Nephrol. https://doi.org/10.1681/ASN.2013080867

  35. Zhao B, Lu Q, Cheng Y et al (2017) A genome-wide association study to identify single-nucleotide polymorphisms for acute kidney injury. Am J Respir Crit Care Med. https://doi.org/10.1164/rccm.201603-0518OC

  36. United States Renal Data System (2017) USRDS annual data report: epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda. https://doi.org/10.1053/j.ajkd.2017.01.020

  37. Neugarten J, Golestaneh L (2018) Female sex reduces the risk of hospital-associated acute kidney injury: a meta-analysis. BMC Nephrol. https://doi.org/10.1186/s12882-018-1122-z

  38. Grams ME, Waikar SS, MacMahon B, Whelton S, Ballew SH, Coresh J (2014) Performance and limitations of administrative data in the identification of AKI. Clin J Am Soc Nephrol. https://doi.org/10.2215/CJN.07650713

  39. Ko S, Venkatesan S, Nand K, Levidiotis V, Nelson C, Janus E (2018) International statistical classification of diseases and related health problems coding underestimates the incidence and prevalence of acute kidney injury and chronic kidney disease in general medical patients. Intern Med J. https://doi.org/10.1111/imj.13729

  40. Borzecki AM, Cevasco M, Chen Q, Shin M, Itani KMF, Rosen AK (2011) How valid is the AHRQ patient safety indicator postoperative physiologic and metabolic derangement? J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2011.01.001

  41. Waikar SS, Wald R, Chertow GM et al (2006) Validity of international classification of diseases, ninth revision, clinical modification codes for acute renal failure. J Am Soc Nephrol 17(6):1688–1694. https://doi.org/10.1681/ASN.2006010073

    Article  PubMed  Google Scholar 

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Acknowledgments

We would like to acknowledge all the HCUP Data Partners that contribute to HCUP because without their contributions, our work would not have been possible. The full list of state organizations can be found at: https://www.hcup-us.ahrq.gov/db/hcupdatapartners.jsp.

Funding

ECB was supported by NIH/NIDDK T32-DK00775 Training Grant.

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Authors and Affiliations

  1. Department of Pediatrics, Division of Nephrology, University of Alabama Birmingham, Birmingham, Alabama, 35233, USA

    Erica C. Bjornstad

  2. Department of Epidemiology, University of North Carolina Gillings School of Public Health, Chapel Hill, NC, USA

    Erica C. Bjornstad, Stephen W. Marshall, Yvonne M. Golightly & Emily W. Gower

  3. University of North Carolina Injury Prevention Research Center, Chapel Hill, NC, USA

    Stephen W. Marshall & Yvonne M. Golightly

  4. Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC, USA

    Amy K. Mottl & Keisha Gibson

  5. University of North Carolina Thurston Arthritis Research Center, Chapel Hill, NC, USA

    Yvonne M. Golightly

  6. Department of Surgery, University of North Carolina, Chapel Hill, NC, USA

    Anthony Charles

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Correspondence to Erica C. Bjornstad.

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The institutional review board at the University of North Carolina at Chapel Hill reviewed this secondary data analysis of de-identified data and classified this as non-human subjects research status.

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Bjornstad, E.C., Marshall, S.W., Mottl, A.K. et al. Racial and health insurance disparities in pediatric acute kidney injury in the USA. Pediatr Nephrol 35, 1085–1096 (2020). https://doi.org/10.1007/s00467-020-04470-1

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  • DOI: https://doi.org/10.1007/s00467-020-04470-1

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