The Prevalence of End Stage Renal Disease in 55-60 African American Males
Purpose of the study,
The objective of this study is to engage in in-depth literature review process to provide an understanding of the prevalence of end-stage renal disease in 50-60 years African American males in Florida United States. Through the, review process it will be possible to assess the determining factors that have been identified by scholars and the techniques that could be used in the development of reputable medical approaches towards mitigation of the disease.
Chronic kidney disease is currently one of the major health problems in the United States and on the global platform. This is because according to existing studies about 26 million adults in the United States have non-dialysis dependent kidney disease and more than 500,000 suffer from end stage renal disease. Collectively, this is representative of approximately 12.5% of the population of the United States (Lipworth et al, 2012). These figures are expected to rise in the next two decades considering that more than two million people will be expected to receive renal replacement therapy. In the United States, African Americans shoulder a burden of end stage renal disease. This is because they constitute approximately 30 % of the disease population (Lipworth et al, 2012). The increased risk and prevalence of this disease among African Americans males aged 50-60 has been established by a large number of studies and the objective of eliminating this racial disparity has become part of the United States national health care agenda. The reasons for racial disparities in the prevalence of end-stage renal disease among African Americans are not fully understood. However, they have been explanations partly focusing on modifiable risk factors such as socio-economic issues, lifestyle, and cultural practices. Co-existing medical conditions have also been used in explaining the racial disparities detailing reasons for the prevalence of the disease. It is likely that a complete picture into understanding the prevalence of this disease among African Americans males aged 50-60 involves an incorporation of a complex interaction between genetic, environmental and socio-cultural factors. The global society is defined by high-level sensitivity and the promotion of equality. From an ethical and moral authority, it is necessary for the global society to address the existing racial disparities from a health care perspective in the prevalence, and treatment of chronic kidney disease with particular interest in end stage renal disease (Lipworth et al, 2012). Through the development of a better understanding of the positive and negative ethic and racial disparities, it will be possible to yield important comprehensions that inform future research initiatives and improve health outcomes for all patients afflicted with end stage renal disease.
The study will embrace a mixed research method in collecting both qualitative and quantitative data through a literature review process. The literature review process will provide an in-depth understanding of the underlying factors that can be used in explaining the prevalence of end stage renal disease among African Americans males. By understanding these factors from the general U.S and global population, it will be possible to develop strategies of managing the disease among African American male population in Florida. Furthermore, through the mixed research method the study will be able to solve the disparities arising from the weaknesses of both qualitative and quantitative research approaches. This will not only enhance the objectivity of the study but also ensure that the resulting recommendations are informed by an array of reputable data gathered from peer-reviewed publications.
According to Norris and Agodoa (2005), the socioeconomic status of patients has a significant effect on the prevalence and treatment of end stage renal disease. These include variables such as low income, poor education background, poor healthcare services, and residing in low income areas. In the United States about 67% of people living in urban poverty areas are African Americans, 12% represent the white while 20% are Hispanics. In addition, the proportions of male Hispanic and African American population living below the federal poverty line are at 28 and 32% respectively compared to 11% of the white population. Poverty is often related to suboptimal house settings, which often leads to surplus exposure to ecological pollutants such as lead. The danger of exposure to contaminants such as lead is associated with an increase in the level of hypertension and weakened renal function.
While referring to the NHANES III study, Norris and Agodoa (2005) realized that from a medical perspective, when compared to the racially white male population, African Americans males have a higher blood lead concentration, which is associated with hypertension and increased blood pressure. Reduced socioeconomic status also has negative effect on access to proper health care, access to health solutions such as kidney transplant and increased mortality among patients with end stage renal disease aged 50-60. According to Norris and Agodoa (2005) in 2001, approximately 45% of African American males and 55% of Hispanic were uninsured or could only receive publically subsidized healthcare compared to 22% of the white population. This means that in such a society those living in abject poverty, despite the increasing need for better health care, often receive the least effective health care. The low socioeconomic status has an effect on the ability of patients to access qualified medical personnel because of delayed referral of patients with chronic kidney disease. This limits the potential for effective and timely interventions that could slow down the progression or minimize possible complications. It is also associated with prolonged stay in hospitals, increased medical expenses, and higher mortality rates.
In the United States, according to Norris and Agodoa (2005), racial minorities such as African Americans and Hispanics are less likely to attain immediate referrals to a nephrologist and undergo timely renal replacement. This can be attributed, at least in part, to lack of health insurance and poverty among other socioeconomic factors. Findings from recent population based studies assert that there is a high probability that the situation will be more complex since with the increase in advocacy for health insurance and the ability of more African Americans to adjust their insurance status, race and socio-economic status have not adversely affected the treatment of chronic kidney disease. This suggests the existence of some level of interdependence among these factors.
Culture in the view of Norris and Agodoa (2005) plays a significant role in informing the attitudes of a society towards healthcare. This includes their perception of illnesses and the best possible remedy. Cultural beliefs also have an effect on lifestyle factors such as diet, a pattern of physical activity, weight, and attitude towards body size. While referring to one of the recent studies in the United States, Norris and Agodoa (2005) found that African Americans males were more likely to be listed as kidney donors compared to their white counterparts. Among these individuals there is often greater willingness to donate when approached by health care workers with similar cultural identities, who have had personal experiences with end-stage renal disease of has some academic background or understanding of the disease. This means that it is necessary for medical practitioners to operate on the awareness of the existing cultural barriers and their effect on the management of end stage renal disease.
From the perspective of pharmacologic intervention, Lipworth et al (2012) assert that there have been studies of inhibitors of renin-angiotensin-aldosterone system (RAAS) aimed demonstrating an improvement in chronic kidney disease among African American males. From the study, there was evidence of a reduction in hypertensive response among African Americans who were receiving RAAS inhibitor monotherapy and relatively role reduction in mortality rates among African Americans suffering from left ventricular hypertrophy. Form the study African American males suffering from hypertension were less likely to show improved clinical outcomes even after the administration of RAAS inhibitors.
While referring to the African American Study of kidney Disease and Hypertension, Norris and Agodoa (2005) assert that the administration of RAAS inhibitors can lead to significant improvement in the clinical outcomes among African Americans males suffering from hypertensive nephropathy. This is because for patients subjected to treatment with angiotensin-converting enzyme (ACE), inhibitor, there is a reduction in the rate of renal events and death. Furthermore, it also contributes to the reduction of incidences of type 2 diabetes mellitus among African Americans. The study by AASK is important giving the prevalence of end stage renal disease among African American males and the fact that data from previous studies have resulted in low usage of RAAS inhibitors as primary therapy among the African American population. The low use of RAAS inhibitor among this high-risk subgroup can be considered as a major contributor to the disproportionate burden of end stage renal disease among African American males compared to the white males.
One of the most common features in access to medical care among African Americans, according to Lipworth et al (2012), is late referral to a nephrologist. This is because of the frequency in the use of synthesis grafts instead of autologous arteriovenous fistulas as the choice for vascular access. The frequency of this choice to vascular access explains why African American males are more likely compared to their white counterparts to be subject to synthetic grafts for vascular access before hemodialysis. This occurs despite potential threats associated with increased rates of thrombosis and infections in the use of such devices.
Additional factors for the prevalence of end stage kidney disease among African American males aged 50-60 include the administration of a lower dose of hemolysis, which is associated with increased mortality when patients of all races are subjected to a common evaluation process. According to Norris and Agodoa (2005), African American males are more likely to receive a lower than required dose of hemolysis compared to the white and the reasons for this phenomenon are largely unknown. In terms of survival outcomes, African American males appear to be less sensitive to lower doses of hemodialysis unlike white patient whose reactions are characterized by lesser tolerance to lower urea reduction ratios. According to recent studies, lower urea reduction ratios among African American males is a consequent of larger urea distribution volume considering that on average these patients have greater body weight, higher total body volume, and larger body surface area compared to white Americans. Other factors contributing to this phenomenon include improved access to medical care, selective survival, and the initiation of renal replacement therapy. Existing evidence suggest that African American males with end stage renal disease on dialysis live longer compared to their white counterparts. There are numerous reason for explain this occurrence and they include, lower rates for renal replacement therapy and survival bias.
Figure 1.0 Prospect of death by gender and race for urea reduction ratio
The field of kidney disease management according to Lipworth et al (2012) is characterized a predominantly white donor population in the United States. This means that African American males who comprise part of the majority end stage renal disease patients are disadvantaged in their chances of receiving a suitable kidney. This situation has been necessitated by lower level of organ donations among African Americans because of a plethora of cultural and socioeconomic factors. Compared to the white population, African American males are less likely to be referred for kidney evaluation at transplant centers, placed on a transplant waiting list of has received a transplant. The existing racial and ethnic differences in accessing organ transplantation have remained significant even after institutional adjustments in terms of patient preferences, perceptions of health care, socio demographic factors, and comorbidities.
While referring to a study of 300 nephrologists in four regions in the United States, Lipworth et al (2012) argue that inability to complete pretransplant evaluations and comorbidities accounted for the differences in referral rates. African American males are often the less likely candidates to be considered for organ transplant and they are more likely to have an incomplete workup. Additional factors for less consideration for kidney transplant among African Americans include presence of active infections and non-cardiac comorbidities. Among patients considered suitable for transplant, African American males are less likely to receive a transplant partly because of institutional racism, which is characterized by bias, prejudice, and stereotypes by health care providers. Additional factors contributing to racial disparities in access rates of kidney transplantation is the belief among healthcare providers that transplantation is less effective in prolonging life compared to other approaches such as dialysis for African Americans.
Inasmuch as higher survival rates from transplantation has been recorded among whites, compared to African Americans, Lipworth et al (2012) indicate that on average the survival benefits of transportation compared to dialysis is significant for both racial groups. If among physical the common perception is that transplantation is less effective for African American patients with chronic kidney disease then they are more likely to advocate for dialysis as a treatment option. This form of bias may also contribute to ineffective communication between physician and patients regarding treatment choices hence the resulting delay may contribute to increased prevalence of end stage renal disease among African American males aged 50-60 years.
Figure 2.0 The percentage of successful African American and white American kidney transplant patients by stage in the United States
Previous studies, according to Lipworth et al (2012), reported that initially African American males who received renal transplant had a high probability of suffering long-term graft failure compared to the white population. This was partly attributed to socioeconomic factor such as disparities in the patients’ insurance status and differences in haplotype matching. However, the introduction of more effective immunosuppressive therapies has contributed to a reduction in the existing disparities. The challenge arising from this development in the medical field includes the inability of African American males suffering from chronic kidney disease to afford the medication in a timely and consistent manner. Lack of consistency in accessing effective post kidney transplant among African Americans can be used in explaining the prevalence of end renal disease among the male population of this ethnic minority in the United States.
From the literature review, it is evident that chronic kidney disease whose management is dependent on the prevalence of end stage renal disease is major health care problem in the United States. Among African American males aged 50-60, the disease is prevalent because of socioeconomic, genetic, medical, and cultural factors that affect this group. Majority of African American males aged 50-60 live below the poverty line and this explains why they may face challenges in accessing proper medical care, proper food, and housing. Exposure to a plethora of risk factors such as toxins, poor diet and inability to access insured medical care have resulted to an increase in the prevalence of end stage renal disease among this group of Africa Americans.
The cultural and racial factors that contribute to the attitudes and perceptions developed by African American males towards medical personnel and the prejudice necessitated by racial bias among medical personnel have also contributed to the prevalence of the disease. This is because through these factors it becomes relatively difficult for patients to perceive access to proper medical care as essential in enhancing their ability to manage chronic kidney disease. In addition, racial biases necessitated by stereotypical connotations among physicians contribute to limited referrals for expert attention by physicians at the low rate of clearance of African American males to access kidney transplant as an effective way of managing renal diseases. Furthermore, through bias it has become relatively difficult for physicians to engage in effective and objective management of chronic kidney disease among African American males hence contributing to high prevalence.
In Central Florida, it is necessary for stakeholders in the field of medical care to engage in the development of innovative ways targeting African American males with the greatest risk of chronic kidney disease to ensure they receive appropriate and timely intervention to enhance the reduction or elimination of progression to end stage renal disease. These would include screening programs for identifying individuals at risk of chronic kidney disease and provide early intervention. Furthermore, increased funding for publicly available healthcare for chronic kidney disease would enhance improved access to healthcare and timely referral to expert physicians for those with low socioeconomic status. Eductaion directed towards primary care givers, physicians and patients would-be effective in overcoming the existing health beliefs and behavior defined by cultural differences. For African American males aged 50-60, adherence to treatment and referral for chronic kidney disease may be improved when healthcare recommendations are provided in a respectful and culturally considerate manner. Initiatives such as an increase in the number of minority physicians practicing within their own communities may facilitate the reduction of some of these cultural barriers.
In the United States, African Americans shoulder a burden of end stage renal disease. This is because they constitute approximately 30 % of the disease population. The increased risk and prevalence of this disease among African Americans males aged 50-60 can be attributed to cultural, socioeconomic, genetic and racial factors which contribute in varieties of capacities. To address this prevalence in Central Florida, United States, stakeholders must develop innovative ways for appropriate and timely intervention to enhance the reduction or elimination of progression to end stage renal disease. Increase in medical funding to improve access to healthcare and timely referrals for those at greatest risk. Educating primary care givers, physicians and patients would-to overcome cultural and racial beliefs on healthcare. Advocacy for adherence to treatment among African American males aged 50-60.
Lipworth. L., Mumma, M. T., Cavanaugh, K. L., Edwards, T. & Ikizler, T. A, (2012) Incidence
and Predictors of End Stage Renal Disease among Low-Income Blacks and Whites. PLoS ONE 7(10): e48407. doi:10.1371/journal.pone.0048407
Norris, K & Agodoa, L. (2005).Unraveling the racial disparities associated with kidney disease.
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