Neighborhood Socioeconomic Status and Cardiovascular Events in Adults With CKD: The CRIC Study

Abstract

Rationale & Objective: In the general population, neighborhood socioeconomic status (SES) has been found to be associated with cardiovascular risk, but this relationship has not been well studied among patients with chronic kidney disease (CKD). This study seeked to evaluate the association between neighborhood SES and cardiovascular outcomes in a CKD cohort. Study Design: Multicenter prospective cohort. Setting & Participants: In total, 3,197 participants in the Chronic Renal Insufficiency Cohort Study without cardiovascular disease at baseline. Exposure: Neighborhood SES quartiles using a validated neighborhood-level SES summary measure for 6 census-derived variables. Outcome: Incident heart failure, myocardial infarction, and all-cause death. Analytical Approach: Cox proportional hazards. Results: During median follow-up of 8.8 years, there were 465 incident heart failure events, 297 myocardial infarctions, and 891 deaths. In a fully adjusted model, among individuals with estimated glomerular filtration rate ≥45 mL/min/1.73 m2, lowest neighborhood SES quartile was associated with higher risk of heart failure (HR, 1.96 [95% CI, 1.04-3.67]) compared with the highest quartile. This association was not significant among those with estimated glomerular filtration rate <45 mL/min/1.73 m2 (P for interaction < 0.1). There was no association between neighborhood SES and myocardial infarction; however, in the same multivariable-adjusted model, less than high school education was associated with higher risk of myocardial infarction (HR, 1.52 [95% CI, 1.06-2.17]). Among those aged greater than 60 years, there was a significant association between the lowest neighborhood SES quartile and death (HR, 1.72 [95% CI, 1.06-2.78]), but this association was not significant among those aged 60 years and younger (P for interaction < 0.05). Limitations: Findings are subject to residual confounding and bias. Conclusions: In a CKD cohort, neighborhood-level SES was associated with incident heart failure among individuals with more preserved kidney function and death in those younger than 60 years. Policies and public health and health system interventions are needed to address individual- and neighborhood-level SES factors to improve outcomes for patients with CKD residing in disadvantaged communities. Plain-Language Summary: Because patients with chronic kidney disease (CKD) experience high rates of cardiovascular complications, we evaluated the relationship between neighborhood-level socioeconomic status (SES) and cardiovascular outcomes using data from the Chronic Renal Insufficiency Cohort Study. We found that residing in disadvantaged neighborhoods was associated with a higher risk of heart failure in those with milder CKD and a higher risk of death in those who were aged less than 60 years. These findings highlight the need for public health and health system interventions to address these disparities.

Keywords

• Chronic kidney disease
• health disparities
• neighborhood socioeconomic status