Social Determinants of Health Negatively Impact Mortality Among Patients With ESKD

Key Takeaways:

• A systematic analysis of published studies relating to end-stage kidney disease (ESKD) found barriers to care across multiple domains: health care access and quality, health care education, economic stability, society and community, neighborhood and environment, and race and ethnicity.
• Access was found to be most affected by socioeconomic status, financial resources (including insurance coverage), education, and geographic location. All these areas disproportionately impact minority and marginalized groups.
• Since social determinants of health (SDOH) impact ESKD mortality, it is important to take them into account during clinical trials. Doing so can help physicians optimize care for underserved populations.

ESKD affects approximately 800 000 people in the US each year, and research has shown that marginalized groups are at greater risk. Researchers conducted a systematic review and meta-analysis of ESKD literature to determine associations between SDOH and ESKD mortality.

A comprehensive search across 5 medical databases (MEDLINE, CINAHL, Web of Science, PubMed, and CENTRAL) yielded 86 relevant studies. These studies explored the following domains: health care access and quality, health care education, economic stability, society and community, neighborhood and environment, and race and ethnicity.

Health Care Access and Quality

Articles relating to this domain considered access to providers, services, and facilities for patients with ESKD. The main barriers to care were limited providers and travel burdens.

Patients living in rural areas were less likely to have easy access to providers, which can lead to delays in diagnosis and treatment. Additionally, a finite number of providers means longer wait times to see a specialist.

Health Care Education

Education was found to have a significant influence on engagement with the health system. Language barriers along with disparities in health literacy and educational resources were associated with delayed treatment and ignorance of navigating the health care system.

Conversely, patients with higher levels of education were more likely to engage with the health system, seek out preventative care options, and adhere to treatment plans. Furthermore, higher education is typically associated with higher socioeconomic status, meaning more insurance coverage, better living conditions, and better access to facilities and providers.

The study’s meta-analysis found an inverse relationship between education level and mortality risk. It was estimated that patients with higher education had a 10% lower risk of EKSD mortality.

Economic Stability

A patient's financial means also contribute to long-term disease management. Underinsurance was frequently cited as an access barrier, revealing how coverage factors into medical decision-making. Additionally, patients with financial insecurity or a lack of paid sick leave were less likely to attend medical appointments, thus delaying care.

Society and Community

The presence of a support system was found to influence a patient’s engagement with the health care system. Patients with strong support systems had higher rates of treatment adherence, whereas socially isolated patients had less engagement with the system.

Studies discussing this domain also examined how discrimination and stigma contributed to medical mistrust, leaving patients to alienate themselves from the health care system and avoid seeking care entirely.

Neighborhood and Environment

This domain relates to a patient’s physical surroundings and daily living conditions. Patients living in areas with environmental pollutants, substandard housing, or limited green spaces had higher rates of respiratory and cardiovascular diseases.

Studies exploring this topic also address how neighborhood impacts access to care. Urban areas were found to have higher numbers of providers than rural areas. Additionally, patients living in urban regions had less travel burden since providers were in closer proximity, and public transportation was more readily available.

An analysis found that patients living in urban areas had approximately an 8% lower risk of ESKD mortality than patients living in rural areas.

Race and Ethnicity

Researchers also analyzed mortality rates across various racial and ethnic groups. Minority populations were found to have a reduced risk of ESKD mortality than White patients. American Indian or Alaskan Native patients had a 16% lower risk of mortality, Black patients had a 19% lower risk, and Asian patients had a 38% lower risk.

These findings reveal a survival paradox. While it appears that White patients are disadvantaged, this population has historically had greater access to health services, and thus more likely to receive preventative care and delay disease progression. Therefore, the higher mortality rate comprises patients diagnosed later in life or with more aggressive forms of kidney disease.

Social Determinants Impede Care Optimization

The various social determinants listed all influence care and mortality among patients with ESKD in some way. Socioeconomic status, education level, insurance coverage, and geographic location were identified as the most significant barriers to care.

The authors express the importance of consistently considering SDOH in clinical settings in order to fully understand the impact they have on patient outcomes.

They said, “By broadening the focus beyond conventional medical interventions, the healthcare researchers and clinicians can make substantive progress in addressing the complex social needs of individuals living with ESKD.”

Reference

Agyapong P, Longacre L, Brooks P, et al. The association of social determinants of health on mortality among adults with end-stage kidney disease: a systematic review and meta-analysis. J Racial Ethnic Health Disparities. 2026. doi:10.1007/s40615-026-02920-4