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Abstract: SA-PO029

Risk of ESKD and Death Among Homeless Veterans with Incident CKD

Session Information

Category: Diversity and Equity in Kidney Health

  • 900 Diversity and Equity in Kidney Health


  • Koyama, Alain K., Centers for Disease Control and Prevention, Atlanta, Georgia, United States
  • Nee, Robert, Walter Reed National Military Medical Center, Bethesda, Maryland, United States
  • Yu, Wei, University of Virginia, Charlottesville, Virginia, United States
  • Choudhury, Devasmita, University of Virginia, Charlottesville, Virginia, United States
  • Heng, Fei, University of North Florida, Jacksonville, Florida, United States
  • Cheung, Alfred K., VA Salt Lake City Health Care System, Salt Lake City, Utah, United States
  • Norris, Keith C., University of California Los Angeles, Los Angeles, California, United States
  • Cho, Monique E., VA Salt Lake City Health Care System, Salt Lake City, Utah, United States
  • Yan, Guofen, University of Virginia, Charlottesville, Virginia, United States

Chronic kidney disease (CKD) requires comprehensive management to limit disease progression, a particular challenge among the homeless. We evaluated the risk of end-stage kidney disease (ESKD), defined by transplant or dialysis requirement, and death among homeless veterans with incident CKD in the US Veterans Health Administration (VHA).


Incident CKD was defined as the first time estimated glomerular filtration rate (eGFR) decreased to <60 mL/min/1.73 m2 for >3 months. We excluded veterans with <2 years of VHA care prior to diagnosis of incident CKD or those with pre-existing ESKD. Homelessness was defined using VHA specific codes and/or ICD diagnosis codes for homelessness recorded ≥1 time during the 2 years prior to incident CKD. Cox proportional hazards models examined the association between homeless status and risk for ESKD and death.


An incident CKD cohort of 836,361 veterans were identified from 2005-2017, with follow-up through 2018. A total of 46,561 veterans (6%) were identified as homeless. In a model adjusted for age, sex, race, incident CKD year and eGFR, homelessness was significantly associated with a 6% increased risk of ESKD and a 46% increased risk of death. Further adjustment for variables that may be both a cause and consequence of homelessness (body mass index, comorbidities, use of renin-angiotensin-aldosterone system antagonists and statins, behavioral factors) attenuated findings for both outcomes. Therefore, the abovementioned factors may in part explain the observed associations between homelessness and ESKD and death.


The hazard for ESKD or death is significantly higher among homeless veterans compared to thosenot experiencing homelessness, and the increased risk is partly driven by modifiable factors. These findings emphasize the importance of housing and comprehensive health care in addressing the difficulties in CKD management among homeless veterans.

Hazard Ratios and 95% Confidence Intervals for the Association Between Homeless Status and ESKD or Death Among Adult Veterans
 Model 1Model 2Model 3
Kidney failure1.91 (1.83-1.99)1.15 (1.10-1.20)1.06 (1.02-1.11)
Death1.01 (1.00-1.03)1.48 (1.46-1.50)1.46 (1.44-1.48)

Model 1: unadjusted; Model 2 adjusts for age, sex, race, incident year; Model 3 additionally adjusts for eGFR;


  • Other NIH Support