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Abstract: FR-OR86

County-Level Structural Racism Predicts Black-White ESKD Patient Mortality Disparities

Session Information

Category: Diversity and Equity in Kidney Health

  • 900 Diversity and Equity in Kidney Health


  • Daw, Jonathan, The Pennsylvania State University - University Park Campus, University Park, Pennsylvania, United States
  • Gillespie, Avrum, Temple University Health System Inc, Philadelphia, Pennsylvania, United States
  • Purnell, Tanjala S., Johns Hopkins Medicine, Baltimore, Maryland, United States

Despite numerous call for structural racism (SR) research in nephrology, no prior research has employed multidimensional, empirical measures of SR to racial disparities in ESKD mortality. We estimate the first-ever analysis of the role of SR in racial disparities in ESKD patient mortality.


We analyze data from United States Renal Data System (USRDS), American Community Survey 2006-10 (ACS), and Vera Institute (VI), linked by county. USRDS ESKD who were alive on Jan. 1, 2011 and lived in a county with ≥1,000 White and Black residents were included. SR was constructed from ACS and VI county Black-White disparities in imprisonment, homeownership, college graduation, median income, unemployment, poverty, and segregation. Black-White disparities in each measure were converted to county z-scores and summed. Patient person-months through Dec. 2019 were analyzed using complementary log-log discrete time survival models. Monthly ESKD treatment was assigned based on treatment received on 1st day of each month (hemodialysis, peritoneal dialysis, deceased donor kidney transplant, living donor kidney transplant). Models controlled for region, county racial composition, and patient gender and birth cohort.


Black race statistically significantly interacted with SR to predict monthly mortality risk among ESKD patients. Black patients experienced survival advantages compared to Whites at lower levels of SR, but experienced survival disadvantages compared to Whites at higher levels of SR. When stratified by monthly treatment, the core finding that Black survival advantages are eroded or erased at higher SR levels was replicated within each treatment group.


County-level SR is a significant determinant of ESKD patient mortality. Future research should prioritize including area-level measures of SR in ESKD disparities research.


  • NIDDK Support