Need for reform in perinatal care to dislodge racial disparities in neonatal acute kidney injuries

Systemic racial disparity in health care is not a new topic for the health care community. Despite being a social construct with no underlying biological basis, race has historically been used to rationalize the persistent gaps in health outcomes among different racial demographics. However, in light of health care reform that focuses on health care delivery as the target for change, many researchers are reviewing the socioeconomic and psychosocial contributors to discrepancies in patient care.

One such researcher is Ray Bignall II, MD, FAAP, FASN, director of Kidney Health Advocacy and Community Engagement in the Division of Nephrology and Hypertension at Nationwide Children’s Hospital and assistant professor of Pediatrics at The Ohio State University College of Medicine. In a commentary on a national study reviewing the trends in racial disparity among premature infants with acute kidney injury (AKI), Dr. Bignall and his co-authors have identified room for research and advocacy that dispels race’s role in biological outcomes. More specifically, he targets areas for reform in perinatal care by conducting the first study that identifies and reports racial disparities in AKI among infants.

“White preterm babies have significantly less AKI than Black infants, with an increased prevalence of AKI among Black infants,” says Dr. Bignall. “The presence of disparity in prenatal care for Black patients lies parallel with discrepancies in preterm birth rates, with rates of prematurity being 1.5 times greater for Black births compared to non-Black births. As impairment in nephrogenesis, or kidney development, is a central concern for premature, low birth weight infants, it is essential to define the web of contributors. We must study the close interplay between social determinants, pathological risks to prematurity and resulting health outcomes to identify and prevent detrimental determinants of AKI.”

Identifying disparities in NICU care, outcomes and AKI diagnosis standards



Dr. Bignall says that to competently address racial disparities in the neonatal intensive care unit (NICU), the medical community must recognize disparities in pregnancy and preterm birth rates. Black women experience greater rates of pregnancy-related death and premature labor than white women, and physicians should redefine the proactive and reactive treatment mechanisms for vulnerable populations.

Dr. Bignall theorizes that differences in perinatal health outcomes may be attributed to a lack of access to equitable prenatal and NICU care, as well as variations in health care coverage, management of pre-existing conditions and social determinants of health. He stresses that further research and analysis is needed to help explain the complex interface between prenatal care, neonatal care, preterm births and AKI prevalence. Aside from these factors, Dr. Bignall finds that even more problems lie ahead.



His commentary documents the inaccurate reporting of neonatal AKI rates among different studies, adding that their reliance on medical record documentation for data results in underreporting.



“Low rates of AKI reporting in infants are multifactorial in nature, as there are multiple steps between an infant having AKI and a neonatologist making a diagnosis of AKI in the medical record,” says Dr. Bignall.

“This must be addressed as AKI presents significant early life implications and consequences along the life course, with 70%-80% of AKI patients developing chronic kidney disease.”



Infants must be recognized as being at high risk for AKI before being screened for the condition, with risk criteria varying among studies. Differences in measurement guidelines further scatter data. Commonly used to detect changes in kidney function, serum creatinine and urine output must be closely monitored. However, Dr. Bignall remarks that the varying frequency and intensity of monitoring among NICUs brings the need for a standardized approach.



“Essentially, we can streamline and standardize the neonatal diagnosis of AKI through the following initiatives: promote a culture of equity, identify social risks, provide respective preventive measures, maintain support through infancy, develop robust quality improvement measures to ensure equitable, high-quality hospital and follow-up care, and advocate for social justice at local, state and national levels,” says Dr. Bignall. “We can do this by improving neonatal AKI knowledge among all stakeholders of infant care, acknowledging implicit bias and disparity, and improving the quality and scope of communication, care and measurement tools relative to neonatal AKI.”

Redefining avenues for research in underlying causes of neonatal AKI disparity

Previous studies have attempted to define racial disparities in neonatal AKI rates through genetic risk, observing the presence of apolipoprotein L1. However, no clinically relevant studies have supported this relationship. Furthermore, only 13% of Black patients carry this gene. Dr. Bignall’s commentary notes that this suggests a stronger connection between maternal utero factors over genetic influence, and that future research should delve beyond race.



“The quest to eliminate racial disparities in neonatal AKI outcomes is unlikely to result in the identification of some elusive allelic variation that predisposes Black babies to this adversity,” says Dr. Bignall. “Instead, it will likely require an ‘all hands-on deck’ approach to decreasing the incidence of preterm birth, and mitigating the harm of structural racism and other social determinants of health on neonates both inside and outside of the NICU.”

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Citation

Bignall ONR 2nd, Harer MW, Sanderson KR, Starr MC. Commentary on “Trends and Racial Disparities for Acute Kidney Injury in Premature Infants: the US National Database” [published online ahead of print, 2021 Apr 8]. Pediatr Nephrol. 2021;10.1007/s00467-021-05062-3. doi:10.1007/s00467-021-05062-3

Elgendy MM, Othman HF, Younis M, Puthuraya S, Matar RB, Aly H. Trends and racial disparities for acute kidney injury in premature infants: the US national database [published online ahead of print, 2021 Feb 22]. Pediatr Nephrol. 2021;10.1007/s00467-021-04998-w. doi:10.1007/s00467-021-04998-w