The Association of Social Determinants of Health on Mortality among Adults with End-Stage Kidney Disease: a Systematic Review and Meta-Analysis

Synthesize evidence from published studies on end-stage kidney disease (ESKD) mortality and determine associations between social determinants of health (SDOH) and ESKD mortality. This PRISMA-guided study examined all published research across four electronic databases. Adults with ESKD living in the United States. Clinical trials, observational, cross-sectional, and prospective/retrospective cohort studies were considered if one or more of the five domains of SDOH were present in the analysis. Extraction was performed independently by two reviewers using a standardized form that captured study purpose and design, outcomes, SDOH domain, setting, participant characteristics, and description of results. A systematic review of all eligible studies was completed. A meta-analysis was conducted using the restricted maximum likelihood method for the random effects model to assess the association of SDOH with mortality. Subgroups were analyzed by SDOH domains. 86 studies met inclusion for the systematic review which were categorized by SDOH domain. Meta-analysis showed that those with higher levels of education (pooled HR 0.83 [95% CI, 0.69 − 0.1.00]) and those living in urban areas (pHR 0.92 [0.88–0.96]) had lower mortality risk. People from various minoritized backgrounds (Black-pHR 0.89 [0.85–0.93]; Asian-pHR 0.59 [0.55–0.64]; and American Indian/Alaska Native-pHR 0.82 [0.77–0.88]) had lower mortality risk compared to White populations. SDOH have a significant impact on mortality outcomes in persons with ESKD. The reductions in mortality risk reveal a survival paradox where it appears that minoritized groups have improved survival outcomes, but they are diagnosed with ESKD earlier than White populations and live on dialysis longer. It is critical to conduct research to develop strategies to mitigate individual social needs. Registered at PROSPERO: CRD42023483453.