Date of Award

2022

Embargo Period

12-14-2027

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Health Sciences

College

College of Graduate Studies

First Advisor

Kelly J. Hunt, PhD

Second Advisor

Roberto Pisoni, MD, MSCR

Third Advisor

Bethany J. Wolf, PhD

Fourth Advisor

David J. Taber, PharmD

Fifth Advisor

John L. Pearce, PhD

Abstract

As the aging population continues to grow so does the prevalence of chronic kidney disease (CKD) and the need for adequate CKD management in those 65 or over who are highly heterogenous in their disease progression. Hospitalization rates for acute kidney injury (AKI) are increasing, especially amongst older adults (≥65) who are at elevated risk given their high comorbidity burden and susceptibility to nephrotoxins. Previous epidemiologic analyses of AKI have focused on hospitalized populations which may bias results towards sicker populations; particularly when results are extrapolated to ambulatory CKD populations. Studies on social determinants of health (SDOH) and disease progression in CKD populations are limited, both in number and range of key areas, especially among older adults who become more vulnerable to stressors as they age. To fill these gaps in the literature, we obtained information on select social and clinical factors and examined their relationship with progression to end-stage renal disease (ESRD) in Veterans ≥65 years of age with incident CKD stage 4 using national VA administrative data. We hypothesize several points: first, that AKI is associated with ESRD, and age is an effect modifier of this relationship; second, an AKI and a rapidly declining kidney function are jointly associated with ESRD; third, a high social vulnerability at the census tract level based on the CDC’s Social Vulnerability Index (SVI) is associated with ESRD. This dissertation identified several clinically relevant joint effects associated with ESRD. However, more Veterans died than progressed to ESRD. Traditional methods of CKD management through means of achieving appropriate target controls can help mitigate the risk of death in this population who have a high comorbidity burden. Outsourcing to primary care or specialty care to alleviate the burden on nephrology should be considered in this group.

Rights

Copyright is held by the author. All rights reserved.

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Available for download on Tuesday, December 14, 2027

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