Structural Racism, Resilience, and Premature Cognitive Aging in End-stage Renal Disease

摘要 在78万患有终末期肾病(ESRD)的成年人中，只有13%的人具有正常的认知功能。我们 研究发现，在35-49岁的终末期肾病患者中，14.0%的人有严重的认知障碍，2.9%的人有严重的认知障碍。 出现功能性依赖提示阿尔茨海默病和相关痴呆症(AD/ADRD)。之后 开始透析的老年(≥65岁)患者终生患AD/ADRD21-25%的风险。较年轻的终末期肾病患者 经历过早的认知老化，需要在整个生命周期内研究认知和AD/ADRD。黑色 终末期肾病患者发生认知功能障碍的可能性是前者的两倍多，后者的可能性高出70%-78% 被诊断为AD/ADRD；这种差异相当于10岁的年龄增长。虽然系统性种族主义是一种 社区老年人健康差距的已知贡献者，其对老年人认知老化的影响 对终末期肾病患者的研究不足。衡量系统性种族主义(即结构性、制度性和 人际关系)对于识别有认知过早老化风险的终末期肾病患者和那些 在种族主义面前坚韧不拔的人。阐明系统性种族主义影响认知的机制 老龄化将导致干预措施和政策，可能防止234,000黑人遭受AD/ADRD的破坏 终末期肾病患者。我们寻求解决国家老龄研究所(NIA)的目标(RFA-MD-21-004)： 是否以及如何将结构性种族主义与包括认知在内的老龄化相关结果联系起来 和AD/ADRD，在多个层面上运行。终末期肾病患者是阐明这些问题的理想人群。 机制：1)30%的患者是黑人；2)87%的患者经历了过早的认知老化；3)所有患者都参加了 国家登记，65%在医疗保险中，用于衡量制度性种族主义。对于所有成年ESRD患者， 在国家登记处/医疗保险数据库中，我们将从公开资料中收集23个结构性种族主义指标 数据，并确定3个制度性种族主义指标。然后，我们将把这些数据与我们正在进行的、由NIA资助的 关于衰老和终末期肾病的多中心前瞻性队列研究(FIRE，n=5,275)，以全面描述系统性疾病 种族主义(终生结构性种族主义、体制性种族主义和人际种族主义)。这是最古老的(&gt；12 年)ESRD队列研究，包括纵向测量全球和特定领域的认知功能。 国家肾脏基金会、阿尔茨海默氏症协会和当地社区顾问委员会将指导 设计和解释以下目标：1)评估结构性和体制性种族主义的影响 关于AD/ADRD事件；2)量化生活过程系统性种族主义对认知障碍的贡献 和下降；以及3)测试对系统性种族主义的复原力是否防止认知障碍和 拒绝。通过采取生命周期方法，并让社区、家庭和患者利益相关者全面参与 在我们研究的各个阶段，我们将确定可行的目标，以提高面对系统性种族主义的复原力。 这些反对结构性种族主义的干预和政策的潜在目标可能会推广到其他 患有慢性病的人群。

ABSTRACT Only 13% of the 780,000 adults living with end-stage renal disease (ESRD) have normal cognitive function. We found that 14.0% of ESRD patients aged 35-49 experience severe cognitive impairment and 2.9% have a co- occurring functional dependence suggestive of Alzheimer’s disease and related dementia (AD/ADRD). After dialysis initiation older (≥65) patients experience a 21-25% lifetime risk of AD/ADRD. Younger ESRD patients experience premature cognitive aging requiring the study of cognition and AD/ADRD across the lifespan. Black ESRD patients are more than twice as likely to develop cognitive impairment and 70%-78% more likely to be diagnosed with AD/ADRD; this disparity is comparable to a 10 year increase in age. While systemic racism is a known contributor to health disparities in community-dwelling older adults, its impact on cognitive aging among ESRD patients is understudied. Measurement of systemic racism (i.e., structural, institutional, and interpersonal) is crucial to identifying ESRD patients who are at risk of premature cognitive aging and those who are resilient in the face of racism. Elucidating mechanisms by which systemic racism impacts cognitive aging will lead to interventions and policies that may prevent the devastation of AD/ADRD for 234,000 Black ESRD patients. We seek to address a National Institute on Aging (NIA) goal (RFA-MD-21-004): “To elucidate whether and how mechanisms connecting structural racism to aging-relevant outcomes, including cognition and AD/ADRD, operate on multiple levels.” ESRD patients are the ideal population to elucidate these mechanisms: 1) 30% of patients are Black; 2) 87% experience premature cognitive aging; 3) all enroll in a national registry and 65% in Medicare for measurement of institutional racism. For all adult ESRD patients in the national registry/Medicare database, we will glean 23 indicators of structural racism from publicly available data and identify 3 indicators of institutional racism. Then, we will link these data to our ongoing, NIA-funded, multi-center, prospective cohort study (FAIR, n=5,275) of aging and ESRD to fully characterize systemic racism (lifecourse structural racism, institutional racism, and interpersonal racism). This is the oldest (>12 years) ESRD cohort study that includes longitudinal measures global and domain specific cognitive function. The National Kidney Foundation, Alzheimer’s Association, and a local community advisory board will guide the design and interpretation of the following aims: 1) To estimate the impact of structural and institutional racism on incident AD/ADRD; 2) To quantify the contributions of lifecourse systemic racism on cognitive impairment and decline; and 3) To test whether resilience to systemic racism protects against cognitive impairment and decline. By taking a lifecourse approach and engaging community, family, and patient stakeholders in all phases of our study, we will identify feasible targets for improving resilience in the face of systemic racism. These potential targets for interventions and policies to counter structural racism will likely generalize to other populations with chronic diseases.