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

摘要 在78万名患有终末期肾病（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，14.0%的35-49岁的ESRD患者患有严重的认知障碍，2.9%的患者患有合并症。 出现提示阿尔茨海默病和相关痴呆（AD/ADRD）的功能依赖。后 开始透析的老年（≥65岁）患者发生AD/ADRD的终生风险为21-25%。年轻ESRD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 ESRD患者发生认知障碍的可能性是其他患者的两倍多， 诊断为AD/ADRD;这种差异相当于年龄增加10岁。虽然系统性种族主义是一个 已知的贡献者在社区居住的老年人的健康差距，其对认知老化的影响， ESRD患者研究不足。衡量系统性种族主义（即，结构性、体制性和 人际关系）对于识别有过早认知老化风险的ESRD患者和 在种族主义面前能恢复过来的人阐明系统性种族主义影响认知能力的机制 老龄化将导致干预和政策，可能会防止AD/ADRD对234，000黑人的破坏 ESRD患者。我们寻求解决国家老龄化研究所（NIA）的目标（RFA-MD-21-004）：“阐明 是否以及如何建立机制，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，在多个层面上运作。ESRD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）所有患者都参加了一个 国家登记处和65%的医疗保险用于衡量制度性种族主义。对于所有成人ESRD患者， 国家登记处/医疗保险数据库，我们将收集23个结构性种族主义的指标，从公开的 收集数据，并确定3项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，由国家情报局资助的， 一项关于老龄化和ESRD的多中心、前瞻性队列研究（FAIR，n= 5，275），以充分表征系统性 种族主义（生命周期结构性种族主义、制度性种族主义和人际间种族主义）。这是最古老的（>12 年）ESRD队列研究，包括纵向测量整体和领域特异性认知功能。 国家肾脏基金会，阿尔茨海默氏症协会和当地社区咨询委员会将指导 （1）评估结构性和体制性种族主义的影响 2）量化生命周期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适应力是否可以防止认知障碍， 下降通过采取生命过程方法，让社区、家庭和患者利益相关者参与所有 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。 这些打击结构性种族主义的干预措施和政策的潜在目标可能会推广到其他国家， 慢性病患者。

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.