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

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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.