Boroumand Farzaneh, Lim Wai H, Bakar Shuvo, Gately Ryan, Lopez Pedro, Sabanayagam Dharshana, van Zwieten Anita, Zhu Lin, Wong Germaine, Teixeira-Pinto Armando
Sydney School of Public Health, University of Sydney, Sydney, Australia.
School of Mathematical and Physical Sciences, Macquarie University, Sydney, Australia.
Kidney Med. 2025 Jul 2;7(9):101061. doi: 10.1016/j.xkme.2025.101061. eCollection 2025 Sep.
RATIONALE & OBJECTIVE: Social gradient in health (a "social gradient in health" refers to the observed pattern in which individuals with lower socioeconomic status typically experience poorer health outcomes than those with higher socioeconomic status. This indicates that health disparities exist across different social levels, with the most disadvantaged groups experiencing the worst health outcomes) is significant and established in patients with kidney failure, but the pathways of this relationship are unknown. We aimed to assess the mediating effects of multimorbidity and geographical remoteness in the socioeconomic status (SES)-death associations.
A cohort study.
SETTING & PARTICIPANTS: All patients with kidney failure aged 18 years and above, who commenced dialysis in Australia from 2005 to 2019.
Area-level SES.
All-cause and cause-specific death.
The effect of SES on all-cause and cause-specific death was analyzed using the inverse probability stabilized weighting. Mediating effects of geographical remoteness, diabetes mellitus (DM) and cardiovascular disease (CVD) on the association between lower SES and all-cause and cause-specific death were explored.
A total of 35,239 patients receiving incident dialysis were included, with a median (p25, p75) follow-up period of 3.3 (1.7-5.9) years. Compared with patients from higher SES, the average hazard rate for all-cause death among those from lower SES was 17% higher (total effect [TE] = 0.17, 95% CI [0.12-0.23]). Proportions of the effects between SES and all-cause mortality mediated by geographical remoteness, CVD, and DM were 29.4%, 11.8%, 17.6%, respectively, whereas SES explained 41.2% of the TE directly. Compared with patients from high SES, patients from lower SES have on average a higher hazard rate of CVD (TE = 0.26, 95% CI, [0.15-0.38]) and infection-related deaths (TE = 0.12, 95% CI, [0-0.25]). The effects of SES on CVD and infection-related deaths were mediated by CVD and DM, but not geographical remoteness.
Potential residual confounding and other latent mediators.
Geographical remoteness, diabetes, and CVD are potential mediators that lie in the pathways between SES and all-cause and cause-specific deaths. A multifaceted approach with sustained efforts from multiple sectors to address these factors may reduce the social disparities observed in patients treated with dialysis.
健康方面的社会梯度（“健康方面的社会梯度”指的是一种观察到的模式，即社会经济地位较低的个体通常比社会经济地位较高的个体健康状况更差。这表明不同社会阶层存在健康差距，最弱势群体的健康状况最差）在肾衰竭患者中很显著且已得到证实，但这种关系的途径尚不清楚。我们旨在评估多种疾病并存和地理位置偏远在社会经济地位（SES）与死亡关联中的中介作用。
队列研究。
2005年至2019年在澳大利亚开始透析的所有18岁及以上的肾衰竭患者。
地区层面的SES。
全因死亡和特定原因死亡。
使用逆概率稳定加权分析SES对全因死亡和特定原因死亡的影响。探讨地理位置偏远、糖尿病（DM）和心血管疾病（CVD）对较低SES与全因死亡和特定原因死亡之间关联的中介作用。
共纳入35239例接受首次透析的患者，中位（第25百分位数，第75百分位数）随访期为3.3（1.7 - 5.9）年。与SES较高的患者相比，SES较低的患者全因死亡的平均风险率高17%（总效应[TE]=0.17，95%置信区间[0.12 - 0.23]）。地理位置偏远、CVD和DM介导的SES与全因死亡率之间的效应比例分别为29.4%、11.8%、17.6%，而SES直接解释了41.2%的总效应。与SES高的患者相比，SES低的患者CVD（TE = 0.26，95%置信区间，[0.15 - 0.38]）和感染相关死亡（TE = 0.12，95%置信区间，[0 - 0.25]）的平均风险率更高。SES对CVD和感染相关死亡的影响由CVD和DM介导，但不由地理位置偏远介导。
潜在的残余混杂因素和其他潜在中介因素。
地理位置偏远、糖尿病和CVD是SES与全因死亡和特定原因死亡之间途径中的潜在中介因素。多部门持续努力采取多方面方法来解决这些因素，可能会减少透析患者中观察到的社会差距。
