Article

Prevalence and Correlates of CKD in Hispanics/Latinosin the United States

Ana C. Ricardo, Michael F. Flessner, John H. Eckfeldt, Paul W. Eggers, Nora Franceschini, Alan S. Go,Nathan M. Gotman, Holly J. Kramer, John W. Kusek, Laura R. Loehr, Michal L. Melamed, Carmen A. Peralta,Leopoldo Raij, Sylvia E. Rosas, Gregory A. Talavera, and James P. Lash

AbstractBackground and objectives The prevalence of ESRD among Hispanics/Latinos is 2-fold higher than innon-Hispanic whites. However, little is known about the prevalence of earlier stages of CKD amongHispanics/Latinos. This study estimated the prevalence of CKD in US Hispanics/Latinos.

Design, setting, participants, & measurements This was a cross-sectional study of 15,161 US Hispanic/Latinoadults of Cuban, Dominican, Mexican, Puerto Rican, Central American, and South American backgroundsenrolled in themulticenter, prospective, population-based Hispanic Community Health Study/Study of Latinos(HCHS/SOL). In addition, the prevalence of CKD in Hispanics/Latinos was compared with other racial/ethnicgroups in the 2007–2010 National Health and Nutrition Examination Survey (NHANES). Prevalent CKD wasdefined as an eGFR ,60 ml/min per 1.73 m2 (estimated with the 2012 Chronic Kidney Disease EpidemiologyCollaboration eGFR creatinine-cystatin C equation) or albuminuria based on sex-specific cut points determinedat a single point in time.

Results The overall prevalence of CKD among Hispanics/Latinos was 13.7%. Among women, the prevalence ofCKD was 13.0%, and it was lowest in persons with South American background (7.4%) and highest (16.6%) inpersons with Puerto Rican background. In men, the prevalence of CKD was 15.3%, and it was lowest (11.2%) inpersons with South American background and highest in those who identified their Hispanic background as“other” (16.0%). The overall prevalence of CKDwas similar in HCHS/SOL compared with non-Hispanic whitesin NHANES. However, prevalence was higher in HCHS/SOL men and lower in HCHS/SOL women versusNHANES non-Hispanic whites. Low income, diabetes mellitus, hypertension, and cardiovascular disease wereeach significantly associated with higher risk of CKD.

Conclusions Among US Hispanic/Latino adults, there was significant variation in CKD prevalence amongHispanic/Latino background groups, and CKD was associated with established cardiovascular risk factors.

Clin J Am Soc Nephrol 10: 1757–1766, 2015. doi: 10.2215/CJN.02020215

IntroductionHispanics/Latinos are the largest minority group inthe United States and this population is projected tobecome one-third of the US population by 2060 (1). Inaddition, Hispanics/Latinos are culturally, socioeco-nomically, and genetically heterogeneous andrepresent a wide variety of national origins (2).CKD is a major health problem in the United Statesand recent evidence suggests that Hispanics/Latinosare disproportionately affected. Over 90,000 USHispanics/Latinos with ESRD were treated by hemo-dialysis in 2011, and the rate of incident ESRD amongHispanics/Latinos is 50% greater than in non-Hispanics(3). However, little is known about the prevalence ofearlier stages of CKD. Estimates of the prevalence ofCKD in the United States are principally derivedfrom the National Health and Nutrition Examina-tion Survey (NHANES). Because NHANES studiedmainly Mexican Americans (one-half of which were

US born), our understanding of differences in CKDprevalence among major Hispanic/Latino backgroundgroups is incomplete. We studied the prevalence andrisk factors associated with CKD in a group of His-panic Americans with a broad range of ethnic back-grounds who were enrolled in a community-basedcohort representative of the US Hispanic/Latinopopulation.

Materials and MethodsStudy ParticipantsThe Hispanic Community Health Study/Study of

Latinos (HCHS/SOL) is a population-based cohort of16,415 Hispanics/Latinos aged 18–74 years from ran-domly selected households in four US field centers(Chicago, Illinois; Miami, Florida; Bronx, New York;and San Diego, California) with baseline examination(2008–2011) and yearly telephone follow-up assess-ment. Participants self-reported their background as

Due to the number ofcontributing authors,the affiliations areprovided in theSupplementalMaterial.

Correspondence:Dr. Ana C. Ricardo,Division ofNephrology,Department ofMedicine, Universityof Illinois, 820 SouthWood Street, M/C793, CSN 418W,Chicago, IL 60612.Email: aricar2@uic.edu

www.cjasn.org Vol 10 October, 2015 Copyright © 2015 by the American Society of Nephrology 1757

Cuban, Dominican, Mexican, Puerto Rican, or Central orSouth American. The category “other” was used for partici-pants belonging to a group not listed or to more than onegroup. The sample design and cohort selection were previ-ously described (4,5). Briefly, a stratified two-stage area prob-ability sample of household addresses was selected in eachfield center. The first sampling stage randomly selected cen-sus block groups with stratification based on Hispanic/Latinoconcentration and proportion of high/low socioeconomic sta-tus. The second sampling stage randomly selected house-holds, with stratification, from US Postal Service registriesthat covered the randomly selected census block groups. Fi-nally, the study oversampled the group aged 45–74 years(n=9714, 59.2%) to facilitate examination of target outcomes.Sampling weights were generated to reflect the probabilitiesof selection at each stage. Of 39,384 individuals who werescreened and selected and who met eligibility criteria, 41.7%were enrolled, representing 16,415 persons from 9872 house-holds. This study adheres to the Declaration of Helsinki andwas approved by the institutional review boards at each fieldcenter where all participants gave written consent.

Data Collection and Variable DefinitionThe baseline study examination included clinical measure-

ments, questionnaires, and fasting venous blood and urinespecimens. Demographic factors, socioeconomic status, ac-culturation, cigarette smoking, and medical history wereobtained using standard questionnaires. Medication use wasascertained by conducting an inventory of all currently usedmedications. BPs were defined as the average of the secondand third of three repeat seated measurements obtainedafter a 5-minute rest. Hypertension was defined as systolicBP $140 mmHg, diastolic BP $90 mmHg, or use of antihy-pertensive medication. Diabetes mellitus was defined asfasting plasma glucose of $126 mg/dl, 2-hour postload glu-cose levels of $200 mg/dl, a hemoglobin A1c level of$6.5%, or use of antidiabetes medication. The presence ofcardiovascular disease was self-reported. CKD awarenesswas ascertained by asking the following question: “Has adoctor ever said that you have kidney problems?”

Kidney Function MeasurementsCreatinine was measured in serum and urine on a Roche

Modular P Chemistry Analyzer using a creatinase enzy-matic method (Roche Diagnostics, Indianapolis, IN). Serumcreatinine measurements are isotope dilution mass spec-trometry traceable. Urine albumin was measured using animmunoturbidimetric method on the ProSpec nephelomet-ric analyzer (Dade Behring GmbH, Marburg, Germany).Serum cystatin C was measured using a turbidimetricmethod on the Roche Modular P Chemistry Analyzer(Gentian AS, Moss, Norway). We estimated GFR usingthree different equations, which were developed frompooling of 5352 participants from 13 studies: (1) ChronicKidney Disease Epidemiology Collaboration (CKD-EPI) cre-atinine, (2) CKD-EPI cystatin C, and (3) CKD-EPI creatinine-cystatin C (eGFRcreat-cyst) (6). CKD was defined by either alow eGFR (,60 ml/min per 1.73 m2) or the presence ofalbuminuria based on spot urine samples using sex-specificcutoffs (urine albumin/creatinine ratio $17 mg/g in menand $25 mg/g in women) (7).

Statistical AnalysesSummary statistics, prevalence estimates, and odds ratios

(ORs) were weighted to adjust for sampling probability andnonresponse as previously described (4,5). All analyses ac-count for cluster sampling and the use of stratification in sam-ple selection. Low eGFR, albuminuria, and CKD prevalencewere computed by sex and for all participants by Hispanic/Latino background with and without adjustment for age.Survey-specific procedures were used to compute 95% confi-dence intervals (95% CIs) to account for the two-stage sam-pling design, stratification, and clustering. Comparisons acrossHispanic/Latino groups were performed using the overallWald test. Multivariable survey logistic regression analyseswere used to examine associations of sociodemographic andclinical factors with prevalence of low eGFRcreat-cyst, albumin-uria, and CKD. ORs with 95% CIs were computed. All statis-tical tests were two sided at a significance level of 0.05. Noadjustments were made for multiple comparisons. All analy-ses were performed using SAS software (version 9.2; SAS In-stitute). Additional analyses were conducted to estimate theprevalence of low eGFR (using the CKD-EPI creatinine equa-tion given that cystatin C was not available in 2007–2010NHANES participants), albuminuria, and CKD among Mex-ican Americans (n=2007), non-Hispanic whites (n=4507), andnon-Hispanic blacks (n=1938) in the 2007–2010 NHANES. Wefollowed recommendations from the National Center forHealth Statistics to account for stratification and clustering ofthe survey design, as well as oversampling of ethnic minoritiesand elderly persons (8). Age-adjusted estimates were calcu-lated using the mean age of participants in HCHS/SOL andNHANES (the mean age for HCHS/SOL participants andNHANES participants was 41 years).

ResultsOf the 16,415 HCHS/SOL participants, 15,161 (92.4%)

were included in analyses to estimate prevalence of loweGFR, albuminuria, and CKD (9032 women and 6129 men);1001 participants (6.1%) were excluded because of missingdata on serum creatinine (n=168), serum cystatin C (n=116),or urine albumin (n=717), and 253 participants were ex-cluded due to missing data regarding race or Hispanic/Latino background group. In addition, 1114 participantswere excluded from regression analyses as a result ofmissing covariate data. Compared with individuals in-cluded in the study, those excluded due to missing datawere of similar age (mean 41 years), sex (women: 49.9%versus 52.5%, P=0.12), and Hispanic/Latino background.The prevalence of CKD and albuminuria was higheramong excluded compared with included participants(22.7% versus 13.4% and 16.1% versus 12.1%, respectively,P,0.001 for each comparison).

Participant CharacteristicsThe mean age was 41 years (Table 1). Compared with

persons without CKD, individuals with CKD were morelikely to be older (48 versus 40 years, P,0.001), have an-nual household income ,$20,000 (48% versus 41%,P,0.001), attain less than a high school education (39%versus 31%, P,0.001), and have health insurance (60%versus 49%, P,0.001). Participants with CKD were alsomore likely to be obese (50% versus 38%, P,0.001), to

1758 Clinical Journal of the American Society of Nephrology

have diabetes (38% versus 11%, P,0.001), and to have BP.140/90 mmHg (30% versus 8%, P,0.001). Participantswith low eGFR had significantly more albuminuria.

Prevalence of CKDThe overall age-adjusted prevalence of CKD was 13.7%

(based on the CKD-EPIcreat-cyst estimating equation). Amongwomen, the overall age-adjusted CKD prevalence was 13.0%;prevalence was lowest in persons with South Americanbackground (7.4%) and highest in persons with Puerto Ricanbackground (16.6%) (Table 2). In men, the overall age-adjusted prevalence of CKD was 14.8% and was lowest(11.2%) in persons with South American background andhighest (16.0%) in those with other Hispanic background(Table 2). CKD awareness was reported by 18% of partic-ipants who met our study criteria for CKD and by 34% ofparticipants with eGFR ,60 ml/min per 1.73 m2 (Table 1).Overall, based on the CKD-EPI creatinine GFR estimatingequation (cystatin C not available in 2007–2010 NHANESparticipants), the age-adjusted prevalence of CKD inHispanics/Latinos from HCHS/SOL was 14.2% (95% CI,13.4 to 15.0) compared with 13.7% (95% CI, 12.6% to 14.8%)in non-Hispanic whites and 17.4% (95% CI, 15.6 to 19.3) innon-Hispanic blacks from the 2007–2010 NHANES (Figure1A). Among women, the age-adjusted CKD prevalence inHispanics/Latinos from HCHS/SOL was 13.6% (95% CI,12.4 to 14.7) compared with 17.9% (95% CI, 16.2 to 19.5) innon-Hispanic whites and 21.2% (95% CI, 18.0 to 24.4) innon-Hispanic blacks from NHANES (Figure 1B). Amongmen, the age-adjusted prevalence of CKD in Hispanics/Latinos from HCHS/SOL was 15.2% (95% CI, 14.1 to 16.3)compared with 9.4% (95% CI, 8.2 to 10.7) in non-Hispanicwhites and 13.0% (95% CI, 10.8 to 15.1) in non-Hispanicblacks from NHANES (Figure 1C). CKD prevalence stratifiedby age is presented in Figure 1, D–F. Of note, the presence ofalbuminuria was the main determinant of CKD in participantsaged 18–44 years, whereas low eGFR was more commonamong individuals aged 55–74 years. Mean serum creatinine,cystatin C, eGFR, and age-unadjusted CKD prevalence, aswell as the percentage of the US Hispanic/Latino populationby eGFR and albuminuria category using the Kidney DiseaseImproving Global Outcomes 2009 definition and classificationof CKD (9) are presented in Supplemental Tables 1–3.

Baseline Clinical and Demographic Factors Associated withCKDThe adjusted prevalence odds for CKD were higher among

Hispanics/Latinos with health insurance (OR, 1.25; 95% CI,1.08 to 1.46), diabetes mellitus (adjusted OR, 1.64; 95% CI, 1.33to 2.04), hypertension (OR, 1.67; 95% CI, 1.37 to 2.04), and self-reported cardiovascular disease (OR, 1.38; 95% CI, 1.07 to1.77). Annual family income .$50,000 was associated withlower odds of CKD (OR, 0.71; 95% CI, 0.54 to 0.94) (Table 3).Hispanic/Latino background group, living in the UnitedStates for $10 years, educational attainment, and body massindex were not significantly associated with prevalent CKD.Similar patterns were observed separately for low eGFRcreat-cyst

and albuminuria (Table 3). In addition, for each 10-year unitincrement in age, the odds of low eGFR were nearly 3-foldhigher (OR, 2.88; 95% CI, 2.32 to 3.57), US-born Hispanics/Latinos had higher odds of low eGFRcreat-cyst (OR, 2.41; 95%

CI, 1.51 to 3.84), and female sex was associated with lowerodds of low eGFRcreat-cyst (OR, 0.73; 95% CI, 0.54 to 0.99).

DiscussionThe burden of CKD in the US population of Hispanics/

Latinos remains uncertain, because the most informative priornational estimate included primarily Mexican Americans andwas performed about a decade ago (10). Similarly, whether thehigher prevalence of ESRD among Hispanics/Latinos is a re-sult of greater prevalence of earlier stages of CKD or morerapid CKD progression (lower competing risk for death beforeESRD) also remains unknown. Our study, the first systematicevaluation of the prevalence of CKD in a large diverse con-temporary cohort of Hispanics/Latinos, adds important in-sights into each of these important questions. We found thatthe prevalence of CKD, defined as either an eGFRcreat-cyst ,60ml/min per 1.73 m2 or albuminuria was 14%, varied mark-edly across Hispanic/Latino background groups and wassimilar to the prevalence of non-Hispanic whites in NHANES.Correlates of CKD included lower annual income, hyperten-sion, diabetes mellitus, and prevalent cardiovascular disease.According to the 2013 US Renal Data System report, the

rate of incident ESRD among Hispanics/Latinos is 50%greater than in non-Hispanics (3). This striking disparity inthe burden of ESRD in Hispanics/Latinos underscores theimportance of understanding the epidemiology of earlierstages of CKD in this population. However, very little isknown about the epidemiology of CKD in Hispanics/Latinos before the onset of dialysis (11). By design,NHANES examines predominantly Mexican Americansand therefore does not provide insights into the prevalenceof CKD in other Hispanic/Latino background groups.Our findings of significant variation in the prevalence of

CKD between Hispanic/Latino background groups haveimportant public health implications. Prevalence was 17% inwomen of Puerto Rican background compared with 7% inwomen of South American background. This is consistentwith a prior finding from HCHS/SOL of substantial differ-ences in cardiovascular risk factor burden among Hispanic/Latino background groups (cardiovascular risk factors arealso risk factors for CKD) (12,13). After adjusting for clinicaland demographic factors, the risk of CKD was similar acrossall Hispanic/Latino background groups. By contrast, theHispanic Health and Nutrition Examination Surveyreported a higher risk for CKD (defined as estimated creat-inine clearance , 60 ml/min per 1.73 m2) in mainlandPuerto Ricans and Cuban Americans compared with Mexi-can Americans (14). However, this survey was conducted.30 years ago and did not include an assessment of urinaryalbumin or serum cystatin C. Our findings in a larger, con-temporaneous, and diverse cohort suggest that differences inCKD prevalence across background groups are explained bymodifiable factors, including diabetes mellitus, hyperten-sion, and cardiovascular disease. Nonetheless, future workis needed to explore the importance of additional risk fac-tors, including genetic susceptibility (e.g., the presence of at-risk variants of apolipoprotein L1,which have been associatedwith increased risk of progression to ESRD in Hispanicswith a greater degree of African ancestry) (15).Although the prevalence of ESRD is higher in Hispanics/

Latinos compared with non-Hispanic whites, we found the

Clin J Am Soc Nephrol 10: 1757–1766, October, 2015 CKD Prevalence in Hispanics/Latinos, Ricardo et al. 1759

Tab

le1.

Clinical

anddem

ograp

hic

charac

teristicsofstudyparticipan

tsbyCKD

status

Cha

racteristic

Ove

rall

CKD

NoCKD

PValue

Album

inuria

NoAlbum

inuria

PValue

eGFR

creat-cy

st

PValue

,60

$60

Number

ofparticipan

ts14

,035

2112

11,923

1900

12,135

386

13,649

Age

,yr

41.1

(40.6to

41.6)

48.2

(47.0to

49.4)

40.0

(39.5to

40.5)

,0.00

146

.6(45.4to

47.9)

40.3

(39.8to

40.8)

,0.00

162

.5(61.1to

63.9)

40.6

(40.1to

41.1)

,0.00

1

Wom

en52

.550

.952

.70.29

50.2

52.8

0.14

48.3

52.6

0.23

$10

yrin

United

States

72.3

77.4

71.5

,0.00

177

.471

.6,0.00

179

.372

.10.06

USborn

23.0

19.5

23.5

0.01

20.4

23.3

0.05

12.7

23.2

,0.00

1Annual

inco

me

,$2

0,00

041

.847

.540

.9,0.00

146

.641

.10.00

356

.941

.4,0.00

1

Lessthan

high

schoo

led

ucation

32.2

39.4

31.1

,0.00

138

.531

.3,0.00

147

.631

.8,0.00

1

Hea

lthinsu

rance

50.7

59.8

49.3

,0.00

157

.749

.8,0.00

178

.750

.1,0.00

1Curren

tsm

oker

21.1

21.1

21.1

0.99

21.0

21.2

0.89

21.9

21.1

0.80

Cardiova

scular

disea

se6.0

12.5

5.0

,0.00

111

.95.2

,0.00

123

.05.6

,0.00

1

Hyp

ertension

21.8

49.2

17.6

,0.00

146

.918

.4,0.00

174

.220

.6,0.00

1SystolicBP,

mmHg

119.8

(119

.3to

120.4)

130.6

(129

.2to

132.1)

118.2

(117

.7to

118.6)

,0.00

113

0.6

(129

.0to

132.1)

118.4

(117

.9to

118.8)

,0.00

113

7.1

(134

.2to

140.1)

119.4

(118

.9to

119.9)

,0.00

1

BP.13

0/80

mmHg

22.0

45.0

18.4

,0.00

145

.118

.8,0.00

156

.221

.2,0.00

1BP.14

0/90

mmHg

11.1

30.0

8.2

,0.00

130

.48.4

,0.00

137

.110

.5,0.00

1BM

I$30

kg/m

239

.949

.638

.4,0.00

149

.538

.6,0.00

152

.139

.6,0.00

1W

aist

circumference,

cm

97.4

(97.0to

97.8)

102.0

(100

.9to

103.0)

96.7

(96.2to

97.1)

,0.00

110

1.6

(100

.5to

102.8)

96.8

(96.4to

97.3)

,0.00

110

5.4

(103

.3to

107.5)

97.2

(96.8to

97.6)

,0.00

1

Diabetes

mellitus

14.6

37.7

11.0

,0.00

136

.611

.6,0.00

154

.113

.7,0.00

1Hem

oglobin

A1c,%

5.7(5.7

to5.8)

6.5(6.4

to6.6)

5.6(5.6

to5.6)

,0.00

16.5(6.4

to6.6)

5.6(5.6

to5.6)

,0.00

16.5(6.3

to6.7)

5.7(5.7

to5.7)

,0.00

1

Triglyc

erides,

mg/dl

114(79to

160)

132(91to

187)

112(77to

159)

—13

1(90to

187)

112(78to

159)

—14

0(108

to18

8)11

3(79to

162)

—

Total

cholesterol,

mg/dl

193.3

(192

.2to

194.4)

195.6

(193

.2to

198.0)

193.0

(191

.8to

194.1)

,0.00

119

5.4

(192

.9to

197.8)

193.1

(191

.9to

194.2)

,0.00

119

5.5

(189

.9to

201.1)

193.3

(192

.2to

194.4)

,0.00

1

LDLch

olesterol,

mg/dl

119.7

(118

.8to

120.7)

119.7

(117

.8to

121.7)

119.7

(118

.7to

120.8)

,0.00

111

9.5

(117

.5to

121.6)

119.8

(118

.8to

120.8)

,0.00

111

9.3

(114

.3to

124.2)

119.8

(118

.8to

120.7)

,0.00

1

HDLch

olesterol,

mg/dl

48.8

(48.5to

49.2)

47.6

(46.8to

48.5)

49.0

(48.6to

49.3)

,0.00

147

.8(46.9to

48.7)

48.9

(48.6to

49.3)

,0.00

145

.7(44.5to

47.0)

48.9

(48.5to

49.2)

,0.00

1

C-rea

ctiveprotein,

mg/L

3.9(3.7

to4.1)

5.8(4.9

to6.7)

3.6(3.4

to3.8)

,0.00

15.8(4.9

to6.8)

3.6(3.4

to3.8)

,0.00

16.6(5.4

to7.9)

3.8(3.6

to4.0)

,0.00

1

Use

ofACEi/ARB

8.5

19.6

6.8

,0.00

118

.47.2

,0.00

133

.08.0

,0.00

1CKD

awaren

ess

—17

.8—

—17

.223

.10.17

33.9

14.3

,0.00

1UrineACR$30

0mg/g

1.4

10.6

——

11.7

——

18.6

1.0

,0.00

1

Forc

ontinu

ousva

riab

les,weigh

tedmean(95%

confi

den

ceinterval)v

alue

sarepresen

tedun

less

othe

rwisesp

ecified

;for

catego

ricalv

ariables,w

eigh

tedprop

ortion

sare

reported.eGFR

,ml/min

per1.73

m2 ;BMI,bo

dymassindex;A

CEi,an

gioten

sin-conv

erting

enzy

meinhibitor;ARB,a

ngioteninreceptor

blocke

r;ACR,a

lbumin/creatinine

ratio;

–,n

otap

plicab

le.

1760 Clinical Journal of the American Society of Nephrology

Tab

le2.

CKD-related

param

etersbysexan

dHispan

icbackgroundgroup

Parameter

All

Cen

tral

American

Cuba

nDom

inican

Mexican

Puerto

Rican

South

American

Other

PValue

Wom

enNum

berof

participan

ts90

3295

111

5589

937

0714

9857

424

8

Urine

ACR,

mg/

g7.4(5.2,1

3.2)

7.3(5.0,1

2.9)

7.3(5.1,1

2.7)

7.1(5.0,1

2.5)

7.7(5.3,1

3.5)

7.8(5.2,1

5.7)

6.5(4.9,1

0.9)

6.8(4.7,9

.8)

Urine

ACR

$25

mg/

g11

.7(10.8to

12.7)

12.6

(9.1

to16

.1)

11.3

(9.3

to13

.3)

11.0

(8.2

to13

.8)

11.8

(10.1to

13.4)

14.6

(12.0to

17.3)

7.2(4.7,9

.6)

8.2(4.4,1

2.0)

,0.00

1

Age

-adjusted

CKD

prev

alen

ceCKD-EPI

creatinine

13.6

(12.4to

14.7)

13.1

(9.7

to16

.4)

11.9

(9.6

to14

.2)

13.3

(10.4to

16.2)

13.4

(11.8to

15.1)

17.4

(14.6to

20.2)

7.7(5.1,1

0.4)

16.6

(5.8,2

7.3)

,0.00

1

CKD-EPI

cystatin

C13

.4(12.4to

14.4)

13.0

(9.6

to16

.4)

12.6

(10.4to

14.9)

12.5

(9.6

to15

.5)

13.8

(12.1to

15.4)

16.8

(14.0to

19.5)

7.2(4.6,9

.9)

10.5

(6.9,1

4.1)

,0.00

1

CKD-EPI

creatinine

+cystatin

C

13.0

(12.0to

13.9)

12.7

(9.4

to16

.1)

11.7

(9.6

to13

.9)

12.5

(9.6

to15

.4)

13.3

(11.6to

14.9)

16.6

(13.8to

19.4)

7.4(4.8,1

0.1)

10.2

(6.6,1

3.9)

,0.00

1

Men Num

berof

participan

ts61

2962

910

4047

922

8910

6941

520

8

Urine

ACR,

mg/

g5.3(3.8,1

0.0)

5.3(3.7,9

.6)

5.6(3.8,1

1.0)

5.2(3.6,1

0.2)

5.2(3.8,9

.1)

5.7(4.0,1

2.4)

5.1(3.7,8

.8)

5.2(3.8,8

.4)

Urine

ACR

$17

mg/

g,%

13.2

(12.1to

14.4)

13.1

(10.5to

15.8)

14.2

(11.5to

17.0)

13.1

(9.4

to16

.7)

12.6

(10.6to

14.6)

14.7

(12.2to

17.3)

10.2

(6.4

toss

14.0)

10.8

(6.0

to15

.6)

0.45

Age

-adjusted

CKD

prev

alen

ceCKD-EPI

creatinine

15.2

(14.1to

16.3)

15.6

(12.9to

18.3)

14.0

(11.5to

16.5)

15.8

(12.2to

19.3)

15.7

(13.7to

17.8)

16.1

(13.6to

18.5)

11.1

(7.4

to14

.9)

15.9

(11.2to

20.6)

0.40

CKD-EPI

cystatin

C15

.6(14.4to

16.7)

15.6

(12.9to

18.3)

14.5

(12.0to

17.1)

16.0

(12.4to

19.5)

15.4

(13.4to

17.5)

18.2

(15.5to

20.9)

10.8

(7.0

to14

.5)

16.1

(11.3to

20.9)

0.09

CKD-EPI

creatinine

+cystatin

C

14.8

(13.7to

15.9)

15.4

(12.7to

18.1)

13.8

(11.2to

16.3)

15.0

(11.6to

18.4)

15.3

(13.2to

17.3)

15.7

(13.3to

18.2)

11.2

(7.4

to14

.9)

16.0

(11.2to

20.8)

0.51

Dataarepresen

tedas

med

ians

(interqu

artilerang

es)o

rpercentag

es(95%

confi

den

ceintervals).A

CR,album

in/creatinine

ratio.CKD-EPI,Chron

icKidne

yDisease

Epidem

iology

Collabo

ration

.

Clin J Am Soc Nephrol 10: 1757–1766, October, 2015 CKD Prevalence in Hispanics/Latinos, Ricardo et al. 1761

overall prevalence of CKD to be similar between these twogroups. This suggests that Hispanics/Latinos may be atincreased risk for CKD progression or alternatively that the

mortality rate before the onset of ESRD is higher in non-Hispanic whites compared with Hispanics/Latinos. How-ever, this hypothesis is not supported by analyses of data

Figure 1. | Age-adjusted, weighted prevalence of CKD in Hispanic/Latino HCHS/SOL participants and Mexican-American, non-Hispanicblack, and non-Hispanic white 2007–2010 NHANES participants. (A) Overall prevalence. (B and C) Prevalence for women (B) and men (C).(D–F) Prevalence for participants aged 18–44 years (D), 45–54 years (E), and 55–74 years (F). HCHS/SOL, Hispanic Community Health Study/Study of Latinos; NH, non-Hispanic; NHANES, National Health and Nutrition Examination Survey.

1762 Clinical Journal of the American Society of Nephrology

from NHANES III (16). Future work is needed to betterunderstand risk factors associated with progression ofCKD in this population and issues related to the compet-ing risks of death and progression to ESRD. The ongoingNational Institute of Diabetes and Digestive and KidneyDiseases–sponsored Hispanic Chronic Renal Insufficiency

Cohort study, which includes Hispanics/Latinos withmild to moderate CKD, is expected to provide additionalinsights into this issue (17).We also found that the prevalence of CKD was higher in

men than women. Furthermore, in multivariable analyses, theodds of eGFRcreat-cyst ,60 ml/min per 1.73 m2 were lower in

Figure 1. | Continued.

Clin J Am Soc Nephrol 10: 1757–1766, October, 2015 CKD Prevalence in Hispanics/Latinos, Ricardo et al. 1763

Tab

le3.

Multivariable

logistic

regressionORsforpreva

lentCKD,low

eGFR

(eGFR

creat-cyst),an

dalbuminuria

Parameter

CKD

Album

inuria

eGFR

creat-cy

st,60

OR(95%

CI)

PValue

OR(95%

CI)

PValue

OR(95%

CI)

PValue

Backgrou

nd

Mexican

Referen

ceReferen

ceReferen

ceCen

tral

American

0.88

(0.70to

1.12

)0.30

0.92

(0.72to

1.17

)0.48

0.81

(0.43to

1.51

)0.50

Cub

an0.92

(0.74to

1.13

)0.42

0.86

(0.69to

1.08

)0.19

1.04

(0.64to

1.70

)0.86

Dom

inican

0.82

(0.64to

1.06

)0.13

0.83

(0.63to

1.08

)0.16

1.04

(0.63to

1.72

)0.87

Puerto

Rican

0.94

(0.76to

1.15

)0.52

0.92

(0.74to

1.13

)0.42

1.20

(0.76to

1.89

)0.44

South

American

0.76

(0.55to

1.04

)0.08

0.75

(0.54to

1.04

)0.09

0.91

(0.45to

1.85

)0.80

Other/mixed

0.74

(0.50to

1.10

)0.14

0.76

(0.51to

1.14

)0.18

1.33

(0.46to

3.89

)0.60

Age

(per

10-yrincrem

ent)

1.02

(0.95to

1.10

)0.56

0.92

(0.85to

0.99

)0.02

2.88

(2.32to

3.57

),0.00

1W

omen

(versu

smen

)0.95

(0.82to

1.11

)0.54

0.96

(0.82to

1.11

)0.58

0.73

(0.54to

0.99

)0.04

Yea

rsin

United

States$10

(versu

s<1

0)0.93

(0.76to

1.12

)0.43

0.96

(0.79to

1.17

)0.70

0.73

(0.48to

1.11

)0.15

USborn(yes

versusno)

1.23

(0.98to

1.54

)0.08

1.14

(0.91to

1.44

)0.25

2.41

(1.51to

3.84

),0.00

1Inco

me($,p

eryr)

20,000

Referen

ceReferen

ceReferen

ce20

,001

–50

,000

0.95

(0.80to

1.12

)0.53

0.98

(0.83to

1.17

)0.85

0.73

(0.50to

1.05

)0.09

.50

,000

0.71

(0.54to

0.94

)0.02

0.73

(0.55to

0.98

)0.03

0.54

(0.29to

0.97

)0.04

Other

(missing

/no

tava

ilable)

0.87

(0.67to

1.14

)0.28

0.86

(0.65to

1.13

)0.28

0.89

(0.51to

1.55

)0.68

Education

,highschoo

lor

grea

ter(yes

versusno)

0.96

(0.82to

1.13

)0.64

0.98

(0.83to

1.15

)0.80

1.02

(0.71to

1.45

)0.92

Hea

lthinsu

rance

(yes

versusno)

1.25

(1.08to

1.46

)0.00

31.20

(1.02to

1.40

)0.03

1.55

(1.08to

2.23

)0.02

Curren

tsmok

er(yes

versusno)

1.01

(0.84to

1.22

)0.88

0.98

(0.82to

1.18

)0.87

1.47

(0.98to

2.21

)0.06

BM

I$30

kg/m

2(yes

versusno)

1.03

(0.86to

1.23

)0.75

1.06

(0.88to

1.28

)0.52

0.87

(0.61to

1.24

)0.45

Waist

circumference

(per

1-cm

increm

ent)

1.00

(1.00to

1.01

)0.34

1.00

(0.99to

1.01

)0.71

1.02

(1.01to

1.03

)0.00

3Hyp

ertension

(yes

versusno)

1.67

(1.37to

2.04

),0.00

11.52

(1.23to

1.89

),0.00

11.90

(1.23to

2.94

)0.00

4SystolicBP(per

10-m

mHgincrem

ent)

1.25

(1.20to

1.32

),0.00

11.31

(1.25to

1.38

),0.00

11.04

(0.95to

1.14

)0.40

Diabetes

(yes

versusno)

1.64

(1.33to

2.04

),0.00

11.52

(1.24to

1.87

),0.00

11.87

(1.23to

2.84

)0.00

3HbA1c

(per

1%increm

ent)

1.28

(1.20to

1.36

),0.00

11.33

(1.25to

1.42

),0.00

10.97

(0.84to

1.11

)0.64

Cardiova

sculardisea

se(yes

versusno)

1.38

(1.07to

1.77

)0.01

1.36

(1.05to

1.78

)0.02

1.52

(1.08to

2.15

)0.02

LDL-C

$10

0mg/dl(yes

versusno)

0.89

(0.76to

1.05

)0.17

0.89

(0.75to

1.06

)0.18

0.90

(0.65to

1.26

)0.54

CRP(per

1-mg/Lincrem

ent)

1.02

(1.01to

1.03

),0.00

11.02

(1.01to

1.03

),0.00

11.02

(1.01to

1.03

),0.00

1

eGFR

,ml/min

per1.73

m2 ;OR,o

ddsratio;

eGFR

creat-cyst,C

KD-EPI

creatinine

-cystatinCeG

FRestimatingeq

uation;

BMI,bo

dymassindex

;HbA

1c,h

emog

lobinA1c;L

DL-C

,LDLch

olesterol;

CRP,

C-reactiveprotein;

95%

CI,95

%confi

den

ceinterval.

1764 Clinical Journal of the American Society of Nephrology

women thanmen. Interestingly, this is the opposite of what hasbeen found in non-Hispanic whites (10). Reasons for these dif-ferences are not clear and need further investigation. It is pos-sible that these contrasting findings may be related to the lackof studies examining the validity of the eGFR equations inHispanic/Latino background groups. In addition, we foundthat the HCHS/SOL participants with CKD were socioeco-nomically disadvantaged and displayed a high burden of car-diovascular risk factors and other comorbidities. More thanone-half had an annual household income ,$20,000, 40%lacked medical insurance, 49% had hypertension, 38% had di-abetes, and one-half were obese. Furthermore, we found aprevalence of current smoking of 21%, which is concerninggiven the known association between smoking and adverseCKD outcomes such as progression to ESRD, cardiovascularevents, and death (18). Interestingly, mean LDL cholesterol was120 mg/dl, which is higher than that reported among 2001–2010 NHANES participants with CKD (111 mg/dl) and with-out CKD (117 mg/dl) (19). Despite the presence of multiplecardiovascular risk factors, only 20% of individuals with CKDwere prescribed either an angiotensin-converting enzyme in-hibitor or an angiotensin receptor blocker, medications that areknown to decrease CKD progression risk (20). Also alarming isour finding that only 18% of individuals with CKD and 34% ofthose with eGFRcreat-cyst ,60 ml/min per 1.73 m2 were awareof having CKD, which is consistent with prior reports (21,22).These findings suggest that there is considerable opportunityto improve CKDmanagement in Hispanics/Latinos, and thereis an urgent need to improve CKD awareness among patientswho might be missing important preventive and therapeuticopportunities that may decrease their CKD progression risk.To estimate GFR in this study, we used three different

equations (creatinine and cystatin C based) that have beenvalidated in large and diverse US populations (6); however,they did not include a significant number of Hispanics/Latinos in the cohorts used to establish them. Despite thisshortcoming, the CKD prevalence estimates were similarfor each of these equations. Future work is needed to val-idate GFR estimating equations in Hispanics/Latinos.Our findings confirmed the strong association of estab-

lished risk factors (e.g., hypertension and diabetes mellitus)with prevalent CKD in the Hispanic/Latino population.Similar to other studies (23–26), we found that lower annualhousehold income was associated with prevalent CKD. Wefound a positive association between having health insur-ance and CKD; the reason for this finding is not clear, butwe suspect that this could be because individuals with CKDhave comorbid conditions (e.g., hypertension, diabetes mel-litus) and therefore may be more likely to seek insurancecoverage. We also examined issues related to acculturation,which are particularly relevant to the Hispanic/Latino pop-ulation. Although place of birth and length of residence inthe United States were not associated with increased risk forCKD (defined as albuminuria or eGFRcreat-cyst ,60 ml/minper 1.73 m2), birth in the United States was associated with a.2-fold higher adjusted odds of having an eGFRcreat-cyst ,60ml/min per 1.73 m2. This potentially suggests that the West-ern lifestyle adopted by US-born Hispanics/Latinos may beassociated with increased risk for CKD and is consistentwith an analysis from NHANES III, which found an associ-ation between birth in the United States and heightened car-diovascular risk (27).

Our study has a number of positive features. First, thiswas a community sample and provides an opportunity toestablish population estimates of prevalence. Second, westudied Hispanics/Latinos with diverse backgrounds.Third, the sample size was relatively large and participantswere recruited from across the United States. Our findingsshould be considered with the following limitations. First,the classification of persons with CKD was based on singlemeasurements of serum creatinine, cystatin C, and urinealbumin. Second, the GFR estimating equations we usedhave not been yet validated in Hispanics/Latinos. Third,the cross-sectional study design limits interpretation ofthese associations. Finally, we used a second, nonconcur-rent study, 2007–2010 NHANES, to compare prevalence ofCKD in HCHS/SOL participants with non-Hispanics.In summary, we found significant variation in CKD

prevalence among Hispanic/Latino background groups. Inaddition, Hispanics/Latinos with CKD have low rates ofhealth insurance, poor control of hypertension, low angiotensin-converting enzyme inhibitor/angiotensin receptor blockeruse, and low awareness of CKD. Correlates of CKD includedlow income, hypertension, diabetes mellitus, and cardiovas-cular disease. Our findings have important implications forpublic health policy targeted at improving access to care andchronic disease management for this rapidly growing pop-ulation. Future research is needed to better identify modifi-able risk factors for CKD progression in Hispanics/Latinos.

AcknowledgmentsThe authors thank theHCHS/SOL staff and participants for their

important contributions. A complete list of staff and investigatorswas provided by Lavange et al. (Ann Epidemiol. 20: 642–649, 2010)and is also available on the study website (http://www.cscc.unc.edu/hchs/).HCHS/SOLwascarriedoutas acollaborative studysupportedby

contracts from the National Heart, Lung, and Blood Institute(NHLBI) to the University of North Carolina (N01-HC65233),University of Miami (N01-HC65234), Albert Einstein College ofMedicine (N01-HC65235), Northwestern University (N01-HC65236),and San Diego State University (N01-HC65237). The following in-stitutes, centers, or offices contribute to the HCHS/SOL through atransfer of funds to the NHLBI: the National Institute on MinorityHealthandHealthDisparities, theNational InstituteonDeafnessandOther Communications Disorders, the National Institute of Dentaland Craniofacial Research, the National Institute of Diabetes andDigestive and Kidney Diseases (NIDDK), the National Institute ofNeurological Disorders and Stroke, and the Office of Dietary Sup-plements. A.C.R. and J.P.L are funded by grants from the NIDDK(K23-DK094829 to A.C.R. and K24-DK092290 to J.P.L.). N.F. issupported by grants from the National Institutes of Health (R21-HL123677-01, 1R01-ES021367-01, and 1R01-HL118305-01A1).

DisclosuresNone.

References1. US Census Bureau: U.S. Census Bureau projections show a

slower growing, older, more diverse nation a half century fromnow, 2102. Available at http://www.census.gov/newsroom/releases/archives/population/cb12-243.html. AccessedSeptembers 11, 2014

2. Gonzalez Burchard E, Borrell LN, Choudhry S, Naqvi M, Tsai HJ,Rodriguez-Santana JR, Chapela R, Rogers SD, Mei R, Rodriguez-

Clin J Am Soc Nephrol 10: 1757–1766, October, 2015 CKD Prevalence in Hispanics/Latinos, Ricardo et al. 1765

Cintron W, Arena JF, Kittles R, Perez-Stable EJ, Ziv E, Risch N:Latino populations: A unique opportunity for the study of race,genetics, and social environment in epidemiological research.Am J Public Health 95: 2161–2168, 2005

3. US Renal Data System: USRDS 2013 Annual Data Report: Atlasof Chronic Kidney Disease and End-Stage Renal Disease in theUnited States, Bethesda,MD,National Institutes ofHealth,NationalInstitute of Diabetes and Digestive and Kidney Diseases, 2013

4. Lavange LM, Kalsbeek WD, Sorlie PD, Aviles-Santa LM, Kaplan RC,Barnhart J, Liu K, Giachello A, Lee DJ, Ryan J, Criqui MH, Elder JP:Sample design and cohort selection in the Hispanic CommunityHealth Study/Study of Latinos. Ann Epidemiol 20: 642–649, 2010

5. Sorlie PD, Aviles-Santa LM, Wassertheil-Smoller S, Kaplan RC,Daviglus ML, Giachello AL, Schneiderman N, Raij L, Talavera G,Allison M, Lavange L, Chambless LE, Heiss G: Design and im-plementation of the Hispanic Community Health Study/Study ofLatinos. Ann Epidemiol 20: 629–641, 2010

6. Inker LA, SchmidCH, TighiouartH, Eckfeldt JH, FeldmanHI, GreeneT, Kusek JW, Manzi J, Van Lente F, Zhang YL, Coresh J, Levey AS;CKD-EPI Investigators: Estimating glomerular filtration rate from se-rum creatinine and cystatin C. N Engl J Med 367: 20–29, 2012

7. Mattix HJ, Hsu CY, Shaykevich S, Curhan G: Use of the albumin/creatinine ratio to detect microalbuminuria: Implications of sexand race. J Am Soc Nephrol 13: 1034–1039, 2002

8. National Center for Health Statistics: Analytical and ReportingGuidelines: The Third National Health and Nutrition Examina-tion Survey, 1988–1994, Hyattsville, MD, National Center forHealth Statistics. 1996

9. Levey AS, de Jong PE, Coresh J, El Nahas M, Astor BC, MatsushitaK, Gansevoort RT, Kasiske BL, Eckardt KU: The definition, clas-sification, and prognosis of chronic kidney disease: A KDIGOControversies Conference report. Kidney Int 80: 17–28, 2011

10. Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, VanLente F, Levey AS: Prevalence of chronic kidney disease in theUnited States. JAMA 298: 2038–2047, 2007

11. Peralta CA, ShlipakMG, Fan D, Ordo~nez J, Lash JP, ChertowGM,Go AS: Risks for end-stage renal disease, cardiovascular events,and death in Hispanic versus non-Hispanic white adults withchronic kidney disease. J Am Soc Nephrol 17: 2892–2899, 2006

12. Daviglus ML, Talavera GA, Aviles-Santa ML, Allison M, Cai J,Criqui MH, Gellman M, Giachello AL, Gouskova N, Kaplan RC,LaVange L, Penedo F, Perreira K, Pirzada A, Schneiderman N,Wassertheil-Smoller S, Sorlie PD, Stamler J: Prevalence of majorcardiovascular risk factors and cardiovascular diseases amongHispanic/Latino individuals of diverse backgrounds in theUnitedStates. JAMA 308: 1775–1784, 2012

13. Levey AS, Atkins R, Coresh J, Cohen EP, Collins AJ, Eckardt KU,Nahas ME, Jaber BL, Jadoul M, Levin A, Powe NR, Rossert J,Wheeler DC, Lameire N, EknoyanG: Chronic kidney disease as aglobal public health problem: Approaches and initiatives -a position statement from Kidney Disease Improving GlobalOutcomes. Kidney Int 72: 247–259, 2007

14. Rodriguez RA, Hernandez GT, O’Hare AM, Glidden DV, Perez-Stable EJ: Creatinine levels among Mexican Americans, PuertoRicans, and Cuban Americans in the Hispanic Health and Nu-trition Examination Survey. Kidney Int 66: 2368–2373, 2004

15. Tzur S, Rosset S, Skorecki K, Wasser WG: APOL1 allelic variantsare associated with lower age of dialysis initiation and therebyincreased dialysis vintage in African and Hispanic Americanswith non-diabetic end-stage kidney disease. Nephrol DialTransplant 27: 1498–1505, 2012

16. Mehrotra R, Kermah D, Fried L, Adler S, Norris K: Racial differ-ences in mortality among those with CKD. J Am Soc Nephrol 19:1403–1410, 2008

17. Fischer MJ, Go AS, Lora CM, Ackerson L, Cohan J, Kusek JW,Mercado A, Ojo A, Ricardo AC, Rosen LK, Tao K, Xie D, FeldmanHI, Lash JP; CRIC and H-CRIC Study Groups: CKD in Hispanics:Baseline characteristics from the CRIC (Chronic Renal In-sufficiency Cohort) and Hispanic-CRIC Studies. Am J Kidney Dis58: 214–227, 2011

18. Ricardo AC, AndersonCA, YangW, Zhang X, FischerMJ, DemberLM, Fink JC, Frydrych A, Jensvold NG, Lustigova E, Nessel LC,Porter AC, Rahman M, Wright Nunes JA, Daviglus ML, Lash JP;CRIC Study Investigators: Healthy lifestyle and risk of kidneydisease progression, atherosclerotic events, and death in CKD:Findings from the Chronic Renal Insufficiency Cohort (CRIC)Study. Am J Kidney Dis 65: 412–424, 2015

19. Kuznik A,Mardekian J, Tarasenko L: Evaluation of cardiovasculardisease burden and therapeutic goal attainment in US adults withchronic kidney disease: An analysis of National Health andNutritional Examination Survey data, 2001-2010. BMC Nephrol14: 132, 2013

20. Jafar TH, Schmid CH, Landa M, Giatras I, Toto R, Remuzzi G,Maschio G, Brenner BM, Kamper A, Zucchelli P, Becker G,Himmelmann A, Bannister K, Landais P, Shahinfar S, de Jong PE,de Zeeuw D, Lau J, Levey AS: Angiotensin-converting enzymeinhibitors and progression of nondiabetic renal disease. Ameta-analysis of patient-level data. Ann Intern Med 135: 73–87, 2001

21. Plantinga LC, Boulware LE, Coresh J, Stevens LA, Miller ER 3rd,Saran R, Messer KL, Levey AS, Powe NR: Patient awareness ofchronic kidney disease: Trends and predictors. Arch Intern Med168: 2268–2275, 2008

22. Li C,Wen XJ, PavkovME, ZhaoG, Balluz LS, Ford ES,WilliamsD,Gotway CA: Awareness of kidney disease among US adults:Findings from the 2011 behavioral risk factor surveillance sys-tem. Am J Nephrol 39: 306–313, 2014

23. Vart P, Gansevoort RT, Coresh J, Reijneveld SA, Bultmann U:Socioeconomic measures and CKD in the United States and TheNetherlands. Clin J Am Soc Nephrol 8: 1685–1693, 2013

24. Bruce MA, Beech BM, Crook ED, Sims M,Wyatt SB, Flessner MF,Taylor HA, Williams DR, Akylbekova EL, Ikizler TA: Associationof socioeconomic status and CKD among African Americans:The Jackson Heart Study. Am J Kidney Dis 55: 1001–1008, 2010

25. Crews DC, Charles RF, Evans MK, Zonderman AB, Powe NR:Poverty, race, and CKD in a racially and socioeconomicallydiverse urban population. Am J Kidney Dis 55: 992–1000,2010

26. Peralta CA, Ziv E, Katz R, Reiner A, Burchard EG, Fried L, KwokPY, Psaty B, Shlipak M: African ancestry, socioeconomic status,and kidney function in elderly African Americans: A geneticadmixture analysis. J Am Soc Nephrol 17: 3491–3496, 2006

27. Sundquist J, Winkleby MA: Cardiovascular risk factors in Mexi-can American adults: A transcultural analysis of NHANES III,1988-1994. Am J Public Health 89: 723–730, 1999

Received: February 20, 2015 Accepted: July 13, 2015

Published online ahead of print. Publication date available at www.cjasn.org.

See related editorial, “The Role of Ethnic Variation and CKD,” onpages 1708–1710.

This article contains supplemental material online at http://cjasn.asnjournals.org/lookup/suppl/doi:10.2215/CJN.02020215/-/DCSupplemental.

1766 Clinical Journal of the American Society of Nephrology