Mary K Roberts, PhD is a Post Doctoral Researcher at the Leverhulme Centre for Demographic Science at the University of Oxford.

Mary K Roberts, PhD

Crisis Point: The Cause and Calamity, Neighborhood Disadvantage and Kidney Disease

Clinicians often think of healthcare as having a problem and a solution, but what if there was more going on underneath the surface?

When it comes to the rising threat of developing 

, there's more at stake than the values we can measure in a lab. This Crisis Point focuses on the detrimental problem of neighborhood disadvantage as the cause and the calamity of kidney disease.

Neighborhood disadvantage is a place-based measure, defined as 1/5th of a population living below the federal poverty line, and with indices such as the Area Deprivation Index (ADI). Measurable data from the US Census Bureau identified 24 million Americans living in disadvantaged neighborhoods, with a disproportionate amount of racial and ethnic families residing within these communities. For example, only 4.3% of white Americans live in a disadvantaged neighborhood compared to 20.9% of black Americans.

These inequities don’t just present through poverty, housing instability, educational opportunities, employment, and access to resources. Neighborhood disadvantage trickles down the line, impacting an individual’s health through daily exposure to unfavorable conditions, including processed food, air pollution, and dehydration. As a result, the pathways to exposure to kidney disease can be represented by acute kidney injury (AKI), with repeated episodes accelerating CKD progression, and they can also be chronic, causing slow debilitating decline over the years.

“I really think that it asks nephrologists and other care providers to treat an individual's social context as part of their care plan,” said Maya Clark Cutaia, PhD, RN, in an interview with 

“We all walk in every day with those things on our backs. You may not see it, but we walk in with our history, our culture, our trauma, you know, our joys, whatever. And if we can take those real-world contexts and apply them to what we want to do next. It'll inform how we treat a patient.”

Statistically, 18.8 to 40 million Americans live within food deserts, characterized by a reliance on gas stations and convenience stores, limited or no access to fresh fruits and vegetables, and poor transportation options and unsafe spaces for exercise.

Having limited access to nutrient-dense options can take a major toll on kidney health. Often, the most affordable and easy choices in disadvantaged neighborhoods are chips, fried food, and sodas, of which the additives and high-sugar levels can build in the kidneys and contribute to inflammation. This differentiates from nephrologists’ kidney-friendly diet recommendations, which are a plant-based protein diet focused on whole foods and vegetables, while taking into account the risk of muscle loss for patients on dialysis.

Previous research has linked food deserts and disadvantaged communities with an increased risk of obesity. In kidney disease, obesity has been seen as both a 

 of further injury and disease progression. Thus, individuals living in disadvantaged communities face environmental factors that minimize their health and exacerbate poor outcomes, adding further barriers to care, especially 

Structural barriers in disadvantaged neighborhoods, such as distance to transplant centers, transportation burdens, and lack of local primary care physicians reflect systemic flaws in the catering of the healthcare system towards advantaged communities.

A majority of patients in these communities either lack awareness or the time to receive routine wellness checks related to the often silent disease of CKD. By the time a patient presents with symptoms of kidney deterioration, they’re often passed the point of early stages and require more in-depth treatment, according to experts. The issue of access and resources will not ultimately resolve itself once a patient presents with symptoms that need treatment.

Patients experiencing CKD in the later stages, especially end stage kidney failure (ESKD) will require dialysis, or in severe cases, transplantation. However, the barriers to care that existed in the beginning stages of their illness become even more pronounced once they require help.

“Neighborhood disadvantage puts people out of the running,” said Clark-Cutaia about the entire continuum of kidney care.

According to a recent study, neighborhood disadvantage is linked to a significant lack of access to waitlisting and kidney transplantation, especially living donor kidney transplantation. This reality can be seen as a representation of the double-sided nature of neighborhood disadvantage and kidney health as the root of the problem and a barrier to a solution.

To combat neighborhood disadvantage and its downstream effects, it is important to meet patients where they are. As clinicians, that means creating a presence in communities through churches, mosques, workplaces, farms, or by connecting with community leaders to build trust in the healthcare system.

Awareness and access can play a major role in improving patient outcomes. For example, on-site education and screening to reduce transportation/time burdens, along with mobile units for blood and urine testing can bypass systemic barriers and help patients get the preemptive help they need.

To address social determinants of health, clincians should aim to implement earlier screening and referrals and to connect patients to social workers for food transporation and social support needs.

Ethically and clinically, health care practitioners have a responsibility to their patients to treat neighborhood disadvantage as a clinical value and to find solutions for these barriers to care the same way they would treat an erroneous lab measure.

 is the inaugural Evelyn Lauder Associate Dean for Nurse Practitioner Programs and Professor at the Hunter-Bellevue School of Nursing at Hunter College.

 is a NIHR Advanced Fellow and Associate Professor (Principal Research Fellow) in Nutrition and Dietetics in the Centre of Obesity Research at University College London (UCL) and programme co-lead of the MSc Dietetics (Pre-registration) course at UCL.

 is the Chief Medical Officer at Evergreen Nephrology.

 is the Chief Executive Officer and Founder of Carna Health.

 is a nephrologist and Professor of Public Health Sciences and Medicine, Division of Nephrology and Hypertension at Loyola University Chicago, and the Editor in Chief of 

 is a postdoctoral researcher at the Leverhulme Centre for Demographic Science at the University of Oxford.

 is the Dr. Robert H and Eva M Moyad Research Professor of Urology, Co-Chief of Dow Division of Health Services Research, Professor of Internal Medicine, and Professor of Urology at the Medical School at the University of Michigan.

Editor’s Note: Cutaia declares no relevant disclosures. Brown reports no relevant disclosures. Pflederer reports relevant disclosures with Evergreen Nephrology. Viscomi reports relevant disclosures with Carna Health, Dama Health, QuantaBrain, and others. Shahinian reports no relevant disclosures.

Christie-Mizell CA. Neighborhood Disadvantage and Poor Health: The Consequences of Race, Gender, and Age among Young Adults. 

International Journal of Environmental Research and Public Health

Neighborhood Atlas - Home. Wisc.edu. Published 2018. 

https://www.neighborhoodatlas.medicine.wisc.edu/

Niculae A, Gherghina ME, Peride I, Tiglis M, Nechita AM, Checherita IA. Pathway from Acute Kidney Injury to Chronic Kidney Disease: Molecules Involved in Renal Fibrosis. 

International Journal of Molecular Sciences

Rhone A. USDA ERS - Documentation. Usda.gov. Published January 5, 2025. 

https://www.ers.usda.gov/data-products/food-access-research-atlas/documentation

American Kidney Fund. Kidney-friendly eating plan | American kidney fund. www.kidneyfund.org. Published December 1, 2021. 

https://www.kidneyfund.org/living-kidney-disease/healthy-eating-activity/kidney-friendly-eating-plan

Bellasi A, Di Lullo L, Di Iorio B. Chronic Kidney Disease: The Silent Epidemy. 

Li Y, Menon G, Kim B, et al. Residential Neighborhood Disadvantage and Access to Kidney Transplantation. 

https://doi.org/10.1001/jamanetworkopen.2025.49679

Videos

7 experts come together to address neighborhood disadvantage and its impact on kidney health in the latest Crisis Point. 

Living Donor Donation Works When Relationships Matter

Despite the benefits of living donor kidney transplantation, donation rates remain low, and recent data suggests willingness to donate is shaped by more than financial concerns.

New research shows that interpersonal and health-related factors, as well as age, sex, and racial or ethnic background, strongly influence whether potential donors take steps toward donation.

“Ultimately, combining structural support with relationally grounded, culturally responsive counseling is likely more effective for increasing living donation than focusing on finances alone,” said Mary K. Roberts, PhD, postdoctoral researcher at the Leverhulme Centre for Demographic Science at the University of Oxford.

Analyzing data from 600 U.S. relatives of kidney disease patients in the 2019 

, Roberts and colleagues identified the strongest motivators and deterrents influencing donation behavior. Improving or extending the recipient’s life and the donor–recipient relationship emerged as the most important motivators, while concerns about donor health, surgery, and finances were the primary barriers.

Willingness to donate also varied across demographic groups. Younger adults were more influenced by match likelihood, current health, and knowledge of living donation, while older adults were more likely to cite their own health as a limiting factor. Women reported greater concerns about finances and recovery than men, and Black and Asian/Pacific Islander respondents were more likely to indicate that surgery or financial concerns reduced willingness. Hispanic and White respondents more often highlighted the potential to extend the recipient’s life as a motivator.

Investigators saw greater willingness was driven by health, relationship, match likelihood, and potential benefit to the recipient, and was linked to completing more donation-related actions, even after adjusting for demographic factors. Conversely, lower willingness related to general views on organ donation, surgery, or recovery predicted fewer actions, underscoring the influence of both personal and relational factors on behavior.

“Programs integrating culturally tailored, patient-focused, and family-centered education can help patients navigate these conversations with potential donors,” Roberts said. “Ensuring donors have ways to access donation services, proactively discussing medical and process concerns, and providing transparency around long-term health risks are especially critical for communities that historically experience disparities in transplant access.”

Roberts suggests improving living kidney donation rates requires a multidimensional approach that addresses both structural barriers and interpersonal concerns, rather than focusing solely on financial support. By combining culturally responsive counseling with practical and medical support, clinicians can help reduce disparities and increase donor engagement across diverse populations.

Editor’s Note: Roberts reports no relevant disclosures.

Roberts MK, Ryan-Claytor C, Salim Z, Kirk JM, Rowe-Nicholls I, Daw J. Factors influencing willingness to pursue living kidney donation among relatives of patients with kidney disease in the United States. 

. Published online February 9, 2026. doi:

https://doi.org/10.1186/s12882-026-04806-3

.DePasquale N, Cabacungan A, Ephraim PL, Lewis-Boyér L, Powe NR, Boulware LE. Family Members’ Experiences With Dialysis and Kidney Transplantation. 

https://doi.org/10.1016/j.xkme.2019.06.001

Willingness to pursue living kidney donation is shaped by relationships, health, and a multidisciplinary approach, not just finances.

Living Donor Donation Works When Relationships Matter With Mary Roberts, PhD

Donor–Recipient Closeness and Perceived Life Extension Drive Living Kidney Donation Decisions

New data from a US-based survey suggest the closeness of the donor–recipient relationship and perceived health benefits for the recipient may be strong motivators for living donors, with insights that could inform counseling strategies in transplant programs.

There are 90,000 individuals awaiting kidney transplants in the US alone, making up 86-87% of the national transplant waiting list. In 2025, the US achieved a record of organ transplants, with a 3% increase in individuals becoming living organ donors, according to data from the Organ Procurement and Transplantation Network. Living donor kidney transplantation has been associated with superior graft survival and improved patient outcomes for patients with ESKD, rates of living donation remain low.

“One of the major gaps in the living donation literature that we were really focused on was that most research examines barriers from the patient or provider perspective,” Mary K Roberts, PhD, Post Doctoral Researcher at the Leverhulme Centre for Demographic Science at the University of Oxford, explained. “We know much less about the donor side, especially in the US, and prior studies have mostly focused on financial concerns.”

In the analysis, Roberts and investigators leveraged data from 600 US relatives of patients with kidney disease who completed the 2019 Families of Renal Patients Survey. In the survey, participants rated 14 considerations, including financial, health, and relational factors, which affected their willingness to be evaluated as living donors.

Older adults were less likely than younger respondents to report reduced willingness for financial reasons, while younger adults more often reported increased willingness based on match likelihood, current health, and knowledge of living donation. Older respondents more often indicated that their own health reduced willingness, and adults aged 40 to 59 most often cited negative effects on their family.

Women were more likely than men to report reduced willingness related to financial and recovery concerns. Asian or Pacific Islander and Black respondents more often reported reduced willingness due to financial issues and the surgery itself, while Hispanic and White respondents more often reported increased willingness related to extending the recipient’s life.

Greater willingness related to match likelihood, current health, the donor–recipient relationship, and the potential to extend the recipient’s life was associated with completing more donation-related actions. Lower willingness tied to general views on organ donation, surgery, or recovery was associated with completing fewer actions.

After adjustment for demographic factors and relationship to the patient, significant associations remained for match likelihood, current health, the donor-recipient relationship, the potential to extend the recipient’s life, and general views on organ donation.

“The findings really suggest that counseling centered around relational and health related motivations tend to really drive action,” said Roberts. “So prior to evaluation, it would be important to explore donor-recipient relationships and acknowledge that, you know, interpersonal closeness might be a motivator for a lot of donors.”

90,000 people are waiting for a kidney. Here’s one way to get them a kidney faster. - UNOS. UNOS. Published January 27, 2025. 

https://unos.org/news/90000-people-are-waiting-for-a-kidney-heres-one-way-to-get-them-a-kidney-faster/

Survey of 600 US relatives finds donor–recipient closeness and expected life extension drive living kidney donation more than financial concerns.

Mary K Roberts, PhD

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