Tim Pflederer, MD, is the chief medical officer at Evergreen Nephrology

Tim Pflederer, MD

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. 

Guiding CKD Care Through Updated Dietary Guidelines, With Tim Pflederer, MD

In response to the recently released federal Dietary Guidelines for Americans, 2025–2030, nephrologists should ensure patients with impaired kidney function, 

) are following individualized, treatment-informed diets.

The US Department of Health & Human Services (HHS) released the updated guidelines on January 7, 2026, emphasizing high-quality protein, healthy fats, fruits, vegetables, and whole grains while discouraging highly processed foods and refined carbohydrates.

“I think the direction of [the guidelines] is right and good for kidney disease, but at the same time, there are nuanced messages that our patients need to hear related to those guidelines,” Tim Pflederer, MD, shared in an interview with 

Patients with renal impairment have reduced glomerular filtration rate (GFR), which limits the kidney’s ability to excrete potassium, phosphorus, and nitrogenous waste from protein metabolism. 

Excess protein, particularly from animal sources

, can increase renal solute load, stimulate hyperfiltration in residual nephrons, and accelerate CKD progression, as Pflederer highlighted in a previous discussion with our team.

Consequently, intake of high-potassium foods and protein must be carefully managed, with attention to laboratory monitoring, CKD stage, and dialysis schedules.

While the guidelines encourage more whole vegetables and fruits, clinicians should encourage their patients with kidney disease to carefully select options. Many common fruits and vegetables are high in potassium, Pflederer explained, including bananas, oranges, potatoes, tomatoes, avocados, and dried fruits.

Hyperkalemia occurs when serum potassium rises above safe physiologic levels, which can trigger cardiac arrhythmias and sudden death. In patients with advanced CKD or ESKD, impaired renal excretion makes them particularly vulnerable. Patients on dialysis rely on the treatment to remove extra potassium, so dietary intake must be carefully adjusted based on the timing of treatments between sessions.

“If they're having difficulty with potassium, they should talk to their physician to make certain that the foods that they're eating that are whole, fresh fruits and vegetables, particularly, are not high in potassium,” said Pflederer.

Clinicians can offer options with regulated levels of potassium, including apples, berries, grapes, white rice, white bread, and fresh white meat. Additionally, cooking methods such as boiling or leaching may reduce potassium content, which may help patients manage intake more safely.

The guidelines also encourage avoidance of processed foods, which Pflederer acknowledges can benefit kidney health. Many processed products contain phosphorus additives, which are almost completely absorbed and can accumulate quickly in patients with reduced kidney function, increasing the risk of mineral imbalances and long-term complications.

In patients with CKD, impaired kidney function reduces phosphate excretion, which can trigger increases in fibroblast growth factor 23 (FGF23) and parathyroid hormone (PTH). Over time, this can weaken bones and cause calcium to deposit in blood vessels and organs, increasing the risk of heart attack, stroke, and other complications.

“Eliminating processed foods will at the same time be overall good for their health, and eliminate and reduce the phosphorus burden that is difficult for people with kidney disease to handle,” said Pflederer.

Editor’s Note: Pflederer reports no relevant disclosures. 

Fact Sheet: Trump Administration Resets U.S. Nutrition Policy, Puts Real Food Back at the Center of Health. HHS.gov. Published January 7, 2026. 

https://www.hhs.gov/press-room/fact-sheet-historic-reset-federal-nutrition-policy.html

Ko GJ, Kalantar-Zadeh K. How important is dietary management in chronic kidney disease progression? A role for low protein diets. 

‌Potassium and Chronic Kidney Disease - DaVita | DaVita. DaVita. Published June 20, 2025. 

https://davita.com/diet-nutrition/articles/potassium-and-chronic-kidney-disease/

Six Steps to Controlling High Potassium. National Kidney Foundation. Published August 12, 2024. 

https://www.kidney.org/news-stories/six-steps-to-controlling-high-potassium‌

‌National Kidney Foundation. Phosphorus and Your CKD Diet. National Kidney Foundation. Published June 26, 2025. 

https://www.kidney.org/kidney-topics/phosphorus-and-your-ckd-diet

Russo D, Battaglia Y. Clinical Significance of FGF-23 in Patients with CKD. 

Tim Pflederer, explains how nephrologists can help patients with CKD and ESKD navigate the 2025–2030 Dietary Guidelines, including managing protein, potassium, and phosphorus intake.

New Federal Dietary Guidelines Impact on Chronic Kidney Disease Management With Tim Pflederer, MD

The newly released 2025–2030 federal Dietary Guidelines for Americans may need careful interpretation for patients with 

, particularly regarding encouraged protein intake.

The guidelines, released by the US Department of Health and Human Services (HHS), emphasize protein, recommend limiting processed foods, and encourage a shift toward whole foods. While these recommendations aim to promote general health in the American population, patients with CKD may require tailored guidance based on their kidney function and individual health status.

Ultimately, nephrologists play a key role in bridging the gap between generalized dietary guidelines and the specific needs of patients with CKD. Dietary management in CKD can also help prevent cardiovascular complications and aid in controlling hypertension and diabetes, common comorbidities. In addition, nutrition may influence how well treatments for kidney disease work. The American Kidney Fund recommends working with a dietitian to develop an individualized, kidney-friendly eating plan accounting for disease stage, comorbidities, and dialysis status.

“A diet that is predominantly plant-based is more protective for the kidneys than a meat-based diet,” said Tim Pflederer, MD, chief medical officer at Evergreen Nephrology, in an interview with 

Most Americans consume diets heavily centered on meat, so nephrologists work with our patients to encourage moderation in protein intake and a focus on vegetarian or plant-focused protein sources.”

Excess protein intake, particularly from animal sources, increases glomerular filtration workload and generates higher levels of nitrogenous waste, such as urea, which can accumulate in patients with reduced kidney function. High protein diets, especially from meat, can also increase intraglomerular pressure and accelerate kidney damage over time.

Plant-based proteins, such as beans, lentils, and nuts, are easier on the kidneys because they generate less acid, produce lower levels of uremic toxins, and contain phosphorus in a less bioavailable form than animal proteins, reducing the risk of hyperphosphatemia. Diets high in acid-producing foods can exacerbate metabolic acidosis, which is common in CKD and contributes to bone demineralization, progression of kidney damage, and increased muscle catabolism.

“I would divide people with kidney disease into two categories. One is those with CKD whose kidneys are functioning adequately, and they're not yet progressed to where they're on dialysis,” said Pflederer. “In that group of patients, it is very clear from the literature that a moderate protein diet is protective of the kidneys compared to a high protein diet, and then, actually more importantly, proteins that are plant-based are better for the kidneys.”

Conversely, insufficient protein intake can lead to loss of lean body mass, sarcopenia, and impaired immune function, particularly in patients on dialysis who have higher protein requirements to compensate for amino acid losses during treatment. The optimal protein intake depends on individualized factors including CKD stage, dialysis status, body weight, and comorbid conditions, balancing the need to preserve muscle mass while minimizing renal stress.

Editor’s Note: Pflederer reports no relevant disclosures.

National Kidney Foundation. Nutrition and Kidney Disease, Stages 1-5 (Not on Dialysis). National Kidney Foundation. Published 2024. 

https://www.kidney.org/kidney-topics/nutrition-and-kidney-disease-stages-1-5-not-dialysis

‌Healthy eating for adults with chronic kidney disease. National Institute of Diabetes and Digestive and Kidney Diseases. Published May 10, 2025. 

https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/healthy-eating-adults-chronic-kidney-disease

Updated federal guidelines highlight protein intake, with Tim Pflederer emphasizing the importance of individualized nutrition strategies for CKD patients


Tim Pflederer, MD

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