Social determinants of chronic kidney disease: from association to clinical and population action

To synthesize recent evidence on how social determinants -socioeconomic conditions, health system, physical environment, psychosocial factors, life course, structural forces, migration, gender, and population vulnerability - shape the risk, progression, and outcomes of chronic kidney disease (CKD), and to identify clinical and health policy implications.

The evidence confirms a consistent and cumulative social gradient: simultaneous exposure to low income, lower education, unemployment, housing insecurity, and barriers to healthcare access is associated with higher CKD prevalence, accelerated progression, and increased all-cause and cardiovascular mortality. At the territorial level, social deprivation explains a significant proportion of the variability in the incidence of kidney failure, partially independent of comorbidities and environmental exposures. Groups affected by structural inequities - migrants, Indigenous populations, rural residents, and women - present persistent barriers in early detection, access to nephrology care, choice of dialysis modality, and transplantation. Environmental factors (pollution, heat, working conditions), together with low health literacy and unmet social needs, amplify these inequalities across the care continuum.

CKD should be understood as a bio-social phenomenon in which risk and access to timely, high-quality care are socially determined. Recent literature advances from the description of inequities toward the identification of critical points in the care trajectory and actionable strategies, including targeted screening, integration with social work, barrier-free communication, and culturally well tolerated approaches.