Chronic Kidney Disease in Context: Detection and Severity Among Afro-Descendant Communities in Colombia

To examine how health insurance and access to care shape the detection of chronic kidney disease (CKD) and to assess determinants of CKD severity among Afro-descendant adults in the Colombian Caribbean. This was a cross-sectional study using community-based screening data and applying multivariable regression and mediation analyses. Urban, rural, and suburban Afro-descendant communities in the Caribbean region of Colombia. Data were obtained from community-based CKD screening efforts (N = 1,327). Proteinuria, assessed using a urine dipstick, was used as an indicator of CKD in the full sample. Among participants with confirmed proteinuria and available creatinine data (n = 326), CKD severity was defined as moderate or worse kidney dysfunction (eGFR < 60 mL/min/1.73 m²). Guided by the Andersen Behavioral Model, we examined predisposing and enabling factors, including insurance type and access to care. Mediation analysis using generalized structural equation models estimated the indirect effects of insurance on access to care. Approximately one-quarter of the participants screened positive for proteinuria, indicating a substantial burden of undetected disease. Having a primary care doctor was associated with a higher probability of proteinuria, whereas difficulty in accessing care was associated with a lower probability, consistent with the detection process. Insurance was not directly associated with proteinuria but operated through access to care, with a significant indirect effect (β = -1.36, p < 0.001). Among individuals with kidney dysfunction, CKD severity was not associated with insurance or reported access barriers. Instead, severity was strongly associated with geographic context, with higher odds observed in rural (OR = 2.65; 95% CI: 1.51-4.65) and suburban communities (OR = 5.04; 95% CI: 1.57-16.19), and lower odds among those with a primary care doctor (OR = 0.42; 95% CI: 0.23-0.77). Access to care influences CKD detection but does not fully explain disease severity. Instead, CKD progression reflects structural and place-based conditions that extend beyond individual access to care. These findings highlight the importance of distinguishing between detection and progression in population kidney health and underscore the need for community-based screening strategies and place-based interventions to reduce CKD inequities among Afro-descendant populations.