LAUSR

Housing is a critical determinant of health, and with the nationwide shortage of affordable housing, job loss, and wage stagnation that were exacerbated during the coronavirus disease 2019 pandemic, those affected by kidney disease have compounded risk for consequences. The housing shortage particularly affects people who have incomes that are at or below the federal poverty level and minoritized populations due to decades of racist housing policies and lending practices. Kidney disease disproportionately affects the same populations; compared with White people the incidence of kidney failure is over three-fold higher for Black people, and individuals living in areas where more than one in five households have incomes below the federal poverty level are 25% more likely to develop kidney failure than individuals not living in those neighborhoods. Although the exact prevalence of unstable housing among people with kidney disease is unknown, housing has become an issue that demands the attention of the kidney community. Compared with housed populations, individuals experiencing homelessness face higher mortality, higher acute care utilization, and higher rates of suicide, unintentional injuries, infectious diseases, mental health problems, substance misuse, and abuse. Those with kidney disease are already at increased risk for these comorbid circumstances. Housing insecurity is defined as having high housing costs or living in overcrowded or unsafe living conditions. People experiencing housing insecurity are three times more likely to develop albuminuria, 60% more likely to postpone needed medical care, and less likely to achieve kidney protective measures such as control of diabetes and hypertension. Among people with kidney disease, housing issues may contribute to worse outcomes by promoting progression to kidney failure and introducing barriers to healthy behaviors and medical care. For example, people with CKD experiencing homelessness are 30% more likely to develop kidney failure or die than people with CKD who are stably housed. Advanced kidney disease in turn increases vulnerability to unstable housing, because many who are already experiencing financial resource strain may suddenly be unable to work and pay for rising housing costs. A lack of housing likely results in people on dialysis or with kidney transplants being unable to store or manage complicated medication regimens. A lack of a permanent address may result in a discontinuation of benefits or insurance. People on dialysis experiencing unstable housing might not be able to follow dietary restrictions due to lack of control over available food, and miss dialysis sessions due to frequent moves and difficulty securing regular transportation. Housing insecurity could significantly impede the proposed End Stage Renal Disease Treatment Choice (ETC) payment model, a national effort to increase kidney transplantation and use of home dialysis modalities, because these treatments are not accessible when someone is experiencing unstable housing. Addressing housing with advocacy and program development may narrow socioeconomic disparities in kidney disease, as has been accomplished in other public health sectors such as infectious diseases. Stable housing has the potential to increase use of home dialysis modalities or transplantation among lowincome patients who are experiencing unstable housing, which in turn could improve quality of life and mortality. Housing interventions, such as permanent supportive housing, have been used for decades for individuals experiencing chronic homelessness with disabling conditions, such as HIV and mental health problems, and should be expanded for people with kidney disease. Permanent supportive housing, which combines housing with services ranging from medical and mental health care to case management, has been shown to keep people housed longer, decrease acute care utilization, and increase outpatient utilization. Additional housing interventions include hospital investments in rental assistance, tiny home communities, rental