The impact of homelessness on kidney outcomes among adults with diabetes

Introduction — People with diabetes experiencing homelessness face barriers to self-management, contributing to suboptimal glycemia and reduced screening for microvascular complications. The objective of the study was to assess whether a history of homelessness is associated with kidney-related outcomes among people with diabetes.

Methods — A propensity-matched cohort study using administrative health data from Ontario, Canada, was conducted, including residents with diabetes who had ≥1 hospital encounter during the study period (2008–2020). Having a history of homelessness was identified using a validated algorithm. Outcomes of interest included nephrologist visits, reduction in estimated glomerular filtration rate (eGFR), initiation of renal replacement therapy, and acute care visits for kidney-related ambulatory care–sensitive conditions. Negative binomial regression and Cox proportional hazard models were used to assess outcomes.

Results — Of 659,877 eligible people with diabetes living in Ontario, 3366 had a history of homelessness, with 2650 successfully matched to non-homeless controls. People with a history of homelessness had similar rates of nephrologist visits compared with those with no history of homelessness (rate ratio [RR] = 1.27; 95% confidence interval [CI]: 0.82–1.97), but had higher rates of hospitalization for chronic kidney disease (CKD)-related conditions, including volume overload (RR = 3.13; 95% CI: 1.62–6.04), hyperkalemia (RR = 3.01; 95% CI: 2.07–4.39), and heart failure (RR = 2.06; 95% CI: 1.62–2.63). They had a higher hazard of eGFR decline (hazard ratio [HR] = 1.71; 95% CI: 1.56–1.88), and renal replacement therapy (HR = 1.65; 95% CI: 1.04–2.60) compared with nonhomeless controls.

Conclusion — Homelessness is associated with higher rates of kidney-related adverse events in people living with diabetes, supporting the need for tailored approaches that reduce barriers to accessing diabetes care.