Among adults with chronic kidney disease (CKD), those with limited health literacy have increased risks for CKD progression, cardiovascular events, hospitalization, and early death, a new study finds.

Investigators asked 3715 patients in the Chronic Renal Insufficiency Cohort (CRIC) study to complete the Short Test of Functional Health Literacy in Adults. Participants read passages of health-related text with incomplete information and needed to select the missing words. The team found that 15% of patients had limited health literacy and 85% had adequate health literacy.

In a model adjusted for sociodemographic factors such as education and income, patients with limited vs adequate health literacy had a 34% increased risk of CKD progression, a 33% increased risk of hospitalization, and a 67% increased risk of a cardiovascular event – all significant findings, Mayra L. Estrella, PhD, MPH, of The University of Texas Health Science Center at Houston, and colleagues reported in Nephrology Dialysis Transplantation. The limited health literacy group had significant 2.1-, 1.8-, 1.6-, and 1.6-fold increased risks for stroke, myocardial infarction, congestive heart failure, and peripheral arterial disease, respectively. This group also had significant 1.5-, 2.4-, and 1.3-fold increased risks for all-cause, cardiovascular, and non-cardiovascular mortality, respectively.

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Results were similar after further adjustment for modifying factors (such as blood pressure and diabetes status), except for CKD progression and non-cardiovascular mortality, which were no longer statistically significant.

Patients with limited health literacy were more likely to have visited a nephrologist than those with adequate health literacy. The groups did not differ in health insurance coverage or use of renin angiotensin system inhibitors. Previous research has associated limited health literacy with lower use of disease prevention services, less knowledge of chronic disease, worse medication adherence, and higher hospitalization. Adequate health literacy, in contrast, may help patients navigate the healthcare system, communicate effectively with healthcare providers, and obtain resources.

“Our findings underscore the need for targeted efforts to address limited health literacy among CKD patients,” Dr Estrella’s team concluded.


Estrella ML, Allen-Meares P, Ricardo AC, et al. Prospective associations of health literacy with clinical outcomes in adults with CKD: findings from the CRIC study. Nephrol Dial Transplant. Published online June 23, 2022. doi:10.1093/ndt/gfac201