Racialized algorithms for kidney function: Erasing social experience

Toward Equitable Kidney Function Estimation in Critical Care Practice: Guidance From the Society of Critical Care Medicine's Diversity, Equity, and Inclusion in Renal Clinical Practice Task Force

OBJECTIVES

Accurate glomerular filtration rate (GFR) assessment is essential in critically ill patients. GFR is often estimated using creatinine-based equations, which require surrogates for muscle mass such as age and sex. Race has also been included in GFR equations, based on the assumption that Black individuals have genetically determined higher muscle mass. However, race-based GFR estimation has been questioned with the recognition that race is a poor surrogate for genetic ancestry, and racial health disparities are driven largely by socioeconomic factors. The American Society of Nephrology and the National Kidney Foundation (ASN/NKF) recommend widespread adoption of new "race-free" creatinine equations, and increased use of cystatin C as a race-agnostic GFR biomarker.

DATA SOURCES

Literature review and expert consensus.

STUDY SELECTION

English language publications evaluating GFR assessment and racial disparities.

DATA EXTRACTION

We provide an overview of the ASN/NKF recommendations. We then apply an Implementation science methodology to identify facilitators and barriers to implementation of the ASN/NKF recommendations into critical care settings and identify evidence-based implementation strategies. Last, we highlight research priorities for advancing GFR estimation in critically ill patients.

DATA SYNTHESIS

Implementation of the new creatinine-based GFR equation is facilitated by low cost and relative ease of incorporation into electronic health records. The key barrier to implementation is a lack of direct evidence in critically ill patients. Additional barriers to implementing cystatin C-based GFR estimation include higher cost and lack of test availability in most laboratories. Further, cystatin C concentrations are influenced by inflammation, which complicates interpretation.

CONCLUSIONS

The lack of direct evidence in critically ill patients is a key barrier to broad implementation of newly developed "race-free" GFR equations. Additional research evaluating GFR equations in critically ill patients and novel approaches to dynamic kidney function estimation is required to advance equitable GFR assessment in this vulnerable population.

The American Society for Bone and Mineral Research Task Force on clinical algorithms for fracture risk report

Using race and ethnicity in clinical algorithms potentially contributes to health inequities. The American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee convened the ASBMR Task Force on Clinical Algorithms for Fracture Risk to determine the impact of race and ethnicity adjustment in the US Fracture Risk Assessment Tool (US-FRAX). The Task Force engaged the University of Minnesota Evidence-based Practice Core to conduct a systematic review investigating the performance of US-FRAX for predicting incident fractures over 10 years in Asian, Black, Hispanic, and White individuals. Six studies from the Women's Health Initiative (WHI) and Study of Osteoporotic Fractures (SOF) were eligible; cohorts only included women and were predominantly White (WHI > 80% and SOF > 99%), data were not consistently stratified by race and ethnicity, and when stratified there were far fewer fractures in Black and Hispanic women vs White women rendering area under the curve (AUC) estimates less stable. In the younger WHI cohort (n = 64 739), US-FRAX without bone mineral density (BMD) had limited discrimination for major osteoporotic fracture (MOF) (AUC 0.53 (Black), 0.57 (Hispanic), and 0.57 (White)); somewhat better discrimination for hip fracture in White women only (AUC 0.54 (Black), 0.53 (Hispanic), and 0.66 (White)). In a subset of the older WHI cohort (n = 23 918), US-FRAX without BMD overestimated MOF. The Task Force concluded that there is little justification for estimating fracture risk while incorporating race and ethnicity adjustments and recommends that fracture prediction models not include race or ethnicity adjustment but instead be population-based and reflective of US demographics, and inclusive of key clinical, behavioral, and social determinants (where applicable). Research cohorts should be representative vis-à-vis race, ethnicity, gender, and age. There should be standardized collection of race and ethnicity; collection of social determinants of health to investigate impact on fracture risk; and measurement of fracture rates and BMD in cohorts inclusive of those historically underrepresented in osteoporosis research.

Racing the Machine: Data Analytic Technologies and Institutional Inscription of Racialized Health Injustice

Recent scientific and policy initiatives frame clinical settings as sites for intervening upon inequality. Electronic health records and data analytic technologies offer opportunity to record standard data on education, employment, social support, and race-ethnicity, and numerous audiences expect biomedicine to redress social determinants based on newly available data. However, little is known on how health practitioners and institutional actors view data standardization in relation to inequity. This article examines a public safety-net health system's expansion of race, ethnicity, and language data collection, drawing on 10 months of ethnographic fieldwork and 32 qualitative interviews with providers, clinic staff, data scientists, and administrators. Findings suggest that electronic data capture institutes a decontextualized racialization within biomedicine as health practitioners and data workers rely on biological, cultural, and social justifications for collecting racial data. This demonstrates a critical paradox of stratified biomedicalization: The same data-centered interventions expected to redress injustice may ultimately reinscribe it.

A Canadian Commentary on the NKF-ASN Task Force Recommendations on Reassessing the Inclusion of Race in Diagnosing Kidney Disease

In 2021, a committee was commissioned by the Canadian Society of Nephrology to comment on the 2021 National Kidney Foundation-American Society of Nephrology Task Force recommendations on the use of race in glomerular filtration rate estimating equations. The committee met on numerous occasions and agreed on several recommendations. However, the committee did not achieve unanimity, with a minority group disagreeing with the scope of the commentary. As a result, this report presents the viewpoint of the majority members. We endorsed many of the recommendations from the National Kidney Foundation-American Society of Nephrology Task Force, most importantly that race should be removed from the estimated glomerular filtration rate creatinine-based equation. We recommend an immediate implementation of the new Chronic Kidney Disease Epidemiology Collaboration equation (2021), which does not discriminate among any group while maintaining precision. Additionally, we recommend that Canadian laboratories and provincial kidney organizations advocate for increased testing and access to cystatin C because the combination of cystatin C and creatinine in revised equations leads to more precise estimates. Finally, we recommend that future research studies evaluating the implementation of the new equations and changes to screening, diagnosis, and management across provincial health programs be prioritized in Canada.

Epistemic Silences and Experiential Knowledge in Decisions After a First Cesarean: The case of a vaginal birth after cesarean calculator

Evidence-based obstetrics can employ statistical models to justify greater use of cesareans, sometimes excluding experiential elements from informed decision making. Over the past decade, prenatal providers adopted a vaginal birth after cesarean (VBAC) calculator designed to support patients in making informed decisions about their births by estimating their probability for a VBAC. Among other factors, the calculator used race and ethnicity to make its estimate, assigning lower probabilities for a successful VBAC to Black and Hispanic patients. I analyze how a diverse group of women and their providers engaged with the VBAC calculator. Some providers used low calculator scores to remove a shared decision-making model by prescriptively counseling Black and Hispanic women who desired a VBAC into undergoing repeat cesareans. Consequently, women racialized by the calculator as Black or Hispanic used experiential knowledge to challenge the calculator's assessment of their supposed lesser ability to give birth vaginally.

Exploring the impact of missingness on racial disparities in predictive performance of a machine learning model for emergency department triage

Objective

To investigate how missing data in the patient problem list may impact racial disparities in the predictive performance of a machine learning (ML) model for emergency department (ED) triage.

Materials and Methods

Racial disparities may exist in the missingness of EHR data (eg, systematic differences in access, testing, and/or treatment) that can impact model predictions across racialized patient groups. We use an ML model that predicts patients' risk for adverse events to produce triage-level recommendations, patterned after a clinical decision support tool deployed at multiple EDs. We compared the model's predictive performance on sets of observed (problem list data at the point of triage) versus manipulated (updated to the more complete problem list at the end of the encounter) test data. These differences were compared between Black and non-Hispanic White patient groups using multiple performance measures relevant to health equity.

Results

There were modest, but significant, changes in predictive performance comparing the observed to manipulated models across both Black and non-Hispanic White patient groups; c-statistic improvement ranged between 0.027 and 0.058. The manipulation produced no between-group differences in c-statistic by race. However, there were small between-group differences in other performance measures, with greater change for non-Hispanic White patients.

Discussion

Problem list missingness impacted model performance for both patient groups, with marginal differences detected by race.

Conclusion

Further exploration is needed to examine how missingness may contribute to racial disparities in clinical model predictions across settings. The novel manipulation method demonstrated may aid future research.

Retaining Race in Chronic Kidney Disease Diagnosis and Treatment

The best overall measure of kidney function is glomerular filtration rate (GFR) as commonly estimated from serum creatinine concentrations (eGFRcr) using formulas that correct for the higher average creatinine concentrations in Blacks. After two decades of use, these formulas have come under scrutiny for estimating GFR differently in Blacks and non-Blacks. Discussions of whether to include race (Black vs. non-Black) in the calculation of eGFRcr fail to acknowledge that the original race-based eGFRcr provided the same CKD treatment recommendations for Blacks and non-Blacks based on directly (exogenously) measured GFR. Nevertheless, the National Kidney Foundation and the American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease removed race in CKD treatment guidelines and pushed for the immediate adoption of a race-free eGFRcr formula by physicians and clinical laboratories. This formula is projected to negate CKD in 5.51 million White and other non-Black adults and reclassify CKD to less severe stages in another 4.59 million non-Blacks, in order to expand treatment eligibility to 434,000 Blacks not previously diagnosed and to 584,000 Blacks previously diagnosed with less severe CKD. This review examines: 1) the validity of the arguments for removing the original race correction, and 2) the performance of the proposed replacement formula. Excluding race in the derivation of eGFRcr changed the statistical bias from +3.7 to -3.6 ml/min/1.73m2 in Blacks and from +0.5 to +3.9 in non-Blacks, i.e., promoting CKD diagnosis in Blacks at the cost of restricting diagnosis in non-Blacks. By doing so, the revised eGFRcr greatly exaggerates the purported racial disparity in CKD burden. Claims that the revised formulas identify heretofore undiagnosed CKD in Blacks are not supported when studies that used kidney failure replacement therapy and mortality are interpreted as proxies for baseline CKD. Alternatively, a race-stratified eGFRcr (i.e., separate equations for Blacks and non-Blacks) would provide the least biased eGFRcr for both Blacks and non-Blacks and the best medical treatment for all patients.

Leveraging Clerkship Experiences to Address Segregated Care: A Survey-Based Approach to Student-Led Advocacy

Phenomenon: Many academic medical centers (AMCs) have a history of separating patients on the basis of insurance status. In New York State, where Black and Latino patients are more than twice as likely to have Medicaid as white patients, this practice leads to de facto racial segregation in healthcare. Emerging evidence suggests that this segregation of care is detrimental to both patient care and medical education. Medical students are uniquely positioned to be change makers in this space but face significant barriers to speaking out about these disparities and successfully advocating for institutional change. Approach: The authors designed, piloted, and distributed a 16-item survey on segregated care to third-year medical students at a large academic medical center in New York City. Students were asked both open- and close-ended questions about witnessing separation and differences in patient care on the basis of insurance during their clinical rotations. The survey was shared with 140 students in March 2019 with a response rate of 46.4% (n = 65). Preliminary findings were presented to school and hospital administrators. Findings: More than half of survey respondents reported witnessing separation of patient care or differences in patient care on the basis of insurance (56.3%, n = 36 and 51.6%, n = 33 respectively). Many students reported that these experiences contributed to cynicism and burnout. The authors leveraged these results to advocate for quality improvement measures. In Ob-Gyn, department leadership launched a clinical transformation taskforce and recruited a new Vice Chair of Clinical Transformation/Chief Patient Experience Officer, whose role includes addressing segregated care and disparities in health outcomes. The hospital committed to establishing integrated practices in new clinical spaces and launching a similar survey among house staff. Insights: Many medical students experience and participate in segregated care during their clerkships and this has the potential to impact their education. Medical students are well-positioned to recognize segregated care across health systems and leverage their experiences for advocacy. A survey-based approach can be a powerful tool enabling students to collect these experiences to address segregated care and other health equity issues.

Prevalence of renal and bone risk factors among individuals prescribed oral pre-exposure prophylaxis for HIV

Objectives

The only available oral pre-exposure prophylaxis (PrEP) regimens approved in the United States to prevent HIV infection during the period covered by this study were emtricitabine/tenofovir alafenamide (F/TAF) and emtricitabine/tenofovir disoproxil fumarate (F/TDF). Both agents have similar efficacy, however F/TAF exhibits improved bone and renal health safety endpoints over F/TDF. In 2021, the United States Preventive Services Task Force recommended individuals have access to the most medically appropriate PrEP regimen. To understand the impact of these guidelines, the prevalence of risk factors to renal and bone health was evaluated among individuals prescribed oral PrEP.

Methods

This prevalence study utilized the electronic health records of people prescribed oral PrEP between January 1, 2015 and February 29, 2020. Renal and bone risk factors (age, comorbidities, medication, renal function, and body mass index) were identified using International Classification of Diseases (ICD) and National Drug Code (NDC) codes.

Results

Among 40 621 individuals prescribed oral PrEP, 62% had ≥1 renal risk factor and 68% had ≥1 bone risk factor. Comorbidities were the most frequent (37%) class of renal risk factors. Concomitant medications were the most prominent (46%) class of bone-related risk factors.

Conclusions

The high prevalence of risk factors suggests the importance of their consideration when choosing the most appropriate regimen for individuals who may benefit from PrEP.

Association of impaired kidney function with dementia and brain pathologies: A community-based cohort study

INTRODUCTION

The relationship between impaired kidney function (KF), dementia, and brain pathologies remains unclear.

METHODS

A total of 1354 dementia- and kidney disease-free participants including 895 with normal and 459 with impaired KF were followed from 2002 until 2020 (median [interquartile range]: 5 [2-9]) to detect incident dementia. KF was assessed at baseline and categorized as normal or impaired. Over the follow-up, 453 participants died and underwent autopsies for neuropathological assessment.

RESULTS

Compared to those with normal KF, the hazard ratios (95% confidence intervals [CIs]) of those with impaired KF was 1.48 (1.15, 1.90)/1.44 (1.10, 1.88) for dementia/Alzheimer's dementia. Furthermore, impaired KF was related to a significantly higher burden of cerebral amyloid angiopathy (CAA; odds ratio = 1.96, 95% CI: 1.17, 3.30), but not to other brain pathologies.

DISCUSSION

Impaired KF is associated with an increased risk of dementia and Alzheimer's dementia. CAA may underlie, in part, this association.

HIGHLIGHTS

Impaired kidney function (KF) was associated with higher dementia and Alzheimer's dementia risk. Impaired KF anticipated dementia and Alzheimer's dementia onset by more than 1.5 years. Impaired KF was significantly related to a higher burden of cerebral amyloid angiopathy (CAA) but not to other brain pathologies.

A Framework for Antiracist Curriculum Changes in Nephrology Education

Addressing persistent racial health disparities in cases of kidney disease will first require significant investment in examining how structural racism has influenced our clinical practice and medical education. Improving how we understand and articulate race is critical for achieving this goal. This work begins with ensuring that race's mention within nephrology literature and curricular materials for medical trainees is thoroughly rooted in evidence-based rationale-not to serve as a proxy for polygenic contributions, social determinants of health, or systemic health care barriers. While many institutions are increasingly recognizing the importance of instituting such changes on behalf of the systematically marginalized patient populations who are most affected by these disparities, there is a paucity of guidance on how to critically appraise and revise decades of pathophysiological and epidemiological findings through an antiracist lens. In this article, we propose an inquiry-based framework with case-study examples to help readers recognize improper use of race within nephrology, assess personal and institutional readiness to introduce changes to said content, and generate materials that center evidence-based findings and reject harmful misinterpretations of race.

A Role for History in Inclusive Nursing Education

BACKGROUND

History is a critical methodology that provides perspective on complex issues in health care today.

METHOD

This article draws on a selection of interdisciplinary scholarship on the history of nursing and health care, including work by scholars of color; lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) scholars; and disability studies scholars, to demonstrate the role of history in inclusive nursing education.

RESULTS

History provides critical perspective regarding how race, gender, class, sexuality, and disability have shaped the development of nursing and the health care system, affected who has been able to access education and careers in nursing, and influenced Americans' access to and experiences of health care.

CONCLUSION

History prepares nursing students to better understand the reasons for and implications of persistent health disparities and inequities in access to nursing education and health care services, providing them with knowledge to advocate for greater health equity and social justice during their nursing careers. [J Nurs Educ. 2022;61(8):469-475.].

What Is a "Racial Health Disparity"? Five Analytic Traditions

What exactly is a "racial health disparity"? This article explores five lenses that have been used to answer that question. It contends that racial health disparities have been presented-by researchers both within academia and outside of it-as problems of five varieties: biology, behavior, place, stress, and policy. It also argues that a sixth tradition exploring class-and its connection to race, racism, and health-has been underdeveloped. The author examines each of these conceptions of racial disparities in turn. Baked into each interpretive prism is a set of assumptions about the mechanisms that produce disparities-a story, in other words, about where racial health disparities come from. Discursive boundaries set the parameters for policy debate, determining what is and is not included in proposed solutions. How one sees racial health disparities, then, influences the strategies a society advocates-or ignores-for their elimination. The author ends by briefly discussing problems in the larger research ecosystem that dictate how racial health disparities are studied.

Prediction of End-Stage Kidney Disease Using Estimated Glomerular Filtration Rate With and Without Race : A Prospective Cohort Study

BACKGROUND

New estimated glomerular filtration rate (eGFR) equations removed race adjustment, but the impact of its removal on prediction of end-stage kidney disease (ESKD) is unknown.

OBJECTIVE

To compare the ESKD prediction performance of different eGFR equations.

DESIGN

Observational, prospective cohort study.

SETTING

7 U.S. clinical centers.

PARTICIPANTS

3873 participants with chronic kidney disease (CKD) from the CRIC (Chronic Renal Insufficiency Cohort) Study contributing 13 902 two-year risk periods.

MEASUREMENTS

ESKD was defined as initiation of dialysis or transplantation. eGFR was calculated using 5 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations based on serum creatinine and/or cystatin C, with or without race adjustment. The predicted 2-year risk for ESKD was calculated using the 4-variable Kidney Failure Risk Equation (KFRE). We evaluated the prediction performance of eGFR equations and the KFRE score using discrimination and calibration analyses.

RESULTS

During a maximum 16 years of follow-up, 856 participants developed ESKD. Across all eGFR equations, the KFRE score was superior for predicting 2-year incidence of ESKD compared with eGFR alone (area under the curve ranges, 0.945 to 0.954 vs. 0.900 to 0.927). Prediction performance of KFRE scores using different eGFR equations was similar, but the creatinine equation without race adjustment improved calibration among Black participants. Among all participants, compared with an eGFR less than 20 mL/min/1.73 m2, a KFRE score greater than 20% had similar specificity for predicting 2-year ESKD risk (ranges, 0.94 to 0.97 vs. 0.95 to 0.98) but higher sensitivity (ranges, 0.68 to 0.78 vs. 0.42 to 0.66).

LIMITATION

Data are solely from the United States.

CONCLUSION

The KFRE score better predicts 2-year risk for ESKD compared with eGFR alone, regardless of race adjustment. The creatinine equation with age and sex may improve calibration among Black patients. A KFRE score greater than 20% showed high specificity and sensitivity for predicting 2-year risk for ESKD.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Health inequities and the inappropriate use of race in nephrology

Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race - a socio-political construct that mediates the effect of structural racism - as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.

Use of Race in Kidney Research and Medicine: Concepts, Principles, and Practice

Black Americans and other racially and ethnically minoritized individuals are disproportionately burdened by higher morbidity and mortality from kidney disease when compared with their White peers. Yet, kidney researchers and clinicians have struggled to fully explain or rectify causes of these inequalities. Many studies have sought to identify hypothesized genetic and/or ancestral origins of biologic or behavioral deficits as singular explanations for racial and ethnic inequalities in kidney health. However, these approaches reinforce essentialist beliefs that racial groups are inherently biologically and behaviorally different. These approaches also often conflate the complex interactions of individual-level biologic differences with aggregated population-level disparities that are due to structural racism (i.e., sociopolitical policies and practices that created and perpetuate harmful health outcomes through inequities of opportunities and resources). We review foundational misconceptions about race, racism, genetics, and ancestry that shape research and clinical practice with a focus on kidney disease and related health outcomes. We also provide recommendations on how to embed key equity-enhancing concepts, terms, and principles into research, clinical practice, and medical publishing standards.

The social life of biomedical data: Capturing, obscuring, and envisioning care in the digital safety-net

Biomedical investment in digital technologies has flooded society with staggering volumes of data, spurring high-tech innovations such as performance metrics, clinical algorithms, and public data dashboards. In examining the social life of data artifacts, scholars draw from actor-network theory to emphasize data's ability to represent social reality while circulating within it, while others suggest formal data models fail to account for invisible relations on the ground. Yet little work has examined the role of human reflexivity in crafting complex human-data configurations in practice, such as how situated human actors relate to data representations within the social reality they intimately know themselves. Drawing on ethnographic fieldwork of Electronic Health Records (EHRs) and data analytics integration from inside the digital safety-net, this article shows how health care workers recognize data simultaneously capture, obscure, and envision their everyday work of caring for the marginalized. By demonstrating how the same data point may in one context demonstrate good care while in another obscure it, these findings suggest need to broaden attention to the social life of data beyond delimited focus on standards and their travels. Digital technologies do not simply capture the social, but multiply it. Biomedical data then do not have one social life, but many.

Limited Evidence for Use of a Black Race Modifier in eGFR Calculations: A Systematic Review

Background

Commonly used estimated glomerular filtration rate (eGFR) equations include a Black race modifier (BRM) that was incorporated during equation derivation. Race is a social construct, and a poorly characterized variable that is applied inconsistently in clinical settings. The BRM results in higher eGFR for any creatinine concentration, implying fundamental differences in creatinine production or excretion in Black individuals compared to other populations. Equations without inclusion of the BRM have the potential to detect kidney disease earlier in patients at the greatest risk of chronic kidney disease (CKD), but also has the potential to over-diagnose CKD or impact downstream clinical interventions. The purpose of this study was to use an evidence- based approach to systematically evaluate the literature relevant to the performance of the eGFR equations with and without the BRM and to examine the clinical impact of the use or removal.

Content

PubMed and Embase databases were searched for studies comparing measured GFR to eGFR in racially diverse adult populations using the Modification of Diet in Renal Disease or the 2009-Chronic Kidney Disease Epidemiology Collaboration-creatinine equations based on standardized creatinine measurements. Additionally, we searched for studies comparing clinical use of eGFR calculated with and without the BRM. 8,632 unique publications were identified; an additional 3 studies were added post-hoc. In total, 96 studies were subjected to further analysis and 44 studies were used to make a final assessment.

Summary

There is limited published evidence to support the use of a BRM in eGFR equations.

Evaluating the Impact and Rationale of Race-Specific Estimations of Kidney Function: Estimations from U.S. NHANES, 2015-2018

BACKGROUND

Standard equations for estimating glomerular filtration rate (eGFR) employ race multipliers, systematically inflating eGFR for Black patients. Such inflation is clinically significant because eGFR thresholds of 60, 30, and 20 ml/min/1.73m2 guide kidney disease management. Racialized adjustment of eGFR in Black Americans may thereby affect their clinical care. In this study, we analyze and extrapolate national data to assess potential impacts of the eGFR race adjustment on qualification for kidney disease diagnosis, nephrologist referral, and transplantation listing.

METHODS

Using population-representative cross-sectional data from the United States National Health and Nutrition Examination Survey (NHANES) from 2015-2018, eGFR values for Black Americans were calculated using the Modification of Diet in Renal Disease (MDRD) equation with and without the 1.21 race-specific coefficient using cohort data on age, sex, race, and serum creatinine.

FINDINGS

Without the MDRD eGFR race adjustment, 3.3 million (10.4%) more Black Americans would reach a diagnostic threshold for Stage 3 Chronic Kidney Disease, 300,000 (0.7%) more would qualify for beneficial nephrologist referral, and 31,000 (0.1%) more would become eligible for transplant evaluation and waitlist inclusion.

INTERPRETATION

These findings suggest eGFR race coefficients may contribute to racial differences in the management of kidney. We provide recommendations for addressing this issue at institutional and individual levels.

FUNDING

No external funding was received for this study.

A Step Toward Health Equity for Veterans: Evidence Supports Removing Race From Kidney Function Calculations

Background

The practice of race-based medicine fails to recognize that race cannot be used as a proxy for genetic ancestry and that racial and ethnic categories are complex sociopolitical constructs without biological basis. Clinical algorithms and equations that incorporate race modifiers and are currently considered standard for diagnosis and management of disease are appropriately being scrutinized for lack of biological plausibility and their role in exacerbating health inequities. In this paper, we review the history, evidence, and implications of using a Black race coefficient when calculating estimated glomerular filtration rate (eGFR) in the diagnosis and management of kidney disease.

Observations

Currently, the US Department of Veterans Affairs (VA) uses the Modification of Diet in Renal Disease (MDRD) equation for eGFR. This equation includes a Black race coefficient that results in an eGFR that is 21% higher for a Black patient when compared with a patient of any other race. The rationale for the inclusion of this coefficient is based on racist science that incorrectly assumes race as a proxy for genetic ancestry. Multiple studies across diverse Black populations demonstrate that the application of a race coefficient in kidney function estimation equations is inferior when compared with the race-neutral option. Furthermore, the most utilized eGFR equations are biased and imprecise. Because eGFR is the primary diagnostic method for detecting and managing kidney disease, preventing its progression, planning for dialysis, and evaluating for transplantation, it is vital that eGFR be as accurate, precise, and equitable as possible.

Conclusions

The incorporation of a race coefficient in kidney estimation equations lacks biological plausibility and its use exacerbates kidney health disparities. Until a better method to estimate kidney function becomes available, a race-neutral option for current estimation equations should be applied for all patients.

The Time Is Now: Racism and the Responsibility of Emergency Medicine to Be Antiracist

The COVID-19 pandemic has shed light on the ongoing pandemic of racial injustice. In the context of these twin pandemics, emergency medicine organizations are declaring that "Racism is a Public Health Crisis." Accordingly, we are challenging emergency clinicians to respond to this emergency and commit to being antiracist. This courageous journey begins with naming racism and continues with actions addressing the intersection of racism and social determinants of health that result in health inequities. Therefore, we present a social-ecological framework that structures the intentional actions that emergency medicine must implement at the individual, organizational, community, and policy levels to actively respond to this emergency and be antiracist.

Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report From the NKF-ASN Task Force

For almost 2 decades, equations that use serum creatinine, age, sex, and race to estimate glomerular filtration rate (GFR) have included "race" as Black or non-Black. Given considerable evidence of disparities in health and health care delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non-GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase 1, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.

Peter WL, Warfield C, Powe NR. Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report from the NKF-ASN Task Force

For almost two decades, equations that use serum creatinine, age, sex, and race to eGFR have included "race" as Black or non-Black. Given considerable evidence of disparities in health and healthcare delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase one, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.