The Road to a Race-Neutral eGFR Equation in Kidney Care
Unveiling Racial Disparities in Kidney Disease Diagnosis and Treatment
The journey towards a race-neutral estimated glomerular filtration rate (eGFR) equation in kidney care has been paved with challenges and insights. Curtis Warfield, a man diagnosed with stage 3 kidney disease, shed light on the inequalities faced by black individuals in the realm of kidney health. The eGFR equation, a crucial determinant in treatment decisions for millions, had long incorporated race as a variable, leading to higher eGFR scores for black individuals and potentially influencing their care pathways.
A Quest for Equality: Advocacy and Initiatives
Warfield’s advocacy efforts, alongside a multi-organization task force led by the National Kidney Foundation, culminated in the proposal of two new race-neutral equations to estimate renal function. These equations, devoid of race-based adjustments, signify a significant shift towards eliminating racial biases in kidney care.
The Changing Landscape: From Proposal to Implementation
In February, the United Network for Organ Sharing proposed abandoning racialized eGFR in favor of a racially neutral approach, marking a pivotal moment in addressing institutional racism within kidney care. The shift towards race-neutral equations reflects a collaborative effort among nephrologists, kidney specialists, patient advocates, and healthcare professionals to promote equality and inclusivity in medical practices.
Challenging the Status Quo: Medical Education and Evolution
The evolution of medical education, particularly in questioning the biological basis of race differentiation in health equations, underscores a paradigm shift in understanding the social construct of race. Institutions like Washington University of Medicine have taken proactive steps to remove racial variables from eGFR equations, signaling a departure from outdated practices rooted in flawed assumptions.
Unpacking the Interim Report: Revisiting the Roots of Racialized eGFR
An interim report by prominent kidney organizations delves into the historical foundations of race-based eGFR equations. The report highlights the 1999 Modification of Diet in Renal Disease study as a pivotal moment in including black individuals in kidney function estimation equations. However, the report scrutinizes the justification for race-based adjustments, citing outdated notions of racial biology and emphasizing the need for a modern, race-neutral approach.
Redefining Health Standards: A Contemporary Perspective
Modern insights challenge the traditional understanding of race as a biological determinant of health. Medical experts emphasize the social construct of race and advocate for evidence-based, equitable healthcare practices that transcend antiquated racial stereotypes.
Embracing Change: Implementing New Equations for Enhanced Care
The introduction of race-neutral equations for estimating kidney function represents a pivotal moment in reshaping healthcare standards. While acknowledging the slight decrease in precision compared to previous equations, experts highlight the importance of holistic clinical analyses that consider a multitude of factors beyond race.
Empowering Patients: The Voice of Advocacy in Healthcare
Warfield’s journey and advocacy efforts underscore the significance of patient voices in shaping healthcare policies and practices. The transition towards race-neutral equations not only promotes equity in kidney care but also sparks critical conversations around broader disparities in healthcare systems.
Exploring the Road Ahead: Towards Inclusive Healthcare Systems
As the healthcare landscape continues to evolve, the integration of race-neutral practices in kidney care sets a precedent for dismantling systemic biases in medical decision-making. While acknowledging the persistent challenges of healthcare disparities, the adoption of equitable healthcare standards signifies a crucial step towards fostering inclusivity and equality in patient treatment.
A Call for Comprehensive Solutions: Addressing Root Causes of Disparities
Addressing deep-rooted disparities in healthcare requires multifaceted solutions that extend beyond equations and metrics. Large-scale investments in community health, coupled with awareness-building initiatives, are essential in mitigating systemic racism and promoting positive health outcomes for marginalized populations.
Beyond Numbers: Humanizing Healthcare through Patient-Centered Approaches
At the heart of healthcare transformation lies a shift towards patient-centered care that prioritizes individual experiences and voices. By centering patient advocacy, healthcare systems can bridge gaps, foster empathy, and cultivate a culture of inclusivity that transcends traditional healthcare norms.
The Road to Equity: Embracing Change in Healthcare
As the narrative of kidney care unfolds, the transition towards race-neutral equations symbolizes a broader movement towards equitable, patient-centered healthcare practices. By challenging outdated norms, fostering advocacy, and embracing inclusive approaches, the healthcare community paves the way for a more just and compassionate medical landscape.
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The first sign that something was wrong with Curtis Warfield came in 2005, when a laboratory test found protein in his urine during a routine checkup. In 2012, Warfield was diagnosed with stage 3 kidney disease. Two years later, he began dialysis.
“When you’re diagnosed, you’re sitting like a deer in the headlights. You don’t know what’s happening. You don’t know what’s coming next,” Warfield said. “All you know is that you have this disease.”
Warfield, a black man, was 52 years old, healthy, and had no family history of kidney disease. As his condition worsened and he sought treatment options, he unknowingly experienced a form of racism: a mathematical equation that counted his race when estimating his kidney function.
That equation, called estimated glomerular filtration rate or eGFR, is an important variable that helps dictate the course of treatment for the approximately 37 million people with kidney disease nationwide. The eGFR equation estimates how well a person’s kidneys filter blood, taking into account age, sex, and levels of creatinine, a waste product naturally produced by people’s bodies that is eliminated through the kidneys. . But it has long involved a controversial variable: race.
If a person identifies as black, the equation adjusts their score, increasing it. Other races are not counted in the equation. As a result, blacks have higher eGFR scores than people of other races. Those scores, which estimate how well the kidneys are working, influence doctors’ treatment recommendations. The lower the score, the more likely a patient is to start dialysis or even receive a kidney transplant.
As the disparities faced by black people with kidney disease have become more widely studied, race-based eGFR has been increasingly questioned by nephrologists, high-profile kidney disease organizations, and, crucially, medical students who questioned their educators on the biological basis for differentiating between black and non-black people.
Warfield has been advocating for others with kidney disease since receiving a transplant in 2015. He joined a multi-organization task force led by the National Kidney Foundation in 2020. The task force spent months delving into the issue, challenging the inclusion of race. in eGFR and finally initiated two new equations to estimate renal function.
The new race-neutral equations came out last fall. And in February, the United Network for Organ Sharing (UNOS), the nonprofit organization that manages the organ donation and transplant system in the US, proposed abandon the use of racialized eGFR in favor of a racially neutral eGFR. As a result, kidney care in the United States is at a turning point in overcoming a deeply entrenched institutionally racist equation.
Removing race from kidney estimates is a crucial step toward reducing disparities in kidney disease and treatment, according to specialists on the National Kidney Foundation task force. Black Americans are at disproportionate risk for conditions that contribute to kidney disease, such as high blood pressure, diabetes, and heart disease. While Black people make up less than 14% of the U.S. population, they make up 35% of people on dialysis, according to the National Kidney Foundation.
“Black people are much less likely to be referred for a transplant, even when they are on dialysis. When they are referred, they are much less likely to appear on the list. When they are listed, they are much less likely to receive a kidney transplant. There are disparities every step of the way,” said Rajnish Mehrotra, MD, chief of nephrology at Harborview Medical Center and professor of nephrology and medicine at the University of Washington.
Those disparities were the basis for the increase in questions from medical students in recent years, Mehrotra said, particularly when it came to the equation students were learning to assess kidney function.
“In class they were told that there is an equation that indicates a different number if you are black and if you are not black. And they questioned the premise of that, as if to say, “What’s the evidence that there’s a difference there?” Mehrotra said. “And so the deeper we dig in terms of looking for evidence to support race-differentiated reporting, we come to the conclusion that the evidence supporting that is not strong at all.”
Washington University of Medicine, where Mehrotra works, became one of the first institutions to remove the racial variable from the eGFR equation in June 2020.
But a broader movement was also underway involving the major professional societies of kidney specialists, the National Kidney Foundation and the American Society of Nephrology, as well as patient advocates (including Warfield), physicians, scientists and technicians. laboratory, all convening with the goal of phasing out racialized eGFR in favor of a race-neutral approach.
In June 2021, a year after Washington Medicine abandoned racialized eGFR, the working group formed by those organizations published a interim report question the use of race as a factor in renal care diagnosis.
According to the report, the racial variable in eGFR arose from research in the 1990s. Published in 1999, the Modification of Diet in Renal Disease (MDRD) study was one of the first to include blacks (an earlier kidney function estimation equation was based entirely on data from white male patients) and found higher levels of serum creatinine among black adults than among their white counterparts, the researchers write. authors of the working group in their report. report.
At the time of the MDRD, making a mathematical adjustment based on race was considered an advance because including blacks in studies was an advance, according to the report.
But within the MDRD there is a worrying justification for the higher creatinine levels among blacks: Previous studies had shown that “on average, blacks have greater muscle mass than whites.” The three studies cited there, published in 1977, 1978 and 1990, compared different health measures, including serum creatinine kinase and total body potassium levels, in black and white study participants. All studies claim that separate reference standards are needed for blacks, attributing differences in outcomes to differences in racial biology.
Today, those conclusions would be questioned.
“Our understanding of race has evolved over the last quarter century,” said Paul Palevsky, MD, president of the National Kidney Foundation and a professor at the University of Pittsburgh, one of the task force’s lead organizations. “Rather than having a biological basis, race is more of a social construct than anything else.”
In September 2021, the task force published its two new equations estimating kidney function. None use race as a factor. One is very similar to the racialized eGFR, which measures creatinine. The other equation adds a second test that measures cystatin C, another chemical in the blood that serves as a filtration marker.
Both equations have been recommended because, although the creatinine test is available in virtually every laboratory in the country, cystatin C is not, resulting in a higher price and less access to the test. The process to move lab practices toward the new standard is underway, Palevsky said, and he is hopeful that major labs will make the change in the coming months.
“In medicine, the time it typically takes from when a clinical practice guideline or recommendation is published to when it actually appears to enter clinical care is about a decade,” Palevsky said. “In this case, what we are seeing is a very rapid implementation of the new equation.”
The new equations are a little less precise compared to the old one, Palevsky and Mehrotra agree. But estimates are just that – estimates – and should be used as just one part of a much more complete clinical analysis of a person’s health and needs.
And as racial disparities in medicine continue to be studied and understood, the impacts of considering race in health care decisions can have a corrosive effect beyond an individual person and their diagnosis, Palevksy said. “As we teach medical students and residents, if we use race-based algorithms, we are reinforcing to them this concept, this false concept, that race is a biological determinant of disease, which it is not.” Palevsky said.
Systemic racism influences the health outcomes of Black people in many different ways, from chronic stress of experiencing racism in a limited way access to healthy foods to the bias of health service providers. These problems are deeply rooted and require their own sustained solutions.
However, the new eGFR equation is a step in the right direction, Palevsky said.
“Will it solve the problem of disparities in kidney care? “I think we would be kidding ourselves if we thought that a simple change in an equation is going to solve much, much deeper problems,” Palevsky said. “Certainly, simply changing an equation will not solve the problems of disparities, many of which are rooted in historical racism.”
These disparities will only be significantly reduced by large-scale investments in the health of poor communities. But either way, the eGFR equation is a significant step for black people with kidney disease. The benefits of the new eGFR equation, Warfield said, expand beyond the equation itself.
“It’s opening eyes and doors to other disparities that are happening, at least within the kidney community, and getting people talking and looking at what’s happening,” Warfield said. “It’s good to know that the patient’s voice is now at the table and being heard, and not just decided by the medical community.”
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