Race and Medicine

Race and Medicine

Source:

Disclosures: Delgado reports her contribution is the result of work supported with the resources and the use of facilities at the San Francisco VA Medical Center. Please see the study for all other authors’ relevant financial disclosures.
September 23, 2021
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NKF-ASN urge ‘immediate adoption’ of race-free equations for assessing kidney function

Source:

Disclosures: Delgado reports her contribution is the result of work supported with the resources and the use of facilities at the San Francisco VA Medical Center. Please see the study for all other authors’ relevant financial disclosures.
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A joint task force of the National Kidney Foundation and the American Society of Nephrology has released its final report on considering race in diagnosing kidney disease and called for immediate adoption of race-free eGFR equations.

The task force was formed in July of 2020 with the goal of creating a “unifying approach” to kidney disease diagnoses, according to members of the task force; the problem with utilizing race in assessments of kidney function stems from the fact that race is a social – not biological – construct and, therefore, may lead to inaccuracies when applied to clinical algorithms, the authors of the report wrote.

NKF-ASN task force
Infographic content derived from NKF-ASN press release.

‘Unifying approach’ for GFR estimation

“Currently, GFR reporting is not uniform, and previous guideline recommendations have taken years, if not decades, to implement. The recommended equations should be adopted promptly to provide standardized reporting of eGFR and thus to enable uniform and consistent clinical practice,” Cynthia Delgado, MD, of the nephrology section at the San Francisco VA Medical Center and the division of nephrology at the University of California, San Francisco, and colleagues wrote.

In the course of 10 months, members of the task force evaluated the current scientific evidence regarding how the inclusion or exclusion of race in eGFR assessments might impact both Black and “non-Black” individuals, considering the strengths and weaknesses of 26 different strategies and seeking the most “patient-centered” approach. Community input also played a role, with the task force inviting students, trainees, clinicians, scientists and other health professionals, as well as patients, family members and other public stakeholders, to provide testimony on how utilizing race might “perpetuate or prevent health care disparities.”

Task force recommendations

From this, Delgado and colleagues developed three primary recommendations. First, they urged all laboratories in the United States to begin using the chronic kidney disease- epidemiology collaboration (CKD-EPI) creatinine equation without including race.

“For U.S. adults (>85% of whom have normal kidney function), we recommend immediate implementation of the CKD-EPI creatinine equation refit without the race variable in all laboratories in the U.S. because it does not include race in the calculation and reporting, includes diversity in its development, is immediately available to all labs in the U.S., and has acceptable performance characteristics and potential consequences that do not disproportionately affect any one group of individuals,” the authors wrote.

Second, the task force recommended that national efforts be made to increase use of cystatin C, “especially to confirm eGFR in adults who are at risk for or have chronic kidney disease.”

According to the authors, combining such filtration markers as creatinine and cystatin C provides more accurate assessments and supports improved clinical decision-making. “Thus, if ongoing evidence supports acceptable performance, the CKD-EPI[cystatin C]cys and CKD-EPI[creatinine-cystatin C]cr-cys_R without the race variable should be adopted to provide more accurate first-line or confirmatory testing as appropriate for the clinical setting,” they wrote.

Third, the task force called for continued research on new endogenous filtration markers that might aid in more accurate measurements of kidney function, as well as the funding of interventions to eliminate racial and ethnic disparities in kidney disease.

Delgado and colleagues acknowledge that ensuring a broad national adoption of these recommendations will be challenging, noting that a “concerted effort” must be made by laboratories, health care systems and providers, health education institutions, and public and private payers, as well as policymakers and federal agencies of HHS.

“Challenges in implementation are vast, time-consuming, and compete against other priorities,” the authors wrote. “Professional societies in all specialties of medicine, academic institutions, health care systems, and relevant industry partners must be committed and unified in driving these recommended changes as the best currently available clinical approach for assessment of GFR.”

In a related press release, NKF President Paul M. Palevsky, MD, FASN, FNKF, and ASN President Susan E. Quaggin, MD, FRCP(C), FASN, emphasized the role these recommendations play in moving toward health equity but also contended more work is needed.

“While the work of the task force is an important initial path forward, both of our organizations are committed to continuing to work to eliminate disparities in the diagnosis and treatment of kidney disease,” Palevsky said.

In her comments, Quaggin expressed the commitment of the NKF and ASN to “ensuring that racial bias does not affect the diagnosis and subsequent treatment of kidney diseases,” while urging the broader medical community to promote equity in all areas of health care.

“By recommending the CKD-EPI creatinine equation refit without the race variable, the task force has taken action and demonstrated how nephrology continues to lead the way in promoting health care justice. It is time for other medical specialties to follow our lead, and NKF and ASN stand ready to help however we can,” she said.

References:

Delgado C, et al. Am J Kidney Dis. 2021;doi:10.1053/j.ajkd.2021.08.003.

Press Release