Establishing a Task Force to Reassess the Inclusion of Race in Diagnosing Kidney Diseases
Of the more than 37 million people affected by kidney diseases in the United States, a disproportionate number are of African American, Hispanic, Asian, and Native American descent. African Americans are three times more likely than Non-Hispanic Whites to experience kidney failure. Such disparities go beyond the high prevalence of kidney diseases and extend into differences in treatment modality, including access to transplantation. While African Americans represent 35% of people receiving dialysis in the United States, they are less likely to be identified as kidney transplant candidates when compared to Non-Hispanic Whites.
The estimated glomerular filtration rate (eGFR) is one of the primary diagnostic methods for detecting and managing kidney disease, planning for dialysis, and evaluating transplantation. The eGFR is derived by an equation that was initially generated by using serum creatinine measurement and included age, sex, race, and/or bodyweight to approximate directly measured kidney function. The use of eGFR is widely accepted and has standardized the diagnosis and care of all patients with kidney diseases, provides reliable and accurate information on kidney function, and helps determine appropriate dosing of medications, as well as the safety of certain tests and procedures, such as CT scans with intravascular contrast or cardiac catheterizations. Almost all clinical laboratories in the United States now report eGFR with any blood test that contains serum creatinine.
Several equations have been developed to estimate kidney function from serum creatinine concentration, adjusting for demographic factors including age, sex, race, and/or bodyweight based on correlations with measured GFR across diverse populations. However, unlike age, sex, and body weight, race is a social, not a biological construct. Including adjustment for race in these eGFR equations ignores the substantial diversity within self-identified Black or African American patients and other racial or ethnic minority groups.
The National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) recognize that the use of race to estimate GFR is an important concern. We applaud the current discussion about this topic within the nephrology community and the broader medical community, as well as by the patients we serve. NKF and ASN are committed to ensuring that clinicians provide the best, most equitable care for each patient.
NKF and ASN have been working separately to address diversity, equity, and inclusion. Together, NKF and ASN are forming a joint task force to examine the inclusion of race in the estimation of GFR and its implications for the diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This task force will issue its initial recommendations in 2020. It is important that any change in eGFR reporting carefully consider the multiple social and clinical implications, be based on rigorous science, and be part of a national conversation about uniform reporting of eGFR across health care systems. The task force will keep laboratories, clinicians, and other kidney health professionals apprised of any potential long-term implications of removing race from the eGFR formula.
As the largest organizations representing kidney patients and professionals, we are committed to ensuring that racial bias does not affect the diagnosis and subsequent treatment of kidney diseases. We will incorporate the concerns of patients and the public, especially in marginalized and disadvantaged communities, as we rigorously assess the underlying scientific and ethical issues embedded in our current practice. We are also committed to ensuring that GFR estimation equations provide an unbiased assessment of kidney function so that laboratories, clinicians, patients, and public health officials can make informed decisions to ensure equity and personalized care for patients with kidney diseases.
About Kidney Diseases
In the United States, more than 37 million adults are estimated to have kidney diseases – and most aren’t aware of it. 1 in 3 American adults is at risk for CKD. Risk factors for kidney diseases include diabetes, high blood pressure, heart disease, obesity, a family history of kidney failure, and being age 60 or older. People of African American, Hispanic, Native American, Asian, or Pacific Islander descent are at increased risk for developing kidney diseases. African Americans are 3 times more likely than Whites, and Hispanics are nearly 1.5 times more likely than non-Hispanics to develop kidney failure.