National Projections for Clinical Implications of Race-Free Creatinine-Based GFR Estimating Equations

Abstract

BackgroundThe National Kidney Foundation and American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease recently recommended a new race-free creatinine-based equation for eGFR. The effect on recommended clinical care across race and ethnicity groups is unknown.MethodsWe analyzed nationally representative cross-sectional questionnaires and medical examinations from 44,360 participants collected between 2001 and 2018 by the National Health and Nutrition Examination Survey. We quantified the number and proportion of Black, White, Hispanic, and Asian/Other adults with guideline-recommended changes in care.ResultsThe new equation, if applied nationally, could assign new CKD diagnoses to 434,000 (95% confidence interval [CI], 350,000 to 517,000) Black adults, reclassify 584,000 (95% CI, 508,000 to 667,000) to more advanced stages of CKD, restrict kidney donation eligibility for 246,000 (95% CI, 189,000 to 303,000), expand nephrologist referrals for 41,800 (95% CI, 19,800 to 63,800), and reduce medication dosing for 222,000 (95% CI, 169,000 to 275,000). Among non-Black adults, these changes may undo CKD diagnoses for 5.51 million (95% CI, 4.86 million to 6.16 million), reclassify 4.59 million (95% CI, 4.28 million to 4.92 million) to less advanced stages of CKD, expand kidney donation eligibility for 3.96 million (95% CI, 3.46 million to 4.46 million), reverse nephrologist referral for 75,800 (95% CI, 35,400 to 116,000), and reverse medication dose reductions for 1.47 million (95% CI, 1.22 million to 1.73 million). The racial and ethnic mix of the populations used to develop eGFR equations has a substantial effect on potential care changes.ConclusionThe newly recommended 2021 CKD-EPI creatinine-based eGFR equation may result in substantial changes to recommended care for US patients of all racial and ethnic groups.

GFR, Race, and Implications

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The latest JASN features a very important submission, by a distinguished authorial roster, concerning the altered clinical use and outcomes once race-independent GFR values are used instead of those derived from Chronic Kidney Disease Epidemiology Collaboration and even more antique formulas. 1 This excellent review, 1 which signposts important possibly life-altering changes in the way that GFR will be applied to patients of all races, carries a serious and troubling statement, namely "A national task force convened by the NKF-ASN 2 recently recommended a new race-free creatinine equation for calculating eGFR. .

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“…The latest JASN features a very important submission, by a distinguished authorial roster, concerning the altered clinical use and outcomes once race-independent GFR values are used instead of those derived from Chronic Kidney Disease Epidemiology Collaboration and even more antique formulas. 1…”

“…This excellent review, 1 which signposts important possibly life-altering changes in the way that GFR will be applied to patients of all races, carries a serious and troubling statement, namely “A national task force convened by the NKF-ASN 2 recently recommended a new race-free creatinine equation for calculating eGFR…its broad effect on recommended clinical care across the eGFR spectrum and across different racial and ethnic groups is not known.” That statement is remarkable as presented, as surely thorough modeling of the clinical impact of such a fundamental change must have been undertaken before, and not after, these changes were adopted. In the event, the new analysis 1 suggests that nationwide implementation of the new eGFR equation may affect recommended care for 100,000s of Black adults and 1,000,000s of non-Black adults, including altered CKD diagnoses; CKD stage reclassifications; and changes in kidney donation eligibility, nephrologist referral, and medication dosing. These are dramatic alterations for a sizable number of patients, as presaged by others.…”

Catalyzing Advocacy and Policies for Patients with Kidney Disease

“…Nephrology is well served by strong sources of reliable information. At JASN , we make extensive use of national resources, such as the USRDS, ORTN/SRTR, 1,3 and National Center for Health Statistics 4 ; they are often the first places we go for data.…”

Author Reply: GFR, Race, and Implications

“…Thank you for your interest in this work and raised questions in your letter 1 concerning the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation and the recent work by Diao and colleagues titled “National Projections for Clinical Implications of Race-Free Creatinine-Based GFR Estimating Equations.” 2 I would like to reassure you that the National Kidney Foundation - American Society of Nephrology (NKF-ASN) Task Force did extensively examine the clinical effect of each of the 26 kidney function estimation approaches evaluated before and not after its final recommendation.…”