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

Abstract

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.Complete author and article information provided before references.

Integrating CKD Into US Primary Care: Bridging the Knowledge and Implementation Gaps

“…2,8 The reasons for observed disparities are multifactorial, but they may be attributed particularly to social determinants of health. 8 As part of American's reckoning with race and ethnicity in society, unconscious clinician biases and institutionalized racism in health care have been increasingly acknowledged as contributors to kidney health inequities. [8][9][10] Unfortunately, there are adverse direct effects resulting from the COVID-19 pandemic among Blacks and Hispanic Americans compared with non-Hispanic White individuals, including dramatically higher rates of hospitalization, acute kidney injury, and death.…”

“…8 As part of American's reckoning with race and ethnicity in society, unconscious clinician biases and institutionalized racism in health care have been increasingly acknowledged as contributors to kidney health inequities. [8][9][10] Unfortunately, there are adverse direct effects resulting from the COVID-19 pandemic among Blacks and Hispanic Americans compared with non-Hispanic White individuals, including dramatically higher rates of hospitalization, acute kidney injury, and death. 2 Indirect pandemic effects in the uninfected population are reduced clinical encounters, increased gaps in care, lower rates of CKD laboratory monitoring, and fewer medication refills for cardiometabolic CKD risk conditions compared with historical controls.…”

“…18 Areas for consideration in this setting would be the potential role of cystatin C testing to help stratify risk with more accurate eGFR cr-cys or 2012 CKD-EPI eGFR cys . 8,20,21 Consequences of CKD G3aA1 in seniors include patient medication safety factors, cardiovascular risk, cognitive impairment risks, and risks of major surgery perioperative acute kidney injury, including absence of evidence to support ACEi or ARB and SGLT-2i use for kidney risk indications. 4,5,12,18,24 Important interventions for CKD management in primary care include hypertension control targets individualized in a range that should generally be less than 130/80 mm Hg with highly motivated patients at the highest cardiovascular risk offered a <120 mm Hg systolic target and targets 140/90 mm Hg or even higher for patients with or at risk for complications of intensive targets such as hemodynamic acute kidney injury or falls.…”

Estimation of Black-White Disparities in CKD Outcomes: Comparison Using the 2021 Versus the 2009 CKD-EPI Creatinine Equations

“…The widely used Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation has used sex, age, race (Black or non-Black), and serum creatinine to calculate eGFR, assigning a 16% higher eGFR for individuals identified as Black despite the same age, sex and serum creatinine. 1 Because race is a social, non-biologic construct, 2,3 to provide a unifying approach for GFR estimation, 3 a new CKD-EPI creatinine equation that does not use the race variable was recently developed 4 and is currently recommended by the National Kidney Foundation and American Society of Nephrology Task Force for U.S. adults. 5,6 To understand the potential impact of the new equation on estimating racial disparities in clinical outcomes, we assessed the Black-White disparities in kidney replacement therapy (KRT) and death as outcomes after incident CKD defined using the 2009 and 2021 CKD-EPI creatinine equations.…”

Race and the Estimation of GFR: Getting It Right

“…The task force's interim report 1 documents a process being undertaken with extraordinary care and thoroughness. The task force has laid out a planned course of action with 3 phases, this being the culmination of phase 1.…”