Trainee Perspectives on Race, Antiracism, and the Path toward Justice in Kidney Care

Heffron, Anna S.; Khazanchi, Rohan; Nkinsi, Naomi T.; Bervell, Joel; Cerdeña, Jessica P.; Diao, James A.; Eisenstein, Leo; Gillespie, Nali; Hongsermeier-Graves, Natasha; Kane, Maddy; Kaur, Karampreet; Seija, Luis; Tsai, Jennifer; Vyas, Darshali A; Zhang, Angela

doi:10.2215/cjn.02500222

Cited by 8 publications

(4 citation statements)

References 10 publications

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“…The NKF-ASN Task Force recommendations follow decisions by major medical centers to remove race from eGFR reporting, most often by direct removal of the coefficient for Black versus non-Black race. 17 These changes were prompted by concerns 2,3,18,19 regarding race-based medicine and structural racism, recognizing the ways that race stratification may influence access to care for Black adults and reinforce misconceptions of intrinsic biologic difference dating back to the 18th century. 4,20–24 However, direct removal also led to significant underestimation of the measured GFR in Black patients.…”

Section: Discussionmentioning

confidence: 99%

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

Diao

Wang

et al. 2022

JASN

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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.

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Section: Discussionmentioning

confidence: 99%

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

Diao

Wang

et al. 2022

JASN

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“…Although some papers are more circumspect [ 20 - 23 ], the systematic review identified fifty reviews, editorials, and commentaries in peer-reviewed journals [ 10 , 13 , 19 , 24 - 70 ] that argued for the abolition of race-based GFR cr estimation because Black race is: 1) a societal rather than biological construct [ 10 , 15 , 24 - 31 , 34 - 45 , 48 - 52 , 55 , 58 , 60 - 67 , 69 , 70 ]; 2) an imprecise proxy for genetic ancestry [ 13 , 24 - 26 , 29 , 31 , 43 , 44 , 46 - 50 , 60 - 65 , 67 , 70 ]; 3) poorly defined [ 10 , 13 , 19 , 34 , 39 , 43 , 44 , 48 - 52 , 55 , 62 , 63 , 67 - 69 ]; and 4) heterogeneous [ 10 , 26 , 29 , 30 , 34 , 35 , 44 , 46 , 52 , 66 , 67 ]. These articles also declared that the race correction: 5) lacked a physiological explanation [ 10 , 25 - 27 , 29 - 31 , 37 , …”

Section: Reviewmentioning

confidence: 99%

“…Students and activists [9][10][11][12][13], concerned about the inclusion of race in the diagnosis and treatment of CKD and other conditions, initiated a debate on the role of race in medicine. They claim that Blacks are denied treatment for CKD because of the race correction factor.…”

Section: Epi Formula For 60-year-old Malesmentioning

confidence: 99%

Retaining Race in Chronic Kidney Disease Diagnosis and Treatment

Williams

2023

Cureus

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The best overall measure of kidney function is glomerular filtration rate (GFR) as commonly estimated from serum creatinine concentrations (eGFR cr ) using formulas that correct for the higher average creatinine concentrations in Blacks. After two decades of use, these formulas have come under scrutiny for estimating GFR differently in Blacks and non-Blacks. Discussions of whether to include race (Black vs. non-Black) in the calculation of eGFR cr fail to acknowledge that the original race-based eGFR cr provided the same CKD treatment recommendations for Blacks and non-Blacks based on directly (exogenously) measured GFR. Nevertheless, the National Kidney Foundation and the American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease removed race in CKD treatment guidelines and pushed for the immediate adoption of a race-free eGFR cr formula by physicians and clinical laboratories. This formula is projected to negate CKD in 5.51 million White and other non-Black adults and reclassify CKD to less severe stages in another 4.59 million non-Blacks, in order to expand treatment eligibility to 434,000 Blacks not previously diagnosed and to 584,000 Blacks previously diagnosed with less severe CKD. This review examines: 1) the validity of the arguments for removing the original race correction, and 2) the performance of the proposed replacement formula. Excluding race in the derivation of eGFR cr changed the statistical bias from +3.7 to -3.6 ml/min/1.73m 2 in Blacks and from +0.5 to +3.9 in non-Blacks, i.e., promoting CKD diagnosis in Blacks at the cost of restricting diagnosis in non-Blacks. By doing so, the revised eGFR cr greatly exaggerates the purported racial disparity in CKD burden. Claims that the revised formulas identify heretofore undiagnosed CKD in Blacks are not supported when studies that used kidney failure replacement therapy and mortality are interpreted as proxies for baseline CKD. Alternatively, a race-stratified eGFR cr (i.e., separate equations for Blacks and non-Blacks) would provide the least biased eGFR cr for both Blacks and non-Blacks and the best medical treatment for all patients.

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“…Some key examples of this mobilization include the White Coats For Black Lives movement 36 ; the recent passing of antiracist resolutions in the American Medical Association's House of Delegates, 37 many of which were originally submitted for consideration by members of the medical student section; student advocacy supporting the elimination of racist medical algorithms 38 ; reimagining of medical school curricula, beginning from an antiracist and abolitionist perspective 39 ; and student leadership identifying and seeking to redress harms arising from unequal access to services. 12 Focused attention on these issues has led to structural and policy changes that have advanced equity and antiracism in broad areas of patient care, 8,40 although not without resistance.…”

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confidence: 99%

Training to Build Antiracist, Equitable Health Care Systems

Manchanda

Sivashanker

Kinglake

et al. 2023

AMA Journal of Ethics

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All clinicians should provide high-quality, safe, and equitable care to every patient and community. Yet, in practice, health care delivery systems are designed and organized to exacerbate inequity in access and outcomes, and clinicians are incentivized to deliver unequal and inequitable care in deeply segregated academic health centers that are structured to reify white supremacy. This article investigates the nature and scope of health professions educators' obligations to acknowledge harms of segregation in health care as widespread, unjust, iatrogenic, and preventable.Causes of Segregated Care Physicians and, indeed, all health professionals should provide high-quality, safe, and equitable care to every single patient and community. Health care systems should commit to antiracist practices and processes to ensure that physicians and other health care professionals are in fact able to provide equitable care. 1 In practice, however, medicine and health care have been designed, organized, and incentivized to deliver highly unequal and inequitable care, which has contributed to widespread, unjust, and preventable harm to and outcomes for individuals and communities that have been historically marginalized. 2 These far-reaching and persistent manifestations of white supremacy-the false hierarchy of human value based on the color of one's skininspired one graduating class at the University of Pittsburgh School of Medicine to create a modern-day Hippocratic Oath. Their oath acknowledges the "fundamental failings of our health care and political systems" in caring for historically marginalized communities and communities excluded from Western health systems and calls for an "enduring commitment to repairing the injustices against those historically ignored and abused in medicine: Black patients, Indigenous patients, Patients of Color and all marginalized populations who have received substandard care as a result of their identity and limited resources." 3 Data indicate that the US health care system is highly segregated and inequitable. 4,5,6 The root causes of these health inequities include, but are not limited to, a pervasive culture of white supremacy in academic health care and research, 7,8 clinicians' and Citation

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Trainee Perspectives on Race, Antiracism, and the Path toward Justice in Kidney Care

Cited by 8 publications

References 10 publications

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

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

Retaining Race in Chronic Kidney Disease Diagnosis and Treatment

Training to Build Antiracist, Equitable Health Care Systems

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