National task force advocates removing race from kidney function algorithm

A national task force announced Thursday that it is recommending the immediate implementation of a new diagnostic equation to measure kidney function, which advocates say will promote health equity and increase access to transplantation for black patients. The recommendation is supported by ongoing research by clinical researchers at the Perelman School of Medicine at the University of Pennsylvania, who have been instrumental in quantifying the benefits and risks of discontinuing the breed in the ‘estimation of renal function. The clinical change, which is expected to take effect at Penn Medicine this year, has been identified as a key priority for the healthcare system’s Action for Cultural Transformation (ACT) strategic plan launched in 2020.

“I hope this change spearheads a movement across medicine for clinicians to reassess whether they are using breed responsibly,” said Nwamaka Eneanya, MD, MPH, nephrologist, assistant professor of medicine and epidemiology and director of health. Fairness, Anti-Racism, and Community Engagement in the Renal Electrolyte and Hypertension Division at Penn.

Eneanya has been a strong advocate for removing race from the kidney function algorithm and is a member of the joint American Society of Nephrology and National Kidney Foundation task force that generated the recommendations. She is also the co-author of an article published this week in the New England Journal of Medicine (NEJM), which introduces new equations for measuring kidney function that do not include race. A second NEJM paper published this week -; co-supervised by Harold Feldman, MD, MSCE, professor of epidemiology and medicine at Penn -; recommends that, as a longer term solution, national efforts be made to increase the widespread use of the protein cystatin C as a biomarker of renal health.

Since direct measurement of kidney function is not possible at the bedside, clinicians instead assess kidney function using an estimating equation called eGFR, which is the estimated glomerular filtration rate. EGFR estimates the amount of creatinine present in a patient’s blood to give a picture of how their kidneys are functioning. Its value is an important part of the information used to determine if and when a patient is referred for certain types of clinical care, including kidney transplantation.

The problem, according to critics of the current equation, is that it assigns a higher eGFR to patients who identify as Black. This means that black patients must achieve higher creatinine levels than white patients to be put on the waiting list for a kidney transplant.

In a widely cited opinion piece published in JAMA in 2020, researchers at Penn Medicine argued that it is harmful for eGFR equations to claim that the function of existing organs is different between individuals who are otherwise identical except for race. They write that population studies reveal only small differences in the distribution of genes between racial groups, and that “the history of medicine offers ample evidence that racial categories have often been arbitrarily generated and sometimes implemented. to reinforce social inequalities “.

The room -; written by Eneanya, with Peter Reese, PhD, MD, MSCE, professor of medicine and epidemiology, and Wei Yang, PhD, associate professor of biostatistics -; helped spark a national conversation about removing race from the kidney function algorithm. In response, the American Society of Nephrology and the National Kidney Foundation established a joint working group to reassess the inclusion of race in eGFR, as well as its implications for the diagnosis and subsequent management of patients with the disease. kidney disease.

The task force’s final report recommends that U.S. clinical labs immediately implement a new CKD-EPI creatinine equation that does not incorporate breed information. This new equation “has acceptable performance characteristics and potential consequences that do not disproportionately affect a group of individuals,” say the authors.

However, the task force report also notes that there should be long-term national efforts to increase routine and timely measurement of cystatin C, rather than or in addition to creatinine, to estimate function. renal. This is due to the fact -; as data from 1,248 chronic renal failure cohort study (CRIC) patients published in the NEJM article co-authored by Feldman shows -; “Estimating GFR using cystatin C generates results similar to estimates based on creatinine and race while eliminating the negative consequences of current race-based approaches.” Currently, Feldman says, cystatin C tests are expensive and less readily available in hospitals and other clinical labs nationwide.

While increasing access to cystatin C-based laboratory tests will be an important future step in the field of nephrology, the removal of race from the eGFR algorithm is a major step towards advancing the equity in health, according to Eneanya and the authors of the joint task force report. .

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University of Pennsylvania

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