- Clinical equations that estimate patients’ kidney function include an adjustment for Black race. This survey-based study found that U.S. transplant centers agree that this adjustment is unsatisfactory.
- Respondents noted a variety of potential benefits and harms of dropping race from these equations.
Washington, DC (October 7, 2021) — Clinical equations that estimate individuals’ kidney function include an adjustment for Black race, which could impact the care of kidney transplant candidates and potential living donors. In a survey-based study of clinicians at U.S. transplant centers, there was a consensus that this adjustment is unsatisfactory, and most centers had or were planning to remove race from kidney function calculations. The study appears in an upcoming issue of CJASN.
Current methods that estimate an individual’s kidney function, or what’s known as a patient’s estimated glomerular filtration rate (eGFR), are based on blood levels of creatinine, a waste product removed by the kidneys. The most commonly used eGFR equations include an adjustment for Black versus non-Black race, resulting in higher eGFR values for a Black patient compared with a non-Black patient. Because race is a social and not a biological construct and because this adjustment could lead to healthcare disparities, the American Society of Nephrology and the National Kidney Foundation have recently endorsed the idea that race modifiers should not be included in equations to estimate kidney function.
In the kidney transplant setting, eGFR values can affect the timing of waitlist access for potential recipients, the selection of potential living kidney donors, and the treatment of patients after they have received a transplant. Therefore, a team led by Krista L. Lentine, MD, PhD (Saint Louis University), Mona Doshi (University of Michigan), and Neeraj Singh (Willis Knighton Health System), as part of the American Society of Transplantation’s Kidney Pancreas Community of Practice policy work group, surveyed clinicians at transplant centers across the United States to assess their opinions and practices related to the use of race-based eGFR equations.
Respondents represented 124 out of 218 (57%) adult kidney transplant programs in the United States. Among the major findings:
- Most (93%) programs use creatinine-based eGFR for listing transplant candidates; however, only 5% of respondents felt that current race-based eGFR calculators are appropriate.
- Most respondents (71%) believed that eliminating race would allow more preemptive waitlisting (when patients with kidney disease are listed for a kidney transplant before requiring dialysis) for Black patients, but a similar number (69%) also raised concerns that such an approach could incur harms.
- More than one-third of the responding programs lacked or were unsure of the availability of other kidney function tests that don’t rely on creatinine.
- 39% of represented centers did not plan to remove race from eGFR calculations (mainly because they were waiting for additional research and consensus data prior to adopting any change), 46% were planning to, and 15% had already done so.
- There was no difference in eGFR eligibility thresholds for Black vs. non-Black living donors.
“Key reasons for believing current approaches are not appropriate include concern for unjustifiably treating race as a biological category rather than as a social construct, concern for perpetuating or extending extant healthcare disparities, including among multi-racial individuals with some Black heritage,” said Dr. Lentine. “However, respondents also acknowledged potential harms of dropping race from eGFR calculations, including overdiagnosis of chronic kidney disease, premature dialysis initiation and diagnosis of allograft failure, and underestimation of kidney function in screening living donor candidates.”
An accompanying editorial provides additional perspectives on the findings and notes that “disparities in access to kidney transplantation precede the use of the race-based [eGFR equations] and are likely to postdate it. Next, we must actively work to eliminate the disparities in health equity that have finally garnered the attention they deserve.”
An accompanying Patient Voice editorial offers insights from a patient who has been living with chronic kidney disease for more than 20 years.
Study co-authors include Mona D. Doshi, MD, Neeraj Singh, MD, Benjamin E. Hippen, MD, Kenneth J. Woodside, MD, Prince Mohan, MD, Hannah L. Byford, RN, MPA, Matthew Cooper, MD, Darshana M. Dadhania, MD, and Sruthi Ainapurapu.
Disclosures: The authors reported no relevant financial disclosures.
The article, titled “Transplant Clinician Opinions on Use of Race in the Estimation of Glomerular Filtration Rate,” will appear online at http://cjasn.asnjournals.org/ on October 7, 2021, doi: 10.2215/CJN.05490421.
The editorial, titled “Race-Based eGFR Assessment for Kidney Transplantation,” will appear online at http://cjasn.asnjournals.org/ on October 7, 2021, doi: 10.2215/CJN.11020821.
The Patient Voice editorial will appear online at http://cjasn.asnjournals.org/ on October 7, 2021, doi: 10.2215/CJN.1101082.
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Clinical Journal of the American Society of Nephrology