Correcting Race-Based Medicine in Chronic Kidney Disease

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In the United States, 15% of the population is estimated to have chronic kidney disease (CKD). In Kentucky, CKD is the 8th leading cause of death, and in 2019, the CKD morality rates among the Black population was 26.4 deaths per 100,00 compared to 22.2 deaths per 100,000 for the white population. Furthermore, 2019 hospitalization data for Medicare beneficiaries in Kentucky shows significant disparities, with 20 per 1,000 Black beneficiaries in Kentucky being hospitalized for CKD versus 10 per 1,000 white beneficiaries. These disparities are significant and warrant evaluation as to what effect the healthcare delivery system is having on such outcomes.

A little over a year ago, the Kentuckiana Health Collaborative began engaging in discussions with our healthcare equity partners, Have a Heart Clinic and the Kentucky Nurses Association, around the use of a race modifier in the Estimated Glomerular Filtration Rate (eGFR) used to diagnosis kidney disease. eGFR is a blood test that measures creatinine levels, which in turn indicates how well kidneys are functioning. A higher eGFR Measures indicates better functioning kidneys.

The variables included in the eGFR equation have historically been age, sex, body weight, and race. Race, however, is not a biological construct. The race modifier often used in this equation multiplies the eGFR rates of people who are Black, versus those who are non-Black on the incorrect and racist assumption that those who are Black have higher muscle mass. Thus, despite having the same result on an eGFR test as those who are not Black, people who are Black are classified as having better kidney function. This classification leads to later diagnosis and less aggressive treatment of chronic kidney disease for this population and therefore worse health outcomes.

In 2018, a University of Washington medical student, Naomi Tweyo Nkinsi, initiated a conversation questioning the use of the race modifier in eGFR after learning of the metric during a class lecture. This conversation sparked a national movement to remove the use of the race modifier in eGFR, which led to the formation of a join task force between the National Kidney Foundation (NKF) and American Society of Nephrology (ASN) to examine it’s use. In September 2021, the task force publicly released their recommendation to remove the race modifier in eGFR to diagnosis kidney disease.

That same month, the KHC convened experts to discuss the use of race as a biological indicator in the assessment, diagnosis, and treatment of kidney function and disease. The session was the first our Healthcare Equity Learning Series, Bridging the Gap from Health Disparities to Anti-Racist Clinical Encounters. The purpose of this series is to examine healthcare’s role and actions in ensuring equitable care and outcomes for all patients. The event opened with a presentation from Stephanie Clouser, KHC Data Scientist, that highlighted the racial disparities that exist in CKD prevalence, hospitalizations, and mortality at the national and state level. After level setting the conversation with data, Naomi Tweyo Nkinsi provided context on race-based medicine and its application to CKD in addition to highlighting her own story of advocacy and challenging the status quo to remove racism in the healthcare system. To reflect on the implications of removing the race modifier from eGFR, a panel discussion was led by Delanor Manson, CEO of the Kentucky Nurses Association, and Mike Imburgia, founder of Have a Heart Clinic. The event recording can be viewed here.

The race modifier included in eGFR for diagnosing CKD is only one example of how racism is embedded in the healthcare system. More importantly, the advocacy of Naomi Tweyo Nkinsi is an example of how the status quo must be challenged and changed in order to build a trustworthy healthcare system that delivers equitable care and outcomes.

The next session of Bridging the Gap from Health Disparities to Anti-Racist Clinical Encounters will be held on December 14, 2021, with a focus on cardiovascular disease. Registration is free and open to the public here.

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