Which Races Are Most At Risk For Chronic Kidney Disease

The disproportionate impact of kidney disease on underrepresented groups, particularly Blacks or African Americans, is evident in many dialysis units, including where we work. Black patients are significantly overrepresented among dialysis patients, yet they are less likely to be referred or receive a kidney transplant. While the reasons for this are complex, they require us to examine and change any current practices that contribute to the disparity. In this issue of JASN and the American Journal of Nephrology, the National Kidney Foundation (NKF)-American Society of Nephrology (ASN) Task Force to Reevaluate the Inclusion of Race in the Diagnosis of Kidney Disease provides its final report and recommendations, providing an important first step in this process.

Over the past 20 years, the automatic reporting of serum creatinine has been accompanied by improved recognition, diagnosis, and staging of CKD. However, using the equation of patient age, sex, race, and serum creatinine reporting, eGFR is higher in those identified as black compared to non-blacks with the same characteristics. Over the past 50 years, there has been an increasing reexamination of the impact of racism in medicine and the use of race in clinical algorithms. Fundamental to this reexamination is the recognition of race as a social construct rather than a biological determinant. In nephrology, led primarily by medical students and trainees, there are loud calls to remove race from the calculation of eGFR. The inclusion of race in the calculation of eGFR has been associated with disparities in care, including delays in the diagnosis of kidney disease and kidney transplant eligibility. A more fundamental issue is the inclusion of social constructs like race that normalize and perpetuate non-scientific and harmful beliefs about race and biology as we train the next generation of healthcare professionals.

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However, there is still much that must be accomplished to achieve the ultimate goal of ensuring an accurate and error-free diagnosis of kidney disease. the ASN and NKF have begun working with the laboratory medicine community to implement the 2021 CKD-EPI creatinine equation as the standard for eGFR reporting, and the NKF's online eGFR calculator has been updated. In addition to implementing the new equation, we need to educate our patients and our colleagues in primary care, endocrinology, cardiology, and other specialties about the implications of this change. It is worth noting that the renal community was the first to remove race from widely used clinical algorithms and provide a pathway for other specialties. We must use the current focus on this issue to demand more change.

A working group in one country has now released its final report with three recommendations.

First, the current eGFR reporting should be immediately replaced by the new 2021 Chronic Kidney Disease Epidemiology Collaborative (CKD-EPI) creatinine eGFR equation, which was developed without considering race as a variable. This formula was developed and evaluated in a diverse population, including previous and new cohorts; is based solely on age, sex, and serum creatinine; provides a level of precision and accuracy that is not comparable to existing formulas; and does not disproportionately affect any one group of individuals. Most importantly, the formula can be rapidly implemented by all laboratories and healthcare systems.

Second, it can be used more often and more widely when assessing renal function. There is evidence that cystatin C, especially when used in combination with creatinine, can be used to assess renal function. However, as described by the Task Force, there are significant barriers that must be addressed before the widespread implementation of cystatin C testing, including lack of availability in all clinical laboratories, high costs, and inappropriately limited insurance coverage, including Medicare. However, as described by the Task Force, there are significant barriers that must be addressed before the widespread implementation of cystatin C testing, including lack of availability in all clinical laboratories, high costs, and inappropriately limited insurance coverage, including Medicare. Laboratory equipment manufacturers, clinical laboratories, and other stakeholders must rapidly increase the availability and reduce the cost of cystatin C testing, and payers must expand coverage for the test. Once these barriers are removed, the benefits of adding cystatin C to routine laboratory records should be identified.

Finally, the Task Force recommends additional research to develop better methods to estimate GFR. renal disease research is significantly underfunded. While the Medicare program spends $130 billion annually to treat patients with kidney disease, including $50 billion for patients with kidney failure, the National Institutes of Health (NIH) spends $700 million annually on kidney research. That's $20 per patient with kidney disease, compared to $300 per patient for cancer research and $2,500 per patient for AIDS research. The fact that the NIH spends so little on diseases that severely affect minority populations and even less on achieving health equity in the diagnosis and treatment of kidney disease is a testament to systemic racism in American health care.

To reduce the burden of excessive costs, you can look for alternative therapies that are beneficial in suppressing or improving kidney disease, for example, you can look for dietary therapies or herbal treatments. Cistanche supplements are very effective in improving kidney disease in humans. Compared to other treatments, Cistanche is low cost and the results are promising. This can also be effective in reducing systemic racism in American healthcare.

REFERENCES:

1. Delgado C, Baweja M, Crews D, Eneanya N, Gadegbeku C, Inker L, et al.: A unifying approach for GFR estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. J Am Soc Nephrol 32: 2994–3015, 2021

2. Delgado C, Baweja M, Crews DC, Eneanya ND, Gadegbeku CA, Inker LA, et al.: A unifying approach for GFR estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease [published online ahead of print September 22, 2021]. Am J Kidney Dis 10.1053/j.ajkd. 2021.08.003

3. Vyas DA, Eisenstein LG, Jones DS: Hidden in plain sight - reconsidering the use of race correction in clinical algorithms. N Engl J Med 383: 874–882, 2020

4. Maglo KN, Mersha TB, Martin LJ: Population genomics and the statistical values of race: An interdisciplinary perspective on the biological classification of human populations and implications for clinical genetic epidemiological research. Front Genet 7: 22, 2016

5. Powe NR: Black kidney function matters: Use or misuse of race? JAMA 324: 737– 738, 2020

6. Eneanya ND, Yang W, Reese PP: Reconsidering the consequences of using race to estimate kidney function. JAMA 322: 113– 114, 2019

7. Schmidt IM, Waikar SS: Separate and unequal: Race-based algorithms and implications for nephrology. J Am Soc Nephrol 32: 529–533, 2021

8. Delgado C, Baweja M, Burrows NR, Crews DC, Eneanya ND, Gadegbeku CA, et al.: Reassessing the inclusion of race in diagnosing kidney diseases: An interim report from the NKF-ASN Task Force. J Am Soc Nephrol 32: 1305–1317, 2021

9. Delgado C, Baweja M, Burrows NR, Crews DC, Eneanya ND, Gadegbeku CA, et al.: Reassessing the inclusion of race in diagnosing kidney diseases: An interim report from the NKF-ASN Task Force. Am J Kidney Dis 78: 103–115, 2021

10. Inker LA, Eneanya ND, Coresh J, Tigh court H, Wang D, Sang Y, et al.; Chronic Kidney Disease Epidemiology Collaboration: New creatinine- and cystatin c-based equations to estimate GFR without race [published online ahead of print September 23, 2021]. N Engl J Med 10.1056/ NEJMoa2102953

11. Hsu CY, Yang W, Parikh RV, Anderson AH, Chen TK, Cohen DL, et al.; CRIC Study Investigators: Race, genetic ancestry, and estimating kidney function in CKD [published online ahead of print September 23, 2021]. N Engl J Med 10.1056/NEJMoa2103753

12. National Institutes of Health: Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC), 2021.