Subtracting racism from the equation of kidney disease

The first sign that something was wrong with Curtis Warfield came in 2005, when a routine laboratory test revealed protein in her urine. In 2012, Warfield was diagnosed with grade 3 kidney disease. Two years later he started dialysis.

“When you are diagnosed, you sit there like a deer in the spotlight. You do not know what is happening. “You do not know what to expect next,” said Warfield. “How do you know you have this disease?”

Smort Warfield, 52, was healthy and had no family history of kidney disease. As his condition worsened, he was working on treatment options, he felt a form of racism without knowing it. a mathematical equation that counted his race when evaluating his kidney function.

This equation, called the glomerular filtration rate, or eGFR, is a powerful variable that helps dictate treatment for approximately 37 million people with kidney disease nationwide. The eGFR equation measures how well the human kidneys filter blood based on a person’s age, sex, and creatinine levels, which are naturally excreted by the kidneys and cleared by the kidneys. But it has long been a controversial variable: race.

If a person identifies himself as a black man, then the equation adjusts their unit by increasing it. No other race is counted in the equation. As a result, blacks have higher eGFR scores than people of other races. These points, which assess the good functioning of the kidneys, influence the recommendations of doctors for treatment. The lower the score, the more likely the patient is to start dialysis or even have a kidney transplant.

As inequalities associated with kidney disease became more widely studied, racial eGFR was increasingly challenged by nephrologists, high-profile kidney disease organizations, and, most importantly, medical students who questioned their educators about the biological basis for their distinction. These are not people.

Warfield protects other people with kidney disease after receiving a transplant in 2015. He joined a multidisciplinary working group led by the National Kidney Foundation in 2020. The working group spent months debating the issue, including race inclusion. In eGFR,: eventually introduced two new equations for assessing kidney function.

New, racially neutral equations emerged last fall. And in February, the United Organ Transplant Network (UNOS), a non-profit organization that runs the organ donation and transplant system in the United States, suggested: abandon the use of racialized eGFR in favor of racially neutral eGFR. As a result, kidney care in the United States is at the crossroads of deep-rooted, institutionalized racism.

Eliminating the racial factor from kidney assessments could be a step towards reducing the disproportion of treatment for kidney disease, according to experts from the National Kidney Foundation Working Group. Black Americans are disproportionately at risk for conditions that contribute to kidney disease, such as high blood pressure, diabetes, and heart disease. Although skin kills less than 14% of the US population, they make up 35% of people on dialysis, according to the National Kidney Foundation.

“Black people are much less likely to be sent for a transplant, even when they are on dialysis. They are much less likely to be listed when referenced. When listed, they are much less likely to have a kidney transplant. “There are inequalities along the way,” said Rajnish Mehrotra, a doctor and director of nephrology at Harborview Medical Center and professor of nephrology at the University of Washington.

Those inequalities have been at the root of questions posed by medical students over the past few years, Mehrotra said, especially when it comes to the equation that students learn to assess kidney function.

“They were told in class that there is an equation where it gives a different number, if you’m black and if you’re not black. And they disputed its premise, for example. “What evidence is there that there is a difference?” Said Mehrotra. “And so, the deeper we went in terms of looking for evidence to support racially differentiated message, the more we came to the conclusion that the evidence to prove it is not strong at all.”

The University of Washington School of Medicine, where Mehrotra works, became one of the first institutions to eliminate the racial variable of the eGFR equation as early as June 2020.

But there was a wider movement, which included leading professional kidney specialists, the National Kidney Foundation, the American Nephrology Association, as well as patient advocates (including Warfield), doctors, scientists, laboratory technicians, and more. meeting with the aim of phasing out racialized eGFR in favor of a racially neutral approach.

In June 2021, a year after Washington Medicine renounced racialized eGFR, a working group set up by those organizations announced: interim report question the use of race as a diagnostic factor in kidney care.

According to the report, racial variability in eGFR is based on research conducted in the 1990s. Published in 1999, Diet Changes in Kidney Disease (MDRD) to study was one of the first to include blacks. Earlier, the equation for assessing kidney function was based on data from completely white, male patients, who found that serum creatinine levels were higher in black adults than in their white counterparts, the study authors wrote. report.

At the time of MDRD, racial-based mathematical adjustment was seen as a breakthrough, as the inclusion of black people in studies in general was a breakthrough, the report said.

However, the MDRD is a troubling reason for high creatinine levels in blacks. Previous studies have shown that “on average, blacks have more muscle mass than whites.” The three studies cited there are published 1977, 1978 և: 1990, compared different health criteria, including serum creatinine kinase, whole body potassium levels, in white study participants. All studies indicate that blacks need separate reference standards, attributing differences in results to differences in racial biology.

Those conclusions were to be challenged today.

“Our understanding of race has evolved over the last quarter century,” said Paul Palsky, a physician and president of the National Kidney Foundation, a professor at the University of Pittsburgh, a leading working group. “Instead of being biologically based, race is more of a social structure than anything else.”

In September 2021, the working group released their two new equations that measure kidney function. No one uses race as a factor. One is very similar to racialized eGFR, which measures creatinine. The other equation adds a second test that measures cystatin C, another blood chemical that serves as a filter marker.

Both equations have been proposed because, although the creatinine test is available in almost all laboratories in the country, cystatin C is not what results in a lower cost նվազ test availability. The process of moving the laboratory to a new standard is under way, Palsky said, adding that he hopes the large laboratories will make the changes in the next few months.

“In medicine, the time it usually takes from the publication of a clinical practice guide or recommendation to the time it actually enters clinical care is about a decade,” Palski said. “In this case, what we are seeing is a very quick implementation of the new equation.”

Palsky եհ Mehrotra agree with the new equations compared to the old equations. But the assessments are just that, the assessments և should be used as just a part of a much more comprehensive clinical analysis of a person’s health և needs.

And as racial disparities continue to be studied and understood in medicine, understanding the impact of racial factors in health decisions can have a devastating effect on an individual beyond their diagnosis, Palksy said. “When we teach medical students to residents, if we use race-based algorithms, we reinforce to them this idea, this false notion that race is the biological determinant of disease, which it is not,” Palski said.

Systemic racism affects skin health in a variety of ways, from: chronic stress limited experience of racism access to healthy food to bias health care providers. These problems are deeply rooted and require sustainable solutions.

The new eGFR equation, however, is a step in the right direction, Palsky said.

“Will it solve the problem of inequality of kidney care?” “I think we would have deceived ourselves into thinking that a simple change in the equation would solve much, much deeper problems,” Palsky said. “Of course, changing the equation alone will not solve the problem of inequality, many of which are rooted in historical racism.”

These inequalities will only be significantly reduced by large-scale investments in the health of poor communities. However, the eGFR equation is still a significant step for kidneys with kidney disease. The benefits of the new eGFR equation, according to Warfield, extend beyond the original equation.

“It opens the eyes and doors to other inequalities that occur, at least in the kidney community, forcing people to talk and look at what is happening,” Warfield said. “It’s good to know that the patient’s voice is now sitting at the table, heard, not just decided by the medical community.”

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