The National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases has released its final report, which outlines a new race-free approach to diagnose kidney disease. In the report, the NKF-ASN Task Force recommends the adoption of the new eGFR 2021 CKD EPI creatinine equation that estimates kidney function without a race variable. The task force also recommended increased use of cystatin C combined with serum (blood) creatinine, as a confirmatory assessment of GFR or kidney function. The final report published in the American Journal of Kidney Diseases (AJKD) and the Journal of the American Society of Nephrology (JASN), was drafted with input from hundreds of patients and family members, medical students and other trainees, clinicians, scientists, health professionals, and other stakeholders to achieve consensus for an unbiased and accurate estimation of GFR so that laboratories, clinicians, patients and public health officials can make informed decisions to ensure equity and personalized care for patients with kidney diseases.
“This recommendation by the NKF-ASN Task Force is an important step forward in assuring health and healthcare equity. We commend the task force for the time, thought, thoroughness, and effort it took to explore this issue deeply and recommend the best path forward for us all,” says NKF President Paul M. Palevsky, MD, FASN, FNKF. “The NKF and ASN urge all laboratories and healthcare systems nationwide to adopt this new approach as rapidly as possible so that we can move towards a consistent method of diagnosing kidney diseases that is independent of race. While the work of the task force is an important initial path forward, both of our organizations are committed to continuing to work to eliminate disparities in the diagnosis and treatment of kidney disease.”
More than 37 million adults in the United States have kidney diseases and 90% aren’t aware they have diminished kidney function. A disproportionate number of these people are Black or African American, Hispanic or Latino, American Indian or Alaska Native, Asian American, and Native Hawaiian or other Pacific Islander. Without a race-free approach to diagnosis, these Americans also face unacceptable health disparities and inequities in healthcare delivery.
“As the largest organizations representing kidney patients and health professionals, NKF and ASN are committed to eliminating health disparities that harm kidney patients and ensuring that racial bias does not affect the diagnosis and subsequent treatment of kidney diseases,” says ASN President Susan E. Quaggin, MD, FRCP(C), FASN. “By recommending the CKD-EPI creatinine equation refit [with a race-free approach], the task force has taken action and demonstrated how nephrology continues to lead the way in promoting health care justice. It is time for other medical specialties to follow our lead, and NKF and ASN stand ready to help however we can.”
The NKF-ASN Task Force organized its work, which took place over a period of 10 months, into three phases: 1) clarify the problem and evidence regarding eGFR equations in the United States.; 2) evaluate different approaches to address use of race in GFR estimation; and 3) provide recommendations for a race-free approach. The group identified 26 approaches for the estimation of GFR and narrowed their focus by consensus to five such approaches.
“The holistic [race-free] approach incorporated input from the medical community and patients to identify an approach that balanced social justice with scientific rigor,” says Cynthia Delgado MD, FASN, Associate Professor of Medicine, San Francisco Veterans Affairs Healthcare System (SFVAHS) and University of California, San Francisco and co-chair of the joint task NKF-ASN task force.
NKF and ASN shared the new equation recommendation with the kidney community – as well as other stakeholders, particularly the medical students, residents, fellows, and other trainees who spearheaded the call to action on this important issue. NKF and ASN encourage the Kidney Disease Outcomes Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) to develop updated guidelines that ensure a uniform approach consistent with the task force’s race-free approach recommendations. Such clinical practice guidelines will help ensure institutions and the laboratory community rapidly adopt the new equation to estimate kidney function. This new approach will replace the existing equations for estimating kidney function and well as assure confirmatory testing is done when there are important clinical decisions. Both the interim and final report will inform the medical community for clinical practice.
“We appreciate the patience of the community as the Task Force developed a sound strategy to not disproportionately disadvantage patients from any particular racial or ethnic group. Our approach was guided by health equity, patient centeredness and patient safety, and was informed by evidence,” says Neil Powe, MD, MPH, MBA, FASN Chief of Medicine at the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and the Constance B. Wofsy Distinguished Professor, vice-chair of Medicine at the University of California San Francisco and co-chair of the joint NKF-ASN task force. “We hope strong efforts will develop new, more informative, GFR markers and unite all of us in a focus on interventions to eliminate health disparities, thereby improving the quality of care for everyone in the United States.”
It’s a common practice in the medical field to use calculations to make accurate estimations that are reliable, non-invasive and identify certain illnesses and their potential risks. Those estimations are often confirmed with additional testing that is more invasive or more expensive. It is expected that it will take laboratories, hospital systems, physician practices, and academic institutions time to incorporate the new approach into their results for doctors and patients.
NKF and ASN recommend diagnosing kidney disease using a blood test for creatinine to estimate GFR and a urine test for albumin to calculate albumin to creatinine ratio (uACR). The new approach may report a different eGFR and could alter the stage of kidney diseases in some people. Patients should learn their latest eGFR and uACR to assess if the new eGFR calculations change their kidney disease status or stage. Patients and healthcare professionals can use an updated eGFR calculator that uses the new equation to determine a non-race-based calculation to assess their kidney function. It’s important for patients to speak with their doctors to determine if this may affect their treatment and care going forward.