On Arguments of Race and Estimated GFR

Update: The Final Report was published on September 23, 2021.

A Special Report published in AJKD highlights an interim report from the joint NKF/ASN Task Force on the inclusion of race in diagnosing kidney disease. eGFR estimation remains an important guide for clinical decision making and continues to evolve with this important reassessment. A guest commentary from Will Ross @rosswr highlights his thoughts on this debate and its effects at a population level.

Over the past year I have seen the nephrology community contort itself into odd and uncomfortable positions around the issue of race and eGFR.  Fortunately for our patients, our community, and the national efforts to promote social justice, we will land awkwardly and still make the right call—extricating race from GFR equations.  As we await the final recommendations of the joint task force established by the National Kidney Foundation and the American Society of Nephrology to reconsider inclusion of race in the estimation of GFR, a concern is that we will have lost valuable time affirming our commitment to racial justice during this period of social, economic, and racial upheaval.

For those of us who are faculty of color, we have waited earnestly for a call to action to eliminate race-based health disparities.  To this day, African Americans are twice as likely to develop advanced kidney disease from diabetes and hypertension and are less likely to be referred for kidney transplantation.  We know the reasons, and we are exhausted in calling out structural racism as the root cause of those disparities.  I was there at the New York Press Club in 2002 when Alan Nelson presented the workshop report that culminated in the seminal report,  Unequal Treatment: Confronting Racial/Ethnic Disparities in Health Care. In the presentation, Dr. Nelson claimed the debate was over regarding the existence disparities and the role of upstream social and structural determinants of health. Yet the deliberations and robust intellectual discussions continue, and will ultimately land us in the right position.  But at what cost?

Some battles should be easier than others.  In the battle to control Lake Erie in the War of 1812, American commander Oliver Hazard Perry had a unique opportunity to dominate the field when the British commander unexpectedly withdrew an offshore blockade. Commander Perry’s forces prevailed, and he famously wrote to his superiors, “We have met the enemy and they are ours.”  In his memo he failed to mention the loss of 80% of his crew, and the capture of only a few British ships and a schooner.   In a similar vein, we have dispatched legions of nephrology personnel across the country to discuss the merits of eliminating race from GRF equations.  I participated in a focus group ably led by the joint NKF/ASN Task Force, and participated in a panel discussion on the subject led by the ASN, “Going Beyond the Statement: Dismantling Systemic Racism in Nephrology”.  My thoughts during that discussion were that kidney disease health disparities preceded the creation of GFR formulae that incorporated race, and those disparities will persist in the absence of major structural change that dismantles systems of oppression in American society. While we pontificate over the benefits and limitations of the eGFR, the costs to society is immense; we will continue to witness a disproportionate number of preventable deaths among African Americans and other people of color. Such myopia places us in the unenviable position of being the Pogo foil who claimed:  “We have met the enemy and he is us.”

Stating unequivocally that structural racism is a threat to American society, and that all vestiges of racism should be removed from science and the practice of medicine, does not constitute a reactionary, left wing moment of “wokeness”.  Nor should nephrologists be reduced to engaging in arguments around race and eGFR that result in us chasing our tails back to the starting line.  Instead, let’s: (1) state the obvious, that there is no role for race in eGFR equations, (2) leave the solution to the capable hands of the joint NKF/ASN Task Force, and (3) work boldly to eliminate health disparities that are perpetuating the unconscionably high morbidity and mortality rates among African Americans with kidney disease.  At that point we will truly be a profession that serves as a beacon of hope and justice for those yearning to reach their full health potential.

– Post prepared by, Will Ross, MD, MPH, Associate Dean for Diversity and Alumni Endowed Professor of Medicine, Division of Nephrology at Washington University School of Medicine. Follow him @rosswr.


To view Delgado et al [FREE], please visit AJKD.org.

Title: A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease
Authors: Cynthia Delgado, Mukta Baweja, Nilka Ríos Burrows, Deidra C. Crews, Nwamaka D. Eneanya, Crystal A. Gadegbeku, Lesley A. Inker, Mallika L. Mendu, W. Greg Miller, Marva M. Moxey-Mims, Glenda V. Roberts, Wendy L. St. Peter, Curtis Warfield, and Neil R. Powe
DOI: 10.1053/j.ajkd.2021.08.003

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