Interim Report on Race and Kidney Function Addresses Process

Eric Seaborg
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The National Kidney Foundation-American Society of Nephrology (NKF-ASN) Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease released its highly anticipated interim report at the start of April. Published concurrently in JASN and the American Journal of Kidney Diseases (AJKD), the report lays out the process the task force is following.

It will take a couple more months to formulate the recommendations, according to a joint statement from the presidents of ASN and NKF, issued on March 9, 2021.

Although many stakeholders expressed hope for a recommended replacement for the use of a race factor in estimated glomerular filtration rate (eGFR) as soon as possible, the news that this report lacked recommendations was greeted mainly with an acknowledgment that the original timeline was overly ambitious for the complex undertaking. “Although I think I (and the medical community) all hoped for immediately actionable recommendations, it is understandable that this is a challenging task in the very short term,” said Elaine Ku, MD, director of the Nephrology Transition Clinic at the University of California, San Francisco (UCSF), who published a study earlier this year in JASN on modifying eGFR thresholds for transplant lists to lessen racial disparities.

The intense spotlight on racial inequities—in American society as a whole brought on by the Black Lives Matter movement and in healthcare highlighted by COVID-19—led ASN and NKF to form the task force in August 2020. Co-chaired by Cynthia Delgado, MD, and Neil R. Powe, MD, MPH, MBA, both at UCSF, the taskforce includes 14 members with broad expertise in healthcare disparities, epidemiology, health services research, genetic ancestry, clinical chemistry, patient safety and performance improvement, pharmacology, and social sciences, as well as two patients.

The task force members “collectively agreed on the confidentiality of deliberations (including refraining from social media commentary) to promote candid opinions and exchange of ideas,” so it did not respond to requests for comment for this article.

The interim report lays out the history and rationale for the use of a race coefficient in eGFR, and the task force inventoried a wide range of potential approaches to eGFR in which race is considered and not considered, including those most widely used currently, those recently adopted at some institutions, and those that have been suggested and are under development. “The use of race to estimate GFR and possible replacements [has] shortcomings that the task force is currently examining,” the report notes. “Nationwide, many institutions have made independent decisions to address race in estimation of GFR, but these approaches vary, and therefore, GFR estimates and subsequent care decisions are not standardized. Final recommendations will be made after the task force examines the strengths and weaknesses of existing and newer approaches to estimating GFR.”

The importance of the work was underscored by the publication of an accompanying joint editorial by Josephine P. Briggs, MD, editor-in-chief of JASN, and Harold I. Feldman, MD, MSCE, editor-in-chief of AJKD. “The task force's interim report documents a process being undertaken with extraordinary care and thoroughness,” they wrote. “As editors we recognize that journals have participated in the dissemination and perpetuation of science that casts race as a biologic construct. Much is being written about how race is a flawed concept, a societal construct that oversimplifies and at times distorts. The editorial teams of both JASN and AJKD are committed to re-examining our own roles and the language we use to talk about these problems.”

All deliberate speed

There is an acknowledged race-against-time element because some institutions feel the pressure to change the equations they use—and some already have (see In a press release announcing the task force interim report, ASN and NKF urged institutions “not to make any changes to how they estimate kidney function until the task force provides its recommendation for the best approach to replace the existing equations for estimating kidney function.”

“I think there is definite concern that some institutions have already enacted changes that they feel are warranted, but it is unclear to me if these decisions were always supported by evidence-based data that outcomes would be improved through the changes that were implemented,” UCSF's Ku said. “It is important that any systematic changes that are implemented are carefully considered and supported by evidence that they will achieve the intended goal of mitigating racial disparities in kidney disease outcomes.”

“Due deliberation is needed, but preliminary recommendations to act on very soon would be great to avoid huge community variations in practice,” said Richard Lafayette, MD, Professor of Nephrology at Stanford University Medical Center. “While it is reasonable for local communities to act quickly on behalf of their population, a deliberative, fully considered solution is a worthwhile goal.”

The task force also notes the larger context that “assessing the inclusion of race in estimating GFR is part of a larger conversation in addressing racial disparities in kidney health.”

“Beyond the inclusion of race in clinical algorithms like eGFR, ASN and NKF assert that racism manifests in many aspects of health care,” ASN President Susan E. Quaggin, MD, FASN, said in a statement accompanying the release of the report. “Both organizations commit to providing resources and expertise to the essential job of dismantling systemic racism in kidney care, research, and education.”