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September 23, 2021
3 minutes to read
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Disclosures: Delgado reports that his contribution is the result of work supported by the resources and use of the facilities at the San Francisco VA Medical Center. Please see the study for relevant financial information from all other authors.
A joint National Kidney Foundation and American Society of Nephrology working group released its final report on consideration of race in the diagnosis of kidney disease and called for the immediate adoption of eGFR equations without race.
The working group was formed in July 2020 with the aim of creating a “unifying approach” to kidney disease diagnoses, according to members of the working group; the problem with using race in kidney function assessments stems from the fact that race is a social construct, not a biological one and, therefore, can lead to inaccuracies when applied to clinical algorithms, wrote the authors of the report.
“Unifying approach” for estimating the GFR
“Currently, GFR reports are inconsistent and recommendations from previous guidelines have taken years, if not decades, to implement. The recommended equations should be adopted quickly to provide a standardized report of eGFR and thus enable uniform and consistent clinical practice ”, Cynthia Delgado, MD, of the nephrology section at the San Francisco VA Medical Center and the nephrology division at the University of California at San Francisco, and colleagues have written.
Over the 10 months, task force members assessed the current scientific evidence regarding how the inclusion or exclusion of race in eGFR assessments might impact black and “non-black” individuals, taking into account the strengths and weaknesses of 26 different strategies and seeking the most “patient-centered” approach. Community input also played a role, with the working group inviting students, trainees, clinicians, scientists and other healthcare professionals, as well as patients, family members and others. public interveners, to testify on how the use of race might “perpetuate or prevent health care.” disparities.
Recommendations of the working group
From there, Delgado and his colleagues developed three main recommendations. First, they urged all labs in the United States to start using the Chronic Kidney Disease and Epidemiology Collaborative Creatinine Equation (CKD-EPI) without including race.
“For American adults (> 85% of them have normal kidney function), we recommend the immediate implementation of the CKD-EPI creatinine equation without the race variable in all laboratories in the United States, because it does not include breed in the calculation and reporting, includes diversity in its development, is immediately available to all laboratories in the United States, and has acceptable performance characteristics and potential consequences that do not affect disproportionately a group of individuals, ”the authors wrote.
Second, the working group recommended that national efforts be made to increase the use of cystatin C, “particularly to confirm eGFR in adults at risk for or with chronic kidney disease”.
According to the authors, the combination of filtration markers such as creatinine and cystatin C provides more accurate assessments and supports better clinical decision making. “Thus, if the current evidence supports acceptable performance, the CKD-EPI[cystatin C]cys and CKD-EPI[creatinine-cystatin C]cr-cys_R without the racial variable should be adopted to provide more accurate first-line or confirmatory testing, depending on the clinical setting, ”they wrote.
Third, the working group called for continued research into new endogenous filtration markers that could help more precise measures of kidney function, as well as funding for interventions to eliminate racial and ethnic disparities in children. kidney disease.
Delgado and his colleagues recognize that it will be difficult to ensure wide national adoption of these recommendations, noting that a “concerted effort” must be made by laboratories, health care systems and providers, and institutions. health education and public and private payers, as well as policy makers. and federal HHS agencies.
“The implementation challenges are vast, time consuming, and compete with other priorities,” the authors wrote. “Professional societies across all specialties of medicine, academic institutions, healthcare systems and relevant industry partners must be engaged and united in driving these recommended changes as the best clinical approach currently available for the assessment of DFG. “
In a related press release, the president of the NKF Paul M. Palevsky, MD, FASN, FNKF, and president of ASN Susan E. Quaggin, MD, FRCP (C), FASN, highlighted the role these recommendations play in moving towards health equity, but also said more work is needed.
“While the task force’s work is an important initial path, our two organizations are committed to continuing to work to eliminate disparities in the diagnosis and treatment of kidney disease,” said Palevsky.
In his comments, Quaggin expressed the commitment of the NKF and ASN to “ensure that racial prejudice does not affect the diagnosis and subsequent treatment of kidney disease,” while urging the medical community to broad to promote equity in all areas of health care.
“By recommending the readjustment of the CKD-EPI creatinine equation without the racial variable, the task force took action and demonstrated how nephrology continues to lead the way in promoting justice in care. health. It is time for other medical specialties to follow our example, and the NKF and ASN are ready to help as much as we can, ”she said.
The references:
Delgado C, et al. Am J Kidney Say. 2021; doi: 10.1053 / j.ajkd.2021.08.003.
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