A Step Toward Health Equity for Veterans: Evidence Supports Removing Race From Kidney Function Calculations
Background: The practice of race-based medicine fails to recognize that race cannot be used as a proxy for genetic ancestry and that racial and ethnic categories are complex sociopolitical constructs without biological basis. Clinical algorithms and equations that incorporate race modifiers and are currently considered standard for diagnosis and management of disease are appropriately being scrutinized for lack of biological plausibility and their role in exacerbating health inequities. In this paper, we review the history, evidence, and implications of using a Black race coefficient when calculating estimated glomerular filtration rate (eGFR) in the diagnosis and management of kidney disease.
Observations: Currently, the US Department of Veterans Affairs (VA) uses the Modification of Diet in Renal Disease (MDRD) equation for eGFR. This equation includes a Black race coefficient that results in an eGFR that is 21% higher for a Black patient when compared with a patient of any other race. The rationale for the inclusion of this coefficient is based on racist science that incorrectly assumes race as a proxy for genetic ancestry. Multiple studies across diverse Black populations demonstrate that the application of a race coefficient in kidney function estimation equations is inferior when compared with the race-neutral option. Furthermore, the most utilized eGFR equations are biased and imprecise. Because eGFR is the primary diagnostic method for detecting and managing kidney disease, preventing its progression, planning for dialysis, and evaluating for transplantation, it is vital that eGFR be as accurate, precise, and equitable as possible.
Conclusions: The incorporation of a race coefficient in kidney estimation equations lacks biological plausibility and its use exacerbates kidney health disparities. Until a better method to estimate kidney function becomes available, a race-neutral option for current estimation equations should be applied for all patients.
In July 2020, the NKF and the ASN established a joint task force dedicated to reassessing the inclusion of race in eGFR calculations. This task force acknowledges that race is a social, not biological, construct.12 The NKF/ASN task force is now in the second of its 3-phase process. In March 2021, prior to publication of their phase 1 findings, they announced “(1) race modifiers should not be included in equations to estimate kidney function; and (2) current race-based equations should be replaced by a suitable approach that is accurate, inclusive, and standardized in every laboratory in the United States. Any such approach must not differentially introduce bias, inaccuracy, or inequalities.”27
Health Equity in the VHA
In January 2021, President Biden issued an executive order to advance racial equity and support underserved communities through the federal government and its agencies. The VHA is the largest integrated health care system in the United States serving 9 million veterans and is one of the largest federal agencies. As VA clinicians, it is our responsibility to examine the evidence, consider national guidance, and ensure health equity for veterans by practicing unbiased medicine. The evidence and the interim guidance from the NKF-ASN task force clearly indicate that the race coefficient should no longer be used.27 It is imperative that we make these changes immediately knowing that the use of race in kidney function calculators is harming Black veterans. Similar to finding evidence of harm in a treatment group in a clinical trial, it is unethical to wait. Removal of the race coefficient in eGFR calculations will allow VHA clinicians to provide timely and high-quality care to our patients as well as establish the VHA as a national leader in health equity.
VISN 12 Leads the Way
On May 11, 2021, the VA Great Lakes Health Care System, Veterans Integrated Service Network (VISN) 12, leaders responded to this author group’s call to advance health equity and voted to remove the race coefficient from eGFR calculations. Other VISNs should follow, and the VHA should continue to work with national leaders and experts to establish and implement superior tools to ensure the highest quality of kidney health care for all veterans.
Acknowledgments
The authors would like to thank the medical students across the nation who have been leading the charge on this important issue. The authors are also thankful for the collaboration and support of all members of the Jesse Brown for Black Lives (JB4BL) Task Force.
