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Group’s efforts lead to removal of race as a variable in common test of kidney function

Jul. 13, 2020, 12:08 PM

 

by Kathy Whitney

A group of Vanderbilt students, residents and faculty — connected through their passion for health equity — have identified and worked together to rectify longstanding concerns about the inappropriate use of race as a variable in the calculation of estimated glomerular filtration rate (eGFR), which estimates a patient’s level of kidney function and helps determine the stage of kidney disease.

In equations for calculating eGFR, Black patients are systematically assigned higher values than non-Black patients, reported in the lab system as eGFR AA. Eliminating the race-based adjustment has several clinical implications: it allows for more timely management and referral of early kidney disease; earlier transplant listing; and more careful medication decisions for Black patients, said Sophia Kostelanetz, MD, MPH, instructor in Med-Peds.

As a resident co-leading the Nashville Chapter for the Campaign Against Racism with Ali Lutz, MDiv, Kostelanetz worked with fellow resident Ndang Azang-Njaah, MD, MPH, and medical students Annie Apple, Karampreet “Peety” Kaur and Tita González Peña to examine the validity of race-based estimation of GFR.

After a thorough evaluation of the underlying scientific evidence, an extensive literature review and consulting with colleagues at other academic medical centers, the students and residents concluded that the use of a race-based adjustment of eGFR, while initially developed based on a regression model, was inappropriate.

“Through this project, we hope to challenge the medical community to re-examine the inappropriate use of race as a proxy of biologic or genetic difference and its resulting impact on patients, including the unjust diversion of attention and resources away from Black patients,” Kostelanetz said on behalf of the group.

“For all of us, this was an opportunity to investigate medical education’s role of pathologizing race and teaching about racial differences as though race is a biologic phenomenon instead of a measure for sociopolitical, economic, environmental and/or cultural context. For the residents and attendings, we were pushed to critically examine the ways in which we interpret this test daily and contribute to structural racism.”

With guidance from multiple advisers, the group developed and presented a proposal for the elimination of race-based eGFR at VUMC to Alp Ikizler, MD, director of the Division of Nephrology and Hypertension, and Julia Lewis, MD, professor of Medicine. With their support and input, the proposal was taken to and supported by W. Kimryn Rathmell, PhD, MD, interim chair of the Department of Medicine.

As a result, the race-based eGFR AA will no longer be reported, effective July 8. In managing patients with chronic kidney disease, the reported eGFR should be interpreted in the context of the patient’s nutritional status and muscle mass.

“In health care, I believe we are only beginning to grapple with the idea that biases (implicit or explicit) are inherent in our thoughts and that we need to critically examine health system processes with respect to their intended and unintended consequences by race and other sociodemographic characteristics. We hope this change in eGFR heralds a willingness to look deeper at these concerns,” said Khaled Abdel-Kader, MD, assistant professor of Medicine, Division of Nephrology and Hypertension.

“The medical students and residents who spearheaded the sustained and collaborative engagement needed to bring this change to fruition demonstrated an exemplary level of critical thinking, maturity and awareness of issues in societal and health equity,” said Beatrice Concepcion, MD, assistant professor of Medicine, Division of Nephrology and Hypertension.

“These students and residents deserve tremendous praise for the courage and leadership they demonstrated in guiding this process and educating faculty and leadership. We look forward to their much-needed future endeavors dedicated to improving equity in medicine and society.”

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