A “race-less” approach to diagnosing kidney disease


A scientific task force called on Thursday to drop a common measure of kidney function that adjusts results by race, providing different ratings for black patients than for others.

The adjustment can make black patients appear less sick than they actually are, according to many experts. Instead, doctors should rely on a race-independent method to diagnose and manage kidney disease, a report from the National Kidney Foundation and the American Society of Nephrology concluded.

The specific recommended equation was described in a study published Thursday in the New England Journal of Medicine.

If adopted, the new approach would affect the hundreds of millions of kidney function tests performed each year in hospitals and outpatient clinics, both for critically ill patients and as part of routine screening blood tests. According to one estimate, one million black Americans could be treated sooner for kidney disease if the diagnostic equation was not adjusted for race.

The report of the working group, published simultaneously in the American Journal of Kidney Disease and the Journal of the American Society of Nephrology, comes amid a nationwide toll on racial health disparities spurred by the Covid-19 pandemic, which has taken a disproportionate toll on people of color and highlighted the excessive burden of chronic disease in these communities .

“The problem is a moral problem,” said Dr. Neil R. Powe, co-chair of the task force and chief of medicine at Zuckerberg San Francisco General Hospital and Trauma Center. “It’s time to take race out of the equation.”

Black and Hispanic Americans have long suffered from high rates of diseases such as diabetes, high blood pressure and obesity, which can exacerbate a Covid crisis. These factors can also increase the risk of developing kidney disease.

Racial disparities in kidney disease are glaring and well documented. Black Americans are more than three times more likely than whites to have kidney failure and require dialysis or a kidney transplant.

Although black Americans make up only 13% of the population, they represent 35 percent of Americans with kidney failure. Over 90,000 Americans are on a kidney waiting list; almost a third are black, about as much as those who are white.

People of color and low-income Americans are less likely to receive good care when the warning signs first appear and chronic kidney disease is preventable. They are more likely to progress to kidney failure and require dialysis, and less likely to be treated by a kidney specialist before they reach this stage, according to a report from the Centers for Medicare and Medicaid Services.

Black Americans too wait longer for an organ, and are less likely to have a kidney donated by a friend or relative, for a variety of complex reasons.

“This new recommendation will ensure that racial bias is not introduced into clinical care, so that someone will no longer be judged on their race and their skin color will dictate the kidney care they receive,” he said. said Dr. Nwamaka Denise Eneanya, a nephrologist at the University of Pennsylvania and a member of the working group.

His work suggests that current measurements used to assess kidney function may underestimate the severity of disease in black patients, delaying referrals to specialists and making them less likely to be placed on transplant waiting lists. you’re welcome.

“Blacks are inadvertently injured because they are considered not sick enough,” Dr. Eneanya said.

Other members of the working group warned that the impact of the change on patient outcomes was uncertain and called on researchers to follow up to assess its impact.

The use of medical decision-making tools that take into account race and ethnicity is not unique to kidney disease. The algorithms and calculators that doctors rely on to guide the diagnosis and treatment of many conditions – from bone density and kidney stones to cancer and lung function tests – include race as a variable, such as described in a document published last year in the New England Journal of Medicine.

“Race is a social construct, not a biological construct,” said Dr. Winfred Williams, deputy head of the renal division at Massachusetts General Hospital in Boston, who co-wrote an editorial on the new equations.

“This can serve as a proxy for other risk factors, including food insecurity, housing insecurity, socio-economic deprivation, all of which can limit access to best health care practices.”

In recent months, several medical companies have taken steps to address this potential bias. In May, the American Academy of Pediatrics officially dropped a practice guideline that considered a baby’s race when assessing risk for urinary tract infection.

The American College of Obstetricians and Gynecologists is currently updating an algorithm that included race and ethnicity in a calculator used to assess the chances of a pregnant woman having a successful vaginal birth after a previous cesarean.

The new report that reassessed the inclusion of breed in the diagnosis of kidney disease was released Thursday, after a year of work and a degree of controversy along the way, the authors said.

The kidneys filter toxins from the blood. The new report recommends using a new equation to estimate filtration rate using a blood test that measures levels of creatinine, a muscle-made waste that is controlled when the kidneys are functioning properly.

A related study, also published Thursday in the New England Journal of Medicine and cited in the report, developed and evaluated new diagnostic methods that do not include race as a variable. The researchers concluded that the new creatinine equation could be adopted immediately.

But the most accurate and neutral way to measure renal filtration rates would be to incorporate blood tests that measure the level of a different marker: a protein produced by cells called cystatin C, which is elevated when the kidneys fail. not work well, the researchers said.

Cystatin C tests are more expensive and less available, but experts have called for making them more accessible and gradually increasing their use.


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