A growing number of both health systems and private physicians in the United States are opting to remove the African American-specific “modifier” in records relating to eGFR (estimated glomerular filtration rate), a stat used to measure one’s degree of kidney function.
The movement to make the change stems from the racial inequality long faced by African Americans regarding access to healthcare. As recently as late June of this year, Massachusetts General Brigham health system has been opting to remove the race-based modifier whenever labs have been reporting on patients’ eGFR levels. The University of Washington health system similarly removed the modifier.
Although the initial push to change the eGFR race-based delineation first occurred in 2017, momentum for the move is clearly gaining traction, with numerous physicians and, Nephrologists in particular, making solid cases for why the medical establishment ought to reconsider their calculation methods for African Americans, primarily those dealing with kidney issues who periodically get their eGFR checked.
Why Was The Modifier Added In The First Place?
The formula underestimating eGFR value in African Americans first emerged in 1999, leading to an “up-adjustment” in eGFR, which although small, was still significant. The initial idea was then perpetuated in 2009 with an “improved calculation” meant to more accurately measure eGFR values based on iothalamate clearance.
The data used in the calculation seemed to indicate an average 16% higher eGFR in African Americans than in people of other races. The “race assessment” argument has always been flimsy at best, however and the social consequences of this have reached far past the initial 1999 study and 2009 follow-up, negatively impacting many African Americans’ healthcare, especially when it comes to crucial kidney treatment.
Harvard Medical Professor Thomas D. Sequist explained that race is a social construct not a biological construct and that the kidney-function race modifier doesn’t take into account the amount of diversity within black patients. He further pointed out the fallacy inherent in using an equation that was developed from only a few thousand patients to imprecisely measure eGFR levels in millions of people. This disconcerting approach has also resulted in numerous health inequities, for example, withholding treatment from people longer than needed because their eGFR levels were within the “acceptable range” for black people.
Some clinicians who think the push to remove the modifier is a bad idea say it might lead to “overestimates of kidney disease severity.” In other words, more African American people may finally be receiving the timely kidney care which would otherwise have not been available to them or withheld for a longer period of time due to an underestimation of their CKD’s severity based on these eGFR level findings. With any kind of kidney care, timeliness is key. “Overestimation” is tantamount to saying CKD isn’t as big of a deal in African American patients, but it is and being as cautious and proactive in kidney care can save lives.
Proponents of the change have proposed a more cautious approach to improve the accuracy of GFR estimates including such strategies as shared decision-making and mindful use of cystatin C, which is an alternative to serum creatinine for determining eGFR.
Brigham and Women’s Hospital Nephrologist, Mallika L. Mendu reviewed numerous cases of patients who would have been reclassified with more severe kidney disease if their eGFR had remained unmodified by the “racial slant.” That reclassification would equate to precious time that could have been used to get on meds, get on dialysis, change diet, add supplements or even, in the worst case scenario, get on a transplant list which, in and of itself, could take years. The far-reaching impact of this eGFR calculation has truthfully been a systemic disservice to African Americans dealing with kidney health issues.
Still other Nephrologists like Vanessa Grubbs are pushing for a rapid shift to a fully race-neutral calculation method which would be based on the cystatin C method. It’s vitally important in these divisive times that we always remember black health and black lives matter, and it is the role of any and all healthcare providers to ensure that whatever methods are used in devising a treatment plan be devoid of discrimination and disparity, because every kidney deserves the same caliber of care.
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