Discarding With the Use of Race Adjustments in Estimated Glomerular Function Rate (eGFR): A Narrative Review and a Path to Remedy

Abstract

Race is not a reliable proxy for genetic difference. In fields of study such as public health, sociology, and genetics, race has long been understood as a social construct, rather than a biological one. Nevertheless, U.S. medicine routinely uses race as a proxy for genetic difference, perhaps most explicitly in race-adjusted clinical formulas such as estimated glomerular filtration rate (eGFR). In medical school, this group of students and faculty was struck by inconsistencies between our curriculum and routine clinical practice. We learned that race is an unreliable proxy for genetic difference, then learned that clinical medicine nevertheless operationalizes race precisely in this way. We were particularly disturbed by the use of race in eGFR: while Black Americans have the highest risk for progression to ESRD and ESRD-related mortality, eGFR paradoxically leads to a healthier estimate of renal function in Black Americans, and therefore risks a delay in clinical evaluation. We decided to look at this issue critically. Ultimately, we were able to remove the use of race adjustment in the way that eGFR is reported at our institution. Our change in reporting is only a small step. Ongoing research is needed to determine if this removal of race from eGFR reporting promotes earlier CKD diagnosis and initiation of interventions for secondary prevention of ESRD among Black patients, as well as earlier accrual of kidney transplant waiting time; potentially mitigating racial disparities in kidney disease outcomes.