Race shouldn't be a factor in diagnosing chronic kidney disease
In recent years, there has been a broad shift in the field of medicine to recognize race as a social construct instead of a biological one. This has made significant changes to the field of nephrology, especially in the diagnosis and treatment of chronic kidney disease.
Chronic kidney disease is a condition characterized by a gradual loss of kidney function, eventually requiring dialysis or even a kidney transplant. The kidneys filter wastes and excess fluids from your blood, which are then removed in urine. With a decrease in kidney function, fluids build up and electrolytes become dysregulated. Without intervention, death ensues.
Kidney function is measured clinically by calculating the urinary excretion of certain substances such as creatinine or the more expensive alternative, cystatin C. These measurements can be challenging and costly, so standard practice is to measure blood creatinine and then utilize a standardized equation (the CKD-EPI creatinine equation) to estimate kidney function.
Common risk factors for chronic kidney disease include age, sex and weight, along with certain risk factors (diabetes, obesity, smoking, family history, etc.). However, most equations have also included an additional factor: race.
The inclusion of race has been controversial for many years as evidence has been amassing to show that it does not add clinical value. Many studies have shown that African-American patients were being underdiagnosed and the severity of their disease was consistently underestimated. This occurred despite the fact that African-Americans have an earlier age of onset, more rapid progression and higher prevalence of chronic kidney disease compared to white patients.
These compounding factors made it difficult for these patients to be referred to nephrologists or to be placed on waiting lists for life-saving transplants. Patients with undiagnosed chronic kidney disease have also experienced economic impacts such as reaching increasing thresholds of disease before they receive disability benefits. As a result, the racial-socioeconomic disparities faced by African-American patients have only been exacerbated by the inclusion of race in the CKD-EPI Creatinine equation.
In late 2021, the National Kidney Foundation and American Society of Nephrology reviewed the amounting evidence and released new guidelines that exclude race from equation. Based on the studies mentioned above, removing race from the equation would be expected to reverse this barrier to care faced by African-American patients by increasing rates of diagnosis.
However, this change has not been seen at University of Florida Health Shands. In contrast, since Shands changed their protocols to exclude race at the start of 2022, there has been a decrease in chronic kidney disease diagnoses among local African-American populations.
Since changes on the medical front have yet to yield expected results, what more can be done to address racial inequity in chronic kidney disease? As previously stated, cystatin C is another substance that can be measured to assess kidney function that is more accurate than creatinine.
An American Society of Nephrology-National Kidney Foundation task force has already proposed a nation-wide switch from creatinine to cystatin C. However, replacing creatinine with cystatin C will be challenging since it is more costly, not routinely used in hospitals and not widely available in rural areas.
Insurance companies could provide more resources to African-American populations such that cystatin C becomes more widely available. Currently, only patients who already have a chronic kidney disease diagnosis are covered by major insurance programs. Major changes that could positively address this issue could include reevaluating the criteria for coverage and making Cystatin C the standard of coverage in chronic kidney disease screening and diagnosis.
This column was written by Daniel Chong, Kendyll Coxen, Chamara Gunaratne, Brice Sewell and Amy Stanley, who are medical students at University of Florida College of Medicine.
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This article originally appeared on The Gainesville Sun: UF med students: Chronic kidney disease diagnosis shouldn't factor race
