Health Equity

Replacing the faulty formula that led to inequity in kidney care

Andis Robeznieks , Senior News Writer

Progress is being made to eliminate one manifestation of structural racism in medicine that has led to worse outcomes for Black patients. And one AMA member has made it her mission to remind her colleagues that, behind all the equations and algorithms used to form a diagnosis, are real people who need to be listened to.

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At issue is the estimated glomerular filtration rate (eGFR), a key measure for calculating kidney function that has long been automatically adjusted to give Black patients a higher number.

The equation has led to underestimating the severity of kidney disease in many Black patients, delaying their access to medication, specialist referral, nutrition therapy, disease education, dialysis and transplant.

New equations that eliminated the automatic race adjustment were developed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and published in the fall of 2021.

Soon afterward, the College of American Pathologists (CAP) urged its members to adopt the new formula “as quickly as feasible.”

A recent study shows that awareness of the new formula is high, with adoption at just more than 30%, with many laboratories reporting they are planning to make the switch.

The study, published in JAMA®, found that 76.9% of labs responding to the survey said they were aware of the 2021 CKD-EPI equations, and 30.3% reported that they had adopted them.

The survey was conducted in March 2022 and, of those labs they had not yet adopted the new equations, 21.6% planned to do so before July 1. Another 10.7% said they would do so by the end of 2022, and 2.2% said they planned to do it sometime this year or later.

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La’Tonzia L. Adams, MD
La’Tonzia L. Adams, MD

La’Tonzia L. Adams, MD, MS, a staff pathologist with the Veterans Affairs (VA) Portland (Oregon) Health Care System, personally saw the consequences of the old race-based eGFR equation and now, professionally, advocates the new formula.

In a CAP video, Dr. Adams tells the story of her father, a Vietnam veteran and firefighter in Gary, Indiana, who had diabetes and was unable to get the specialty care he needed.

She said the family was growing increasingly frustrated until one day her mother just said, “I’m tired of this,” and took him to an emergency department. There, he was diagnosed with kidney failure and told that he needed emergency dialysis.

“I don’t know how that was so missed,” said Dr. Adams, an AMA member and director of microbiology/molecular microbiology, chemistry, and support services at her Veterans Health Administration facility.

“I was willing to be a donor for him,” she said. “The goal for us was to get him strong enough to be able to have a transplant, and it just didn't happen.”

Dr. Adams knows that if her father had been tested using a race-free formula, it would have helped him gain access to more treatment options earlier.

She added, however, that along with using a faulty formula, doctors wouldn’t listen to her father’s medical complaints and prescribed antidepressants rather than treating his failing kidneys—a bias in care sometimes called diagnostic overshadowing.

“We're not just numbers and algorithms—we are actually human,” Dr. Adams said. “Tests are helpful, but you have to use your knowledge of your patient. What's the patient telling you? What are they looking like? What do you see? Your best tools are your ears and your eyes.”

Learn about the AMA’s strategic plan to embed racial justice and advance health equity.

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The VA Kidney Medicine Program issued a plan for all of its labs to use the race-free eGFR formula by April 1, 2022, and most have reported doing so.

Jonathan R. Genzen, MD, PhD
Jonathan R. Genzen, MD, PhD

AMA member Jonathan R. Genzen, MD, PhD, lead author of the JAMA study, said there are plans to repeat the survey in March.

“We want to verify whether those other laboratories that believed they would incorporate the equation before the end of the (2022) calendar year have actually done so,” said Dr. Genzen, a clinical professor in the University of Utah pathology department and chief medical officer for Associated Regional and University Pathologists (ARUP).

“With the continued attention, we have pretty good reason to believe that that number of laboratories that have incorporated the new equations should then continue to increase,” said Dr. Genzen, who chairs the CAP Clinical Chemistry Committee.

The questionnaire was sent to 6,317 labs that participated in a CAP general chemistry proficiency testing survey and includes responses from 68% of those. Many of them are large or hospital-based facilities, and so many smaller labs—including some that may be found in physician offices—were not fully represented in the dataset. These smaller labs tended to be less aware of the new equations with adoption less common.

The survey results show a step forward for health equity, Dr. Genzen said.

This step is vital “because it acknowledges the importance of equity and the practical things that health systems can do to help improve health equity and to eliminate bias—in this case bias introduced by race-adjustment factors,” he said. “But this is certainly not the only process within a health system that may be subject to inequity, and I think it helps set a greater light on some possibilities and things that we can do to promote equity.”

Meanwhile, a study published in eClinicalMedicine, quantifies the harmful impact of race-adjusted eGFR. Researchers found that without the eGFR race adjustment:

  • 3.3 million more Black Americans would reach a diagnostic threshold for stage 3 chronic kidney disease.
  • 300,000 more would qualify for beneficial nephrologist referral.
  • 31,000 more would become eligible for transplant evaluation and waitlist inclusion.

“Abandoning racialized eGFR calculations dismantles discriminatory and unscientific practices and provides opportunity for more accurate, thoughtful and equitable medicine,” says the study, co-written by researchers from Yale, Brown, Harvard, McGill and the University of California, San Francisco.

The United Network for Organ Sharing adopted a policy last summer requiring transplant hospitals to only use eGFR formulas that do not incorporate race as a proxy for genetic or biologic ancestry. These hospitals are also required to reassess waiting times for patients who were negatively affected by the use of formulas with racist race-based modifiers and credit them for “time lost.”

The AMA declared racism as an urgent public health threat in 2020 and released a plan to mitigate its harm. Physician advocates and researchers working in partnership with institutions and impacted communities to adopt reparative solutions to inequity show a path forward.

Learn about the work of the AMA Peer Network for Advancing Equity through Quality and Safety.