Structural racism in health care is real, and three ways its manifestation can be seen and measured are in the treatment and health outcomes for patients with kidney disease and, ultimately, the likelihood that they will receive a lifesaving transplant.

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“Unfortunately, the facts are incontrovertible,” said Paul Palevsky, MD, president of the National Kidney Foundation (NKF). “People who identify as Black, Hispanic, Native American, Native Hawaiian and Pacific Islander are more likely to develop kidney disease, disproportionately progress to kidney failure, are less likely to be treated with home dialysis, and are much less likely to be referred, listed and receive a kidney transplant.” 

Dr. Palevsky made his remarks while delivering his presidential address at the NKF’s 2021 Spring Clinical Meetings, held virtually this year due to the pandemic. His talk was followed by a keynote presentation from AMA Chief Health Equity Officer Aletha Maybank, MD, MPH

The pandemic exposed glaring inequities that exist broadly across American health care, Dr. Palevsky said, noting that, among Black and Hispanic dialysis patients, COVID-19 hospitalization rates were more than 1.5 times higher than rates for non-Hispanic white dialysis patients. 

A critical issue has been a key measure for calculating kidney function, the estimated glomerular filtration rate (eGFR), which for decades has been automatically adjusted to give a higher number for Black patients. 

As a result, two people, with the same age, sex, laboratory data and only differing in the color of their skin will have different reported eGFR, Dr. Palevsky said. He added that an NKF-American Society of Nephrology joint task force affirmed that race is a social—not a biological construct—and agreed that race modifiers should not be used in equations estimating a patient’s kidney function. 

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This affirmation echoes policies adopted at the AMA House of Delegates’ November 2020 AMA Special Meeting

“It’s not simply about the graphs, the numbers, and the charts,” Dr. Maybank said in her keynote address. “It’s about the experiences of people, and it’s about experiences of families, and the experiences of their children and what they’re going to pass from generation to generation.” 

She added that an “embodiment of racism” is the chronic stress that physically wears a person down and that can eventually lead to hypertension, heart disease and kidney disease. 

Dr. Maybank described the NKF’s efforts to remove race from medical equations as a “fantastic movement” that sets a direction for other organizations to follow. 

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One organization that recently did just that is the M Health Fairview system in Minneapolis, which established a task force last year to examine the issue and recommended removing race-based eGFR adjustments. 

“The now-recognized truth is that racial differences in health care primarily reflect dose exposure to racism and other social determinants of health linked to racism,” task force members wrote in “Reckoning with History,” an essay appearing in Minnesota Medicine, a publication of the Minnesota Medical Association. 

“We need to stop doing what we know is causing harm,” Kristina Krohn, MD, a hospitalist who served as task force chair, noted in a blog item posted on the M Health Fairview website. 

“The race-adjusted eGFR algorithm makes a Black person’s kidneys seem healthier than they may really be,” said Dr. Krohn an assistant professor at the University of Minnesota Medical School’s department of medicine. “That can result in delays if that person needs access to nephrologists or counseling to manage their chronic kidney disease—including delays in being listed for kidney transplant.” 

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