While working as a Medical Assistant, I had a patient who presented with Type 2 Diabetes, Renal Failure, and left toes necrosis. During his visit, he expressed how tired he was from the weekly dialysis. Not only did I empathize with him, but I understood him. Part of the reason why I became interested in medicine was that my father had kidney failure and underwent dialysis for eight years. Eight years on the transplant list? Why so long, you may ask? Aside from a major shortage of organs from deceased and living donors (Beyar, 2011), a clinical measurement used to determine kidney disease risk and transplantation eligibility is the estimated Glomerular filtration rate.
Glomerular filtration rate (GFR) is an index of kidney function that varies according to age, sex, and body size. For nearly four decades, clinicians have employed race multipliers in eGFR calculations, which systematically affect disease management for Black Americans (Tsai, 2022). In the U.S health systems, there are two main equations that have been used to determine glomerular filtration rate, which are the Modification of Diet in Renal Disease (MDRD) equation and the 2009 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation (Bhuvanakrishna, 2015). These equations included race adjustments that multiply eGFR by 1.21 or 1.16, respectively, if the patient identified as “Black” (Tsai, 2022). A study analyzed that without the race adjustment, more than 3 million more Black Americans would reach the threshold for Stage 3 Chronic Kidney Disease (Tsai, 2022). This is crucial because not only does it affect the diagnosis and treatment plan, but it also allows patients to qualify for nephrologist referrals and transplant evaluations much earlier on.
Now, my father was diagnosed with kidney failure in 2010, and did not receive a kidney until 2018. As a son, all I could do was pray and hope for a new kidney for him, but I also asked myself why it took so long when he is doing everything right? Going to his dialysis, following up with his doctor, eating a well-balanced meal (because my mom forced him to), and his lab results were good? Well, I guess his eGFR must have been “out of range” to qualify for a kidney. Kidney function level was calculated from equations that adjusted the result if the individual was of Black race, and it wasn't until recently that a new equation was developed in 2021 that eliminated “race” as a factor. A study examined this equation and found that, with the new equation, the number of Black adults classified with kidney disease increased while that of non-Black adults decreased (Oliver III, 2024) . These results emphasize how both the positive and negative outcomes need to be monitored with this new equation.
This change is progress, but it’s only a small part of addressing racial disparities in kidney care and healthcare more broadly. In addition, this shift reflects an obligation to address and uphold ethical principles of non-maleficence and beneficence in clinical care. The "race" factor inflated the eGFR values, causing an indirect harm to patients by keeping them longer on the waitlist or withholding referrals. Now, something that is lingering is that we've seen how race has been a major factor in the history of medicine. From forced sterilizations, usage of HeLa cells, unethical studies like the Guatemala and Tuskegee Syphilis study, to the use of race markers in kidney function, and many more, the only question I ask is, what else? What else in our current healthcare systems uses “race” as a factor? What else in our medical school education and hospitals uses “race” as a hidden marker? As future educators and clinicians, it is important to confront these questions and challenge the legacy of medical racism in books and metrics used to provide care and act in accordance with what benefits the patient most.
References
Beyar, R. (2011). Challenges in organ transplantation. Rambam Maimonides medical journal, 2(2), e0049.
Bhuvanakrishna, T., Blake, G. M., Hilton, R., Burnapp, L., Sibley-Allen, C., & Goldsmith, D. (2015). Comparison of estimated GFR and measured GFR in prospective living kidney donors. International urology and nephrology, 47(1), 201-208.
Oliver III, J. D., Nee, R., Marneweck, H., Banaag, A., Koyama, A. K., Pavkov, M. E., & Koehlmoos, T. P. (2024). Impact of race-free glomerular filtration rate estimations on CKD prevalence in the US Military Health System: a retrospective cohort study. Kidney medicine, 6(8), 100861.
Tsai, J. W., Cerdeña, J. P., Goedel, W. C., Asch, W. S., Grubbs, V., Mendu, M. L., & Kaufman, J. S. (2021). Evaluating the impact and rationale of race-specific estimations of kidney function: estimations from US NHANES, 2015-2018. EClinicalMedicine, 42.
Wow, thank you for sharing this. It’s heartbreaking to think that something like a built in race factor adjustment could have delayed care for so many people, like your dad. It’s really eye opening to realize how many “standard” medical practices are rooted in racism and bias in healthcare. This new equation without the race factor incorporated is a step in the right direction, but like you mentioned, there’s still a long way to go.
ReplyDeleteYour discussion also reminds of other forms of bias in healthcare, like how women are often taken less seriously when presenting with symptoms. In addition, women frequently have their heart disease symptoms unrecognized because they may experience signs that are different from a male’s heart attack pattern.
There’s also research that shows that women have been found to wait significantly longer than men to receive pain medications when they’re experiencing acute pain. It really shows how much work still needs to be done in healthcare, and as future physicians we really have to be mindful of these disparities and intentional about providing care to serve everyone fairly.