Kansas physicians ditch rules treating white people’s kidney disease more seriously 

Clinicians had long shorted Black patients with kidney disease by measuring organ performance differently based on race. Now Kansas City physicians disregard race when determining when to put patients on dialysis or a transplant waiting list.

by J. Duncan Moore Jr.

Kidney disease was the 10th leading cause of death in Kansas for 2021.

The state saw 550 deaths and recorded the 16th worst death rate in the country.

Nationally, Black and Hispanic residents accounted for a significantly higher number of those deaths than the white majority.

Black people make up about 13% of the U.S. population, yet they comprise 35% of Americans with kidney failure and 40% of those on dialysis. 

In 2021, the rate of end-stage renal disease among Black Americans ran 3.8 times the rate for whites. For Native Americans, it was 2.3 times as high. And for Hispanics, twice as high.

“There is truly an uneven burden of kidney disease among Blacks, and among Hispanics as well,” Said Dr. Emmanuel Adomako, a nephrologist, or kidney disease specialist, at the University of Kansas Health System.

Until recently, one contributor to that inequity was baked into standard medical practice. Doctors used a different metric for Black people’s kidney function than for white people’s.

“With the same level of creatinine (a key measure of kidney function), white people were classified as having more advanced kidney disease than Black people,” said Dr. Sylvia E. Rosas, a nephrologist in Boston who is also president of the National Kidney Foundation. “It affected Black people because they were referred later for transplant.” 

That delayed transplants, extended the sometimes-brutal time of relying on dialysis and increased their chance of dying while waiting for a new kidney.

“That demonstrates the inequity,” said Kathy Elliston, a Black woman in the Northland who got a kidney transplant three years ago at St. Luke’s Hospital. “From the standpoint of people of color, they do not have the same advantages in access to medical care that anyone else has.”

That’s changing. Since 2020, the medical community has revised the equation for diagnosing kidney disease. The new equation removes any race-based qualifiers.

“We were using this variable that had nothing to do with your kidney,” Rosas said in an interview. “It’s not like the kidneys of Black people work differently from the kidneys of white people.” 

The new equation is being phased in rapidly. The University of Kansas is now using the revised algorithm in its hospitals and clinics, Adomako said. On the national level, CommonSpirit Health –  a large Roman Catholic health system that operates 1,000 care sites and 140 hospitals in 23 states, including three hospitals in western Kansas – has implemented the change since it was introduced in 2021.

“We expect that establishing more equitable measures will improve earlier diagnosis of kidney disease,” speed treatment and lead to quicker transplants, Dr. Ankita Sagar, CommonSpirit health system’s vice president for clinical standards and variation reduction, said in an email.

This change in kidney care comes amid a national reconsideration of the ways racial assumptions or biases in health care may hurt patients. Other diagnostic tests, such as for breathing function and bone density, also have used race in the calculation. 

The burden of kidney disease falls most heavily on Black and Hispanic people, Native Americans and Pacific Islanders. 

The leading causes of kidney disease include diabetes, high blood pressure, obesity, heart disease and environmental factors – all of which are more prevalent among those racial and ethnic groups. Roughly 37 million Americans have diabetes and another 96 million have prediabetes. 

Many people of West African ancestry carry a gene that predisposes them to kidney disease, which can lead to high blood pressure and kidney failure. The gene for sickle-cell disease, most offen found in persons of African descent, also can affect the kidneys. 

“We are looking at the population of African-Americans who have increased risk of kidney disease, increased risk of dialysis, and at the same time the equation we are using to measure kidney health overestimates their kidney function,” Adomako said. “(That) means patients may not get their needed treatment.”

The high death rate of Black and Hispanic Americans during the COVID pandemic brought  renewed attention to the gap between health and care for different demographic groups. 

Black kidneys are like white kidneys

Kidneys are small but complicated organs. They eliminate waste, synthesize hormones, build bone health and regulate blood pressure. To evaluate kidney health, doctors rely on a variety of tests and lab results, some of them time-consuming and expensive. 

The “estimated glomerular filtration rate,” or eGFR, uses clearance of creatinine – a protein waste byproduct – to gauge the organs’ performance. The eGFR helps doctors decide on prognosis and treatment, including when a patient needs to go on dialysis or qualifies for a transplant.

Healthy kidneys in a younger person might filter blood at a rate of more than 90 milliliters per minute. An older person with Stage 3 chronic kidney disease might be at an eGFR of 30 to 44. The lower your eGFR, the worse shape your kidneys are in. At 15 milliliters per minute, you are in kidney failure. When they can only process 20 milliliters of blood a minute, you might qualify for a transplant.

If you were white.

If you were a Black person, the eGFR threshold sat 16% higher.

Under the new formula, the same standards apply regardless of race. 

More race-neutral medicine

Since the eGFR equation was first developed in the late 1990s, race has been included as a variable. The original algorithm was considered a step forward. The test was easy, cheap and widely available. 

Initial studies found that creatinine levels were higher in people who self-reported as Black, so the equation corrected for that — even when their actual measured kidney function was the same as non-Black people with lower creatinine levels.

But the study size was small and Black people were underrepresented in the sample, Adomako said. Over time, he said, “we began to realize that there were issues with correcting for race. 

“Race is a social construct. I am originally from Ghana,” he said. “I had a classmate whose mother was Ukrainian. If she is categorized as Black, she would have a different eGFR range.” 

That would affect how soon she would be considered to have advanced kidney disease or be eligible for a transplant.

Besides, Rosas said, “A lot of people are mixed – let’s say 40% Black. Who defines what’s Black?” 

And the delay in putting someone on a kidney transplant list can sometimes prove fatal.

“If you are going to get on the list a couple of years faster than somebody, you are more likely to get your transplant before another person,” Adomako said. “This is a matter of life and death.” 

Dialysis can prove critical in the meantime, he said, but “dialysis is not a complete replacement for kidney function. The death rate is quite high.”

Additionally, Rosas said, past diagnosis standards were inconsistent. Different regions, states and health systems used their own criteria to determine degrees of kidney failure. 

“You’re in Kansas City, and in Missouri you have one result from the formula, but you go across to Kansas, and you get another result from another formula,” she said. “If we are not using the same formula, you get incorrect results.” 

The National Kidney Foundation is encouraging all health systems and laboratories to use the 2021 equation that deletes racial considerations.

The change to the eGFR equation is an outgrowth of the country’s renewed look at race after George Floyd’s murder and subsequent protests in summer 2020. Medical students raised the issue. 

In school, they were learning there is no difference biologically between Black, white and Asian patients. Then when they went into practice, they found a formula that used race. 

“Is it really Black race, or is it social determinants of health” producing these discrepancies? Rosas said. “Why are we doing things this way? It’s really about access to health care, neighborhoods where they live. The most likely determinant of your health is actually your ZIP code.” 

In July 2020, the National Kidney Foundation and the American Society of Nephrology jointly commissioned a review of the diagnostic guidelines and race. A final report came out in September 2021. Since then, Rosas said, the foundation has been working with laboratory partners, pathologists, physician practices and hospitals to implement the new algorithm. By March 2023, 68.5% of all laboratories were using the new equation, up from 30.3% a year earlier.

A success

Kathy Elliston, the successful transplant patient from Kansas City, North, struggled with her kidney failure. Her lungs started to fill up with fluid.

“I almost drowned. You can’t breathe. You can’t walk. You can’t lay down, or the fluid starts coming up,” she said. “You have to be still.”

She got a transplant three years ago. Now she is 70.

 “It’s going very well. I feel great,” Elliston said. “I am in better health than I have been in my life.” 

Dialysis centers like this one tend to be located in neighborhoods of people of color, where kidney diseases runs higher. Credit: Scott Canon / The Wichita Beacon

Ditching racial qualifiers

This article was republished here with the permission of: The Beacon