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June 6, 2019

Reconsidering the Consequences of Using Race to Estimate Kidney Function

Author Affiliations
  • 1Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 3Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA. 2019;322(2):113-114. doi:10.1001/jama.2019.5774

Clinicians estimate kidney function to guide important medical decisions across a wide range of settings, including assessing the safety of radiology studies, choosing chemotherapy, and reviewing the use of common nonprescription medications such as nonsteroidal anti-inflammatory drugs. Because direct measurement of kidney function is infeasible at the bedside, the usual approach involves using estimating equations that rely on serum creatinine. These equations assign a higher estimated glomerular filtration rate (eGFR) to patients who are identified as black. Yet in some medical and social science disciplines, a consensus has emerged that race is a social construct rather than a biological one.1 In this Viewpoint, we argue that the use of kidney function estimating equations that include race as a variable cause problems for transparency and unduly restrict access to care in some cases, yet offer only modest benefits to precision.

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2 Comments for this article
Hear! Hear!
David Power, MBBS MPH | University of Minnesota Medical School
Thank you for this thoughtful and well-written commentary on such an important topic. As anthropologists have told us for decades, race - especially in the multicultural setting of the US - is a social construct. Holding on to these antiquated racial norms is the antithesis of evidence-based medicine. Better to completely ignore any potential influence of race than to incorrectly attribute significance that does not exist. Bravo! - let's continue to document that the emperor is indeed wearing no clothes.
"Race" is a 19th Century Fiction, But Ignoring the Ancestry of Genetic-Niche Populations Endangers the Lives of African-Americans
Constance Hilliard, Ph.D. | University of North Texas
I agree with the authors of “Reconsidering the Consequences of Using Race to Estimate Kidney Function” that the “term” race is pseudo-scientific and antiquated. But I am equally aware of how damaging a polite, well-intentioned refusal to acknowledge ancestry can be in the medical treatment of non-European genetic populations. My work, as a historian of African evolutionary history and genomics, explores the etiology of certain diseases for which African-Americans have unusually high susceptibilities. But the first step in doing so, is defining with some level of precision the genotype of a 17th-19th century population, whose distinguishable genomic traits, no longer exist in contemporary West Africa. That is, the ancestors of the 37 million African-Americans of slave (also known as “legacy”) descent, came from a sodium-deficient region of West Africa that was 500 to 1,000 miles inland of the Atlantic coast. They were genetically adapted to surviving the sweltering heat of this salt-less no-man’s-land on a diet of 200-300 mg/sodium/day, which not even coastal West Africans could handle. Today’s legacy African-Americans are generally 75% Niger-Kordafanian West African, 24% Northern European and 1% Native American. In consuming on average 3500 mg/sodium/day, it is not surprising that they suffer unusually high rates of salt-sensitive hypertension and renal failure. To suggest, as the Viewpoints authors do, that estimated glomerular filtration rates (eGFR) not take account of genetic ancestry, because American society at large confuses the term “race” with “human genetic diversity”, would be a dangerous step backwards in treating this genetic population.