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July 29, 2020

Black Kidney Function Matters: Use or Misuse of Race?

Author Affiliations
  • 1Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco
JAMA. 2020;324(8):737-738. doi:10.1001/jama.2020.13378

Racial discrimination has been a lightning rod for passionate discourse and social action in the US for decades, if not centuries. The recent killings of African Americans by law enforcement has amplified the discourse. Health care has not been immune to such tragedies, with past experimentation without informed consent and segregation in health care facilities. These were systemically ingrained, institutional practices without ethical or evidentiary footing. Race was an identifying characteristic used to implement practices that resulted in consequences for health and well-being. The use of race in algorithms for clinical care, including for kidney disease, has generated and now even more so is generating discourse and action about current-day, systemic discrimination in health care.

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    5 Comments for this article
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    eGFR
    Charles Hubbert, MD | Self
    I think we could do just as well without the concept and practice of race, but it is politically important presently, and it stimulates more "research" and "scientific" papers (RCTs?). Fortunately I was never smart enough to understand eGFR anyway, so I went into psychiatry. So be it.
    CONFLICT OF INTEREST: None Reported
    "Race"
    Antonio Amoroso, MD | University of Turin - Italy
    I think the term "Race" should be avoided. It is better to define population variability by a patient's continent origin. Instead of race I think it is more correct to utilize words such as "geographical origin" or "ethnicity."
    CONFLICT OF INTEREST: None Reported
    Race as a Social Construct
    Paloma Carcamo, MD |
    It's important to remember that a designation of "race", even when self-determined, does not necessarily correlate with a set of clinical characteristics. While it may be useful to collect information on race or ethnicity to look at, for instance, health disparities or social determinants, it may be counterproductive to use in clinical contexts. Making clinical judgments based on a patient's race may mean making assumptions about their physiology that are likely not true, as race is a socially and not genetically defined construct.
    CONFLICT OF INTEREST: None Reported
    eGFR correction for SOFA score
    James Lin, MD | UCLA
    Comparative differences in creatinine can change patients' eligibility for scarce resources in a triage protocol. Specifically, creatinine of 1.2 vs 1.1 mg/dL scores 1 vs 0 point on SOFA, which is the most common "objective" score used in triage protocols nationally. Without race correction for eGFR in a validated score, populations with higher creatinine levels (whom are already disproportionately suffering in the COVID-19 pandemic) are further penalized in "objective" crisis allocation.
    CONFLICT OF INTEREST: None Reported
    Look at the Evidence, Not the Politics
    Mitchel Galishoff, MD | Private Practice, Valley, AL
    In reading this piece I was expecting a scientific analysis and reassessment of the current equations for estimating GFR. Logically, one would go back to the original work and critically analyze the impact of race on the estimation of renal function. If flaws were found then a scientific response is needed along with analysis of later work that may have resulted in different outcomes. If the latter is not available, then a call for and persuit of additional studies using a gold standard to come up with an alternative equation for estimating GFR is needed.

    The
    author does not do this. Rather than taking a scientific approach what we see here are argument from social justice and history. It may or may not be the case that modifications in the equations for estimating GFR to include race and gender are necessary. The purpose is not racial discrimination but to come up with a reliable means of estimating residual renal function to guide us in the care of our patients.

    Besides the initiation or renal replacement therapy, contraindications and adjustments to medications, risks of procedures, prognosis of other illness and care planning are greatly affected by this. To underestimate or overestimate renal function may result in a patient being denied or given treatment based upon GFR cutoff values.
    CONFLICT OF INTEREST: None Reported
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