A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease

Cynthia Delgado, Nephrology Section, San Francisco Veterans Affairs Medical Center and Division of Nephrology, University of California San Francisco, San Francisco, California. Electronic address: Cynthia.Delgado@ucsf.edu.
Mukta Baweja, Nephrology Division, Department of Medicine and Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York.
Deidra C. Crews, Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Nwamaka D. Eneanya, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Crystal A. Gadegbeku, Department of Nephrology and Hypertension, Department of Medicine, Cleveland Clinic, Cleveland, Ohio.
Lesley A. Inker, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
Mallika L. Mendu, Division of Renal Medicine and Office of the Chief Medical Officer, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
W Greg Miller, Department of Pathology, Virginia Commonwealth University, Richmond, Virginia.
Marva M. Moxey-Mims, Division of Nephrology, Children's National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC.
Glenda V. Roberts, External Relations and Patient Engagement, Kidney Research Institute and Center for Dialysis Innovation, University of Washington, Seattle, Washington.
Wendy L. St Peter, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota.
Curtis Warfield, National Kidney Foundation, New York, New York.
Neil R. Powe, Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and University of California San Francisco, San Francisco, California. Electronic address: Neil.Powe@ucsf.edu.

Document Type

Journal Article

Publication Date

2-1-2022

Journal

American journal of kidney diseases : the official journal of the National Kidney Foundation

Volume

79

Issue

2

DOI

10.1053/j.ajkd.2021.08.003

Keywords

CKD prevalence; CKD screening; chronic kidney disease (CKD); creatinine; end-stage kidney disease (ESKD); estimated glomerular filtration rate (eGFR); estimating equation; ethnicity; filtration marker; health care equity; health disparities; kidney disease; kidney disease diagnosis; laboratory medicine; medical decision making; public health; race; race coefficient; renal function

Abstract

BACKGROUND: In response to a national call for re-evaluation of the use of race in clinical algorithms, the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) established a Task Force to reassess inclusion of race in the estimation of glomerular filtration rate (GFR) in the United States and its implications for diagnosis and management of patients with, or at risk for, kidney diseases. PROCESS & DELIBERATIONS: The Task Force organized its activities over 10 months in phases to (1) clarify the problem and evidence regarding GFR estimating equations in the United States (described previously in an interim report), and, in this final report, (2) evaluate approaches to address use of race in GFR estimation, and (3) provide recommendations. We identified 26 approaches for the estimation of GFR that did or did not consider race and narrowed our focus, by consensus, to 5 of those approaches. We holistically evaluated each approach considering 6 attributes: assay availability and standardization; implementation; population diversity in equation development; performance compared with measured GFR; consequences to clinical care, population tracking, and research; and patient centeredness. To arrive at a unifying approach to estimate GFR, we integrated information and evidence from many sources in assessing strengths and weaknesses in attributes for each approach, recognizing the number of Black and non-Black adults affected. RECOMMENDATIONS: (1) For US adults (>85% of whom have normal kidney function), we recommend immediate implementation of the CKD-EPI creatinine equation refit without the race variable in all laboratories in the United States because it does not include race in the calculation and reporting, included diversity in its development, is immediately available to all laboratories in the United States, and has acceptable performance characteristics and potential consequences that do not disproportionately affect any one group of individuals. (2) We recommend national efforts to facilitate increased, routine, and timely use of cystatin C, especially to confirm estimated GFR in adults who are at risk for or have chronic kidney disease, because combining filtration markers (creatinine and cystatin C) is more accurate and would support better clinical decisions than either marker alone. If ongoing evidence supports acceptable performance, the CKD-EPI eGFR-cystatin C (eGFR) and eGFR creatinine-cystatin C (eGFR) refit without the race variables should be adopted to provide another first-line test, in addition to confirmatory testing. (3) Research on GFR estimation with new endogenous filtration markers and on interventions to eliminate race and ethnic disparities should be encouraged and funded. An investment in science is needed for newer approaches that generate accurate, unbiased, and precise GFR measurement and estimation without the inclusion of race, and that promote health equity and do not generate disparate care. IMPLEMENTATION: This unified approach, without specification of race, should be adopted across the United States. High-priority and multistakeholder efforts should implement this solution.

Department

Pediatrics

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