Achieving Equity in Kidney Care

In the U.S., as in many other parts of the world, people tend to have worse outcomes from many health conditions if they belong to a racial, ethnic, or other traditionally marginalized group.

Many people assume that there are inherent physical differences between people of different races or that race is determined by genes. But, biologically speaking, there are no separate human races. There is more genetic variation within “race groups” than between them.

Race is a social construct that changes depending on time and place through history. The idea that race is a meaningful natural category is a dangerous myth that has adversely affected certain populations in our society at all levels…including within the field of medicine.

The health care system at large has sometimes embraced false beliefs about racial differences in people’s bodies — and the way we assess kidney health and kidney donor eligibility are prime examples.

Why Kidney Health Matters

Our kidneys play a vital role in our bodies. They filter out waste, remove excess fluid, and preserve a healthy balance of water, salts, and minerals in our blood.

A variety of health problems can damage our kidneys, including:

• Type 1 or type 2 diabetes
• High blood pressure
• Systemic lupus erythematosus
• Long-time use of certain medications
• Lead poisoning

So it’s important to regularly monitor kidney health, especially in people who have risk factors for kidney disease.

How Racial Bias Has Affected Kidney Disease Diagnosis

The easiest way to assess a person’s kidney health is through their estimated glomerular filtration rate (eGFR). This involves using a simple blood test to measure how well a waste product called creatinine is being filtered out of someone’s blood.

Beginning in the 1970s, a few small, flawed studies suggested that Black people have higher blood creatinine levels than white people. Ever since, different eGFR scales have been used to evaluate Black and non-Black patients. This has caused many Black patients’ kidney function to be considered healthy — when their exact same creatinine levels would have signaled poor kidney health in non-Black patients.

As a result, early-stage kidney disease has been systematically underdiagnosed in Black patients for decades. This is one of many reasons why Black people are three times more likely to experience kidney failure than white patients.

Many health care entities have already stopped using the racial adjustment for eGFR measurements. For instance, the National Kidney Foundation and American Society of Nephrology recommended ending this practice in 2021. The Organ Procurement and Transplantation Network (OPTN) has required transplant hospitals to stop using the racial variable in eGFR calculations since July 27, 2022, and has shortened kidney transplant wait times for almost 15,000 patients disadvantaged by the race-based eGFR.

But removing the racial adjustment from eGFR measurement in all areas of health care takes time. And as long as it’s still being used by anyone, kidney disease diagnoses will keep being missed in Black patients.

Faulty assumptions about racial differences also play a role in the way we assess whether a donated kidney should be used for transplantation. And that must also change.

How Racial Bias Has Shaped Kidney Donation

When people experience kidney failure, there are two options for keeping them alive. One is dialysis; the other is kidney transplantation.

Living, healthy people can (and do) donate their kidneys, but that doesn’t nearly meet the demand for kidney donations. Right now, people usually have to wait three to five years to receive a kidney transplant in the U.S.

Kidneys are among the many things harvested from organ donors when they die. This makes about 20,000 kidney transplants possible every year in the U.S.

But not every kidney is healthy, and if you use an unhealthy kidney there’s a higher risk of rejection. That is why there is a kidney donor risk index (KDRI). The KDRI is used to predict whether a donated kidney is likely to fail. And the KDRI takes various factors into consideration, including the donor’s:

• Age, height, and weight
• History of hypertension or diabetes
• Creatinine level
• Whether the donor had hepatitis C
• Cause of death
• Ethnicity (Black vs. non-Black)

At some point, researchers looking at their database of transplants observed that kidneys from Black people had a slightly higher rate of graft failure and drew the conclusion that, all other things being equal, kidneys from non-Black donors were of better quality. That’s how ethnicity became to be part of the KDRI equation.

But subsequent studies have shown that removing a donor’s race from the KDRI makes an insignificant difference in kidney transplantation success. And it would immediately make more kidneys available for those who need them.

Because of numerous structural barriers in access to health care, Black patients are less likely to receive kidney transplants than non-Black patients and are under-represented on kidney transplant waitlists. This is not okay. We need to make as many suitable donor kidneys available as possible. Transplantation can mean life or death for someone experiencing kidney failure.

Working to Improve Equity in Kidney Outcomes

Independence Blue Cross (IBX) is part of the Regional Coalition to End Race-Based Medicine, a group of health care entities working together to accelerate progress on eliminating racial adjustments like the ones used in eGFR and KDRI. This should help reduce inequities in kidney disease. But it will take time to dismantle these deeply entrenched racially discriminatory practices in medicine (as in many other areas of life).

If you are getting a blood test to measure your kidney health, ask your health care practitioner if they are factoring in your race when they calculate your eGFR. If they are, ask them to update their practices. You can direct them to the American Society of Nephrology and National Kidney Foundation recommendation, which makes it clear that race has no place in eGFR calculation.

The more we all work together, the faster we can dismantle racial bias in medicine.