University of Maryland Medicine—which is comprised of the University of Maryland Medical System (UMMS) and the University of Maryland School of Medicine (UMSOM)—has announced that it will end the use of a long-standing clinical standard for measuring kidney function that factors a patient’s race into the diagnosis of chronic kidney disease (CKD). The change could increase access to speciality care, including eligibility for kidney transplantation, for thousands of Black people living with advanced kidney disease, a press release states.
By late January 2022, the University of Maryland Medicine system, including its flagship academic hospital, the University of Maryland Medical Center (UMMC), will transition to new a standard of evaluating kidney function, eliminating whether a patient is “African American or non-African American” as a factor. This move follows a review by University from Maryland School of Medicine (UMSOM) clinicians and scientists of recently released recommendations from professional societies.
By one estimate, the release notes, approximately 720,000 Black Americans might be treated earlier for kidney disease if race were removed from the calculations of kidney function. In Maryland, and the Mid-Atlantic region of the USA more broadly, thousands of people could be impacted by this transition to race-free estimated glomerular filtration rate (eGFR)—a measure reflecting how well a person’s kidneys filter waste.
“This is a significant development for University of Maryland Medicine and for academic medicine in general,” said Mohan Suntha, president and CEO of UMMS (Baltimore, USA). “We are in a period of evolution toward truly understanding the scope and impact of race-based disparities in healthcare and taking steps to address inequities. I commend our physician leadership and University of Maryland School of Medicine partners who have taken swift and decisive action to operationalise this change across our system hospitals, programmes and clinical partners. We are proud to be among the nation’s first academic medical systems leading this imperative.”
Since 1999, nephrologists across the USA have used an equation to estimate GFR. This equation relies on levels of creatinine—a byproduct of muscle and protein metabolism—from the blood. In addition to age and gender, the calculation takes into account whether a patient is “African American or non-African American” and assigns a multiplier based in part on a discredited notion that Black people tend to have more muscle mass than people of other races, the release continues. This higher value often overestimates the health of Black patients’ kidneys, pushing them above the threshold for diagnosis of advanced kidney disease and, as such, leads to delayed referral for speciality care, or even disqualification for kidney transplantation.
Following a report last year in the New England Journal of Medicine, the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) formed a joint taskforce to review the use of race in eGFR calculations. In September 2021, the group endorsed a new calculation without the race coefficient. A committee of University of Maryland Medicine researchers, kidney specialists, clinical quality leaders and health equity champions then quickly convened to closely review the new guidance and drive forth a strong recommendation for change. This change was also enthusiastically endorsed by the Quality and Safety Committee of the UMMS Board.
“We are working expeditiously, but responsibly, to take race out of the equation,” said Stephen Seliger, associate professor in the Department of Medicine, Division of Nephrology, UMSOM, and an attending nephrologist at UMMC (Baltimore, USA). “But, anytime we advance change, we need to make sure we are not introducing unintended consequences. We have engaged a multidisciplinary team to develop a roadmap that will ensure a strong degree of accuracy in our evaluation of CKD and its severity for all patients. We also want to ensure that our systems, and internal and external stakeholders, are all aligned. While the shift in the numbers seems small, the implications are not trivial. The elimination of race-based adjustments will alter reality for many of our patients.”
In the USA, Black adults are three times more likely to suffer from kidney failure—making up roughly a third of US dialysis patients, while comprising only 13% of the population. Delays in diagnosis only exacerbate this gap. And, according to UMMS experts, while time is of the essence, getting this transition right is equally important. As such, the fact University of Maryland Medicine is acting to implement this change so quickly is a testament to the leadership roles the institution has in the academic medicine and health system arenas, the release adds.
UMSOM is also a participating site in the APOL1 Long-term Kidney Transplantation Outcomes Network (APOLLO), led by the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health (NIH). Many Black people who eventually need kidney transplants have a genetic variant called APOL1—short for apolipoprotein L1. In Africa, APOL1 protects against African sleeping sickness. In the USA, APOL1 seems to increase the risk of kidney disease, however. APOLLO participants, including both kidney donors and recipients of kidney donations, undergo DNA tests to determine the variant’s effects on kidney transplant outcomes.
“We know that Black people historically suffer disproportionately from CKD, and we have long sought a solution to improve outcomes,” said E Albert Reece, executive vice president for Medical Affairs at the University of Maryland, Baltimore, and the John Z and Akiko K Bowers distinguished professor and dean at UMSOM (Baltimore, USA). “Changing the very method we use to diagnose kidney disease could be a gamechanger for many patients whose eGFRs may have appeared to be in normal range previously. If they do, in fact, have kidney disease, finding out earlier could make a difference in the person’s long-term health. The decision to stop using race-based eGFR calculations at University of Maryland Medicine could effectively level the playing field, which was sorely needed.”
“This is an historic step forward, and one I hope will bring greater awareness to the inherent flaws in many medical measurements that can foster the disproportionate toll chronic disease takes on people of colour,” added UMMS chief diversity, equity and inclusion officer Roderick K King. “Achieving equity in the diagnosis and treatment of kidney disease will clearly require interventions beyond the adoption of a race-independent eGFR calculation. But, I am encouraged by the far-reaching impact this will have in the communities we serve and honoured to work alongside colleagues who share my dedication to driving progress.”
