The following few sentences, though understated and technical, herald a tectonic shift at Oregon Health and Science University and in American medicine amid a national judgment on racism:
“Effective January 19, 2022, Oregon Health & Science University Clinical Laboratories will transition from using the Modification of Diet in Renal Disease (MDRD) equation for estimating glomerular filtration rate (eGFR) to the epidemiology of chronic kidney disease. Collaboration (CKD-EPI) Creatinine equation.
The new protocol excludes race as a variable. Instead, CKD-EPI eGFR results are based on serum creatinine, age, and gender, and are normalized to 1.73 m² body surface area.
Since the origins of modern medicine, doctors have used calculations called clinical algorithms to determine the course of diagnosis and treatment of patients with many diseases, including chronic kidney disease (CKD). Although the algorithms have changed as medical knowledge has advanced over time, in many cases one thing has remained the same: many of these calculations take into account the race of the patient.
The practice has always been seen as responding appropriately to the differing prevalence or severity of disease in various populations. But of late, it has come under scrutiny for, instead, potentially limiting diagnosis and treatment to members of communities who need it most.
The kidney disease algorithm change, championed by the American Society of Nephrology and the National Kidney Foundation, is the first such change OHSU and hospitals nationwide are making in treating a myriad of diseases. . It is also just one of many steps needed to achieve health equity and eliminate structural racism in medicine and medical education.
“Unpacking practices that embody structural racism and are rooted in the very foundations of medicine is a massive, multi-layered task and is only one aspect of eradicating the health disparities that manifest according to racial criteria and cause untold and unacceptable suffering,” said Derick DuVivier, MD, MBA, OHSU Senior Vice President for Diversity, Equity and Inclusion. “OHSU’s decision to remove race as a determining factor in the diagnosis and treatment of kidney disease is one of many decisions we will make based on science and our values.”
Said John Hunter, MD, CEO of OHSU Health, “Across all of our medical specialties nationally and internationally, the medical profession is scrutinizing our algorithms to root out instances where the use of race as a factor is determined to impede rather than “to promote health. equity. The decision made in nephrology will be the first of a long series.
While not a new debate, discussion has reignited in the medical community as Americans took to the streets following the police killing of George Floyd on May 25, 2020. June 18 2020, less than a month later, the New England Journal of Medicine article “Hidden in Plain Sight: reconsidering the use of racial correction in clinical algorithms“, became the rallying cry.
“Despite mounting evidence that race is not a reliable indicator of genetic difference,
the belief that it has become entrenched, sometimes insidiously, in medical practice,” wrote Darshali A. Vyas, MD, and co-authors, who cite detailed examples from cardiology, obstetrics, urology, oncology, endocrinology, pulmonology, thoracic surgery and nephrology.
In the field of nephrology, doctors have long estimated kidney function — or how well the kidneys filter impurities from the blood — by measuring what’s called estimated glomerular filtration rate (eGFR). The measurement is used to determine who should be diagnosed with CKD, receive medication, undergo dialysis, or be a candidate for a kidney transplant. As Vyas and his co-authors explain, with detailed footnotes included in the article:
“These algorithms result in higher reported eGFR values, suggesting better kidney function, for anyone who identifies as black. The algorithm developers justified these results with evidence of higher average serum creatinine concentrations in blacks than in whites. Explanations that have been given for this discovery include the notion that black people release more creatinine into their blood initially, in part because they are more muscular. Analyzes have cast doubt on this claim, but race-corrected eGFR remains the norm.
“Proponents of the equations have acknowledged that racial adjustment “is problematic because race is a social rather than a biological construct,” but warn that ending eGFR racial adjustment could lead to overdiagnosis and overtreatment of black patients. Conversely, racial adjustments that yield higher estimates of kidney function in black patients could delay their referral to specialist care or transplantation and lead to poorer outcomes, when blacks already have higher rates of end-stage kidney disease and death from kidney failure than the general population.”
To take part
In September 2020, the American Society of Nephrology and the National Kidney Foundation convened a task force on the issue. In September 2021, the task force recommended moving to a calculation that does not include race. Recommendations went further to include more aggressive routine care for all patients with or at risk of kidney disease, and research to identify new markers that will help eradicate racial and ethnic disparities.
On January 12, 2022, Dinushika Mohottige, MD, Camara Jones, MD, MPH, Ph.D. (who gave the Hatfield lecture at OHSU in January 2020) and co-authors published a definitive article in the Clinical Journal of the American Society of Nephrology, “Use of race in kidney research and medicine: concepts, principles and practice.”
They note that, in essence, seeking to associate the higher incidence of disease and death from kidney disease among black Americans with their inherent biology identifiable by their skin color confuses the complex interactions of biological differences that are identifiable in all humans at the individual level with the population. – level disparities that are due to structural racism.
In short, the condition of dark-skinned people is blamed on people, not conditions, many of which – including access to quality housing, education, health care and a sense of security in the everyday life – were systematically constructed and imposed.
At OHSU, shortly after the “Hidden in Plain Sight” article was published, Sharon Anderson, MD, a nephrologist, presented the issue to the OHSU Academic Board of Health, which she chaired as Dean of the School of Medicine. Following the national recommendation in September 2021, the Academic Council forwarded the new recommendations to the OHSU Health System Management Team, which, combined with a recommendation from the Department of Pathology, approved the change in December for the implemented in Epic, OHSU’s electronic health record. platform, January 19. Implementation within the VA Portland healthcare system is expected to occur by April 2022.
“As a nephrologist for many decades, I have always tried to follow the best available evidence and recommendations in the care of my patients; but the practice of medicine must include continuous review in order to move forward,” said Anderson, who ended his service as dean Sept. 30, replaced by David Jacoby, MD. “I’m proud that nephrology is the first specialty to adopt a race-free replacement for a clinical algorithm, providing an important patient-centered and evidence-based first step in a much larger effort to eliminate disparities. This was an important initiative of OHSU’s Academic Board of Health, which, because it connects academic and clinical missions, is uniquely positioned to advise the health care system on best practices to help eliminate structural racism in medicine.