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Panel recommends against use of race in assessment of kidney function – Boston, Massachusetts

Boston, Massachusetts 2021-09-23 12:30:41 –

NSThe Expert Task Force on Thursday announced a new and long-awaited approach to diagnosing renal function, stating that no racially controversial algorithm is needed in the assessment of renal disease.

A new recommendation is the use of race-based tools in medicine Outdated and wrong Because race is not a good substitute for genetic variation — and some races send the message that they are biologically inferior. Many also underestimate the degree of illness in black patients with individual racial thresholds for classifying kidney disease, receiving the specialized kidney treatment they need or waiting for a transplant. It claims to be unlikely to be on the list.

Black Americans four times More likely to have kidney failure than white Americans and less likely to suffer from end-stage renal disease despite a higher incidence Kidney transplant..

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Improving lab results using equations or algorithms has been a long-standing practice in medicine. The first commonly used equation to assess kidney function was introduced in the mid-1970s and was based on a patient sample containing only white men, which may have been incorrect from the beginning. These equations were first adjusted for gender. Then, in the late 1990s, when studies showed that black patients had higher average levels of creatinine (a by-product of muscle metabolism, a marker of kidney function) than white patients, the equation was more accurate. Race-tuned quotes to provide.

However, studies have shown that races are not always accurately reported and do not include multi-ethnic people, so using race as a substitute for genetics There is a problem. Some of these early studies on creatinine levels were probably inaccurate, and one determined the race “probably by examining skin color.” Ancestors can be much more important than race in determining genetic susceptibility to disease, but they are rarely tested in most clinics. Many also explain why some black patients may have high serum creatinine levels and may differ significantly between people of the same race than people of different race levels of markers. I argue that there is no biologically plausible reason to do so.

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NS Task force report It is recommended to use the modified equation without racial correction to estimate renal function (or GFR, glomerular filtration rate) using serum creatinine. This equation is called the “eGFR2021 CKD EPI creatinine equation” and was recalculated using data from a large and diverse patient pool rather than simply removing the racial correction from the previously used equation. , Is considered a “refit” equation. .. The new equation is one of the 26 approaches considered by the Task Force.

While the creatinine test is useful for screening, the report provides a second recommendation as it may require further confirmation. This encourages clinicians who need more information about kidney function to order tests for the different blood marker, cystatin C. It provides a better indicator of renal function than either test alone when used in combination with creatinine. (Cystatin C is not routinely used as a marker because tests for cystatin C are not available in most laboratories or large numbers of analyzers and are expensive. Task force members are on the better. As a demand, we hope these things will change in the near future. The tests will be bigger.)

“If I had my own way, I want everyone to go out and have the option to use these. [combination] I’ll test it tomorrow, but it’s not in every lab yet, “said Leslie, a task force member and director of the Tufts Medical Center’s Kidney Function Evaluation Center, who led the CKD-EPI research team to develop the new equation. A. Inker says. .. For now, she said, the new race-free equation provides very accurate results and is ready to use.

The Task Force Report was published on the same day as two new reports from The New England Journal of Medicine. Cystatin C works better As a diagnostic tool and as an explanation for it New recommended equation And although not perfect, it was shown to be much more accurate in black patients and only slightly off in non-black patients. NS editorial In the journal, he said that stopping racial correction is an important step that can lead to early identification and care of the most endangered patients.

Complaints about the use of racial algorithms have been bubbling over the years, but have grown even larger last year as racial calculations have spread nationwide. Due to concerns from medical and trainees, some large hospital systems, including Vanderbilt University and the University of Washington, have already withdrawn racial corrections, while others have a task force for guidance. I was waiting for a report.

Some nephrologists withdraw racial corrections, Other inequality For black patients who are not covered by life insurance because of improper medication of some drugs or chemotherapy, have been diagnosed with kidney disease, or cannot be a kidney donor.

The 14-member task force of the National Kidney Foundation and the American Society of Nephrology considers hundreds of treatises, hours of expert testimony, and patient feedback, saying they don’t want to cause further harm with the new recommendations. We have carefully considered these issues. The Panel unanimously agreed that the use of race in the assessment was not appropriate. Cynthia Delgado, an associate professor at the University of California, San Francisco and an associate professor of nephrology at the San Francisco VA Medical Center, said: Co-chair of the Task Force. “Patients can be reassured that they are fair about how they are evaluated.”

The Task Force leader said the internal deliberations could not be discussed, but the debates were sometimes controversial and said the group took longer than expected (one year) to reach an agreement. Some people were worried that the Task Force might take years to reach the decision, or postpone the decision by requesting more data.

Nephrologist President Paul Palevsky of NKF welcomed this decision as a major improvement towards health fairness in his field, but said more needs to be done. .. “If you include race in the GFR equation or other algorithms in medicine, you’ll get the wrong message. It reinforces this notion that skin color promotes biology, but it’s not. “He said. “But anyone who thinks this is the perfect solution is deceiving themselves to deal with racism and racism in the treatment of kidney disease.”

Vanessa Grubbs, Nephrologist in the San Francisco Bay Area Fighting the algorithm For more than a decade, “the fact that a national task force was needed to do this shows how well institutional racism is in medicine.”

“It’s great that they did this, but I don’t know the fact that it took years, and the number of meetings to discuss what we already know, but the races are essentially different. It shows how engrossed the country is in trying to prove, “Grabs said.

Palevsky recommends using the “refit” creatinine equation without race modification, eliminating the need for experimental equipment changes or upgrades, facilitating the exchange or pooling of software and, in some cases, experimental results. All you have to do is change the code used for. His foundation has prepared and educated lab leaders to process medical tests. “They have been very enthusiastic,” he said. “They are preparing for this.”

He said patients can check kidney function under a modified equation using: calculator On the NKF website. Many black patients whose kidney function may be underestimated using racial correction have moved themselves to the advanced stage of the disease or to the point recommended for transplantation. You may notice. He advised the patient to discuss their concerns with a doctor or nephrologist.

Marika L. Mendu is a nephrologist who served as the Task Force and Executive Medical Director of Brigam Health’s clinical practice, which abandoned racial correction of kidney diagnosis in June 2020 after protests by medical students and residents.Wondering how the removal of racial correction affects the patient, she helped her behavior Research Find out how approximately 2,000 black kidney patients in the Partners HealthCare system are reclassified.

Mendu finds that removing racial multipliers reclassifies one in three patients to more severe renal disease and many patients move to stage 4, the final stage before renal failure. Did. She also found 64 patients who were not previously eligible to meet the criteria for kidney transplantation. Her findings favored removing a race-based algorithm that she hadn’t previously questioned, she said.

“Honestly, I regarded this as the gospel. I didn’t even think about it. Mendu, who graduated from medical school in 2009, said,” Our generation, what we are taught. It shows that I’m not always questioning what I’m doing. I’m really proud of this generation of medical students who are questioning everything. “

Mendu said a medical student protest that began in the hospital around 2016 revisited the algorithm she had long taken for granted. “Many said,’This is based on good science. Don’t open this can of worms.” But when I saw it, it didn’t make sense to me. ” She said.

While happy with the new recommendations, Mendu said he, like other Task Force members, believes that the work needed to close health inequalities in his area has just begun. Her study showed that even if black patients were eligible for a transplant under a racially modified algorithm, they were rarely referred for a transplant. “My hope is that this is the beginning of a conversation to end these truly serious disparities,” she said.



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