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, Mukta Baweja, Deidra C. Crews, Nwamaka D. Eneanya, Crystal A. Gadegbeku, Lesley A. Inker, Mallika L. Mendu, W. Greg Miller, Marva M. Moxey-Mims, Glenda V. Roberts, Wendy L. St. Peter, Curtis Warfield, Neil R. Powe

Research output: Contribution to journalReview articlepeer-review

50 Scopus citations

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 (eGFRcys) and eGFR creatinine–cystatin C (eGFRcr-cys_R) 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.

Original languageEnglish (US)
Pages (from-to)268-288.e1
JournalAmerican Journal of Kidney Diseases
Volume79
Issue number2
DOIs
StatePublished - Feb 2022

Bibliographical note

Funding Information:
Cynthia Delgado, MD, Mukta Baweja, MD, Deidra C. Crews, MD, ScM, Nwamaka D. Eneanya, MD, MPH, Crystal A. Gadegbeku, MD, Lesley A. Inker, MD, MS, Mallika L. Mendu, MD, MBA, W. Greg Miller, PhD, Marva M. Moxey-Mims, MD, Glenda V. Roberts, BSc, Wendy L. St. Peter, PharmD, Curtis Warfield, MS, and Neil R. Powe, MD, MPH, MBA, Drs Delgado and Powe are cochairs of the NKF-ASN Task Force. No funding was provided to the Task Force members. The ASN and NKF provided administrative assistance for scheduling and convening of Task Force members. CD reports that her contribution is the result of work supported with the resources and the use of facilities at the San Francisco Veterans Affairs Medical Center. MB reports having other interests in/relationships with Physicians for Human Rights and Young Center for Immigrant Children's Rights. DCC reports having other interests in/relationships with American Board of Internal Medicine (via the nephrology board), American College of Physicians (via the Council of Subspecialist Societies), and NKF of Maryland/Delaware (via the board of directors); serving as cochair of Bayer HealthCare Pharmaceuticals Inc. on the patient and physician advisory board steering committee for the Disparities in Chronic Kidney Disease Project, in the advisory group for Health Equity Collaborative, as associate editor of Kidney360, and on advisory boards for Optum Labs and Partner Research for Equitable System Transformation after COVID-19 (PRESTAC); serving on the editorial boards for CJASN, JASN, and Journal of Renal Nutrition; receiving research funding from Somatus Inc.; and having consultancy agreements with Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation. NDE reports having consultancy agreements with DaVita and Somatus, and serving as a scientific advisor for, or member of, Healthcare: The Journal of Delivery Science and Innovation and Kidney Medicine. CAG reports serving as a scientific advisor for, or member of, the ASN Council. LAI reports serving as a scientific advisor for, or member of, Alport Foundation, Diametrix, and Goldfinch; having other interests in/relationships with ASN (as a member), National Kidney Disease Education Program (as a member), and NKF (as a member); having consultancy agreements with Diamtrix and Tricida; and receiving research funding from NIH, NKF, Omeros, Reata, and Retrophin. MLM reports having ownership interest in, and serving as a scientific advisor for, or member of, RubiconMD. WGM reports having consultancy agreements with Baebies; and receiving honoraria from, and serving as a scientific advisor for/member of, Clinical Chemistry. MMM-M reports serving as an associate editor for JASN, on the scientific advisory boards for NephCure International and NKF, and on the editorial board for Pediatric Nephrology; and receiving research funding from Rockwell Medical and Travere. GVR reports receiving research funding from Ambulatory Kidney to Improve Vitality Human Factors Project funded by the Veterans Administration, Center for Disease Innovation, and Kidney Precision Medicine Project (KPMP) funded by National Institute of Diabetes and Digestive and Kidney Diseases; serving on a speakers bureau for American Association of Kidney Patients (AAKP); having other interests in/relationships with AAKP, APOLLO Recruitment and Dissemination Committees, ASN COVID-19 Response Team and Transplant Subcommittee, ASN Nephrologists Transforming Dialysis Safety Quality, Assessment, Improvement and Education Work Group, Can-SOLVE CKD International Research Advisory Committee, International Nephrology Society Patient Group, Kidney Health Initiative (KHI) Patient Family Partnership Council, NKF Ambassador, and NKF Kidney Advocacy Committee Diversity Workgroup; receiving honoraria from serving on the APOL1 Community Advisory Board, APOLLO Community Advisory Committee, Critical Path Institute (C-Path) Patient AKI, KPMP Patient Advisor for Community Advisory Committee, and Northwest Renal Dietitians Annual Conference; serving as a scientific advisor for, or member of, APOLLO Community Advisory Board, ASN COVID-19 Response Team, ASN COVID-19 Transplant Subcommittee, Can-SOLVE CKD International Research Advisory Committee, Center for Dialysis Innovation Patient Advisory Board, C-Path Patient Engagement Committee, Home Dialyzors United Advisory Committee, KHI Patient and Family Partnership Council, and Kidney Research Institutes Patient Advisory Committee; having consultancy agreements with C-Path AKI Project and Options Unlimited International LLC (information technology management consulting firm); and having an ownership interest in Microsoft (via stock) and Options Unlimited International. WLSP reports receiving honoraria from American Nephrology Nursing Association, Integritas Group, Letters and Sciences, and OptumLabs; serving on the Centers for Medicare and Medicaid Services Technical Expert Panel on Development of a Quality Measure Assessing Delay in Progression of CKD, and Technical Expert Panel for Quality Insights Kidney Care Pilot Project; serving as a scientific advisory board member for the NKF; and having consultancy agreements with Total Renal Care Inc. CW reports having other interests in/relationships with Home Dialyzors United (via the board of directors) and NKF Indiana (via the board of directors). NRP reports serving as an associate editor for JASN; and receiving honoraria from, and serving as a scientific advisor for/member of, Patient-Centered Outcomes Research Institute, Robert Wood Johnson Foundation, University of Washington, Vanderbilt University, and Yale University. We thank Ms Nilka R?os Burrows from the Division of Diabetes Translation, Centers for Disease Control and Prevention for information and discussion on the potential implications of eGFR approaches for population surveillance and tracking of kidney disease. The authors thank all who testified and provided expertise and evidence at the Task Force sessions and forums, and Mr Killian Gause and Ms Riley Hoffman for assistance during the sessions. The authors also thank Dr Flor Alvarado and Dr Abinet Aklilu for assistance in compiling information on diversity in equation development, and Sara Couture and Shiyuan Miao for their assistance with the construction of figures and tables. The authors thank the leadership of the NKF and ASN for their support of the Task Force and the entire health care community for their patience in identifying an evidence-based, unifying path forward for estimation of GFR. This report and its recommendations concerning the inclusion of race in the estimation of GFR in the United States are advisory only. They are not clinical guidelines, do not define a standard of care, and do not constitute the practice of medicine. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every health care professional reviewing the recommendations in the report is responsible for evaluating the appropriateness of applying them to any particular clinical situation. Received July 24, 2021, at JASN and AJKD. Evaluated by 3 external peer reviewers, with direct editorial input from a JASN Deputy Editor and an AJKD Acting Editor-in-Chief. Accepted in revised form by both journals September 5, 2021. The involvement of an Acting Editor-in-Chief was to comply with AJKD's procedures for potential conflicts of interest for editors, described in the Information for Authors & Journal Policies. Because Drs Moxey-Mims and Powe are Associate Editors of JASN, they were not involved in the peer-review process for this manuscript; another editor oversaw the peer-review and decision making process for this manuscript. Copyright ? 2021 by National Kidney Foundation, Inc and the American Society of Nephrology. All rights reserved. This article is being published concurrently in the Journal of the American Society of Nephrology and American Journal of Kidney Diseases. The articles are identical except for stylistic changes in keeping with each journal's style. Either of these versions may be used in citing this article. Published online by Elsevier September 23, 2021 with doi 10.1053/j.ajkd.2021.08.003.

Funding Information:
CD reports that her contribution is the result of work supported with the resources and the use of facilities at the San Francisco Veterans Affairs Medical Center. MB reports having other interests in/relationships with Physicians for Human Rights and Young Center for Immigrant Children’s Rights. DCC reports having other interests in/relationships with American Board of Internal Medicine (via the nephrology board), American College of Physicians (via the Council of Subspecialist Societies), and NKF of Maryland/Delaware (via the board of directors); serving as cochair of Bayer HealthCare Pharmaceuticals Inc., on the patient and physician advisory board steering committee for the Disparities in Chronic Kidney Disease Project, in the advisory group for Health Equity Collaborative, as associate editor of Kidney360, and on advisory boards for Optum Labs and Partner Research for Equitable System Transformation after COVID-19 (PRESTAC); serving on the editorial boards for CJASN, JASN, and Journal of Renal Nutrition; receiving research funding from Somatus Inc.; and having consultancy agreements with Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation. NDE reports having consultancy agreements with DaVita and Somatus, and serving as a scientific advisor for, or member of, Healthcare: The Journal of Delivery Science and Innovation and Kidney Medicine. CAG reports serving as a scientific advisor for, or member of, the ASN Council. LAI reports serving as a scientific advisor for, or member of, Alport Foundation, Diametrix, and Goldfinch; having other interests in/relationships with ASN (as a member), National Kidney Disease Education Program (as a member), and NKF (as a member); having consultancy agreements with Diamtrix and Tricida; and receiving research funding from NIH, NKF, Omeros, Reata, and Retrophin. MLM reports having ownership interest in, and serving as a scientific advisor for, or member of, RubiconMD. WGM reports having consultancy agreements with Baebies; and receiving honoraria from, and serving as a scientific advisor for/member of, Clinical Chemistry. MMM-M reports serving as an associate editor for JASN, on the scientific advisory boards for NephCure International and NKF, and on the editorial board for Pediatric Nephrology; and receiving research funding from Rockwell Medical and Travere. GVR reports receiving research funding from Ambulatory Kidney to Improve Vitality Human Factors Project funded by the Veterans Administration, Center for Disease Innovation, and Kidney Precision Medicine Project (KPMP) funded by National Institute of Diabetes and Digestive and Kidney Diseases; serving on a speakers bureau for American Association of Kidney Patients (AAKP); having other interests in/relationships with AAKP, APOLLO Recruitment and Dissemination Committees, ASN COVID-19 Response Team and Transplant Subcommittee, ASN Nephrologists Transforming Dialysis Safety Quality, Assessment, Improvement and Education Work Group, Can-SOLVE CKD International Research Advisory Committee, International Nephrology Society Patient Group, Kidney Health Initiative (KHI) Patient Family Partnership Council, NKF Ambassador, and NKF Kidney Advocacy Committee Diversity Workgroup; receiving honoraria from serving on the APOL1 Community Advisory Board, APOLLO Community Advisory Committee, Critical Path Institute (C-Path) Patient AKI, KPMP Patient Advisor for Community Advisory Committee, and Northwest Renal Dietitians Annual Conference; serving as a scientific advisor for, or member of, APOLLO Community Advisory Board, ASN COVID-19 Response Team, ASN COVID-19 Transplant Subcommittee, Can-SOLVE CKD International Research Advisory Committee, Center for Dialysis Innovation Patient Advisory Board, C-Path Patient Engagement Committee, Home Dialyzors United Advisory Committee, KHI Patient and Family Partnership Council, and Kidney Research Institutes Patient Advisory Committee; having consultancy agreements with C-Path AKI Project and Options Unlimited International LLC (information technology management consulting firm); and having an ownership interest in Microsoft (via stock) and Options Unlimited International. WLSP reports receiving honoraria from American Nephrology Nursing Association, Integritas Group, Letters and Sciences, and OptumLabs; serving on the Centers for Medicare and Medicaid Services Technical Expert Panel on Development of a Quality Measure Assessing Delay in Progression of CKD, and Technical Expert Panel for Quality Insights Kidney Care Pilot Project; serving as a scientific advisory board member for the NKF; and having consultancy agreements with Total Renal Care Inc. CW reports having other interests in/relationships with Home Dialyzors United (via the board of directors) and NKF Indiana (via the board of directors). NRP reports serving as an associate editor for JASN; and receiving honoraria from, and serving as a scientific advisor for/member of, Patient-Centered Outcomes Research Institute, Robert Wood Johnson Foundation, University of Washington, Vanderbilt University, and Yale University.

Publisher Copyright:
© 2021 National Kidney Foundation, Inc and the American Society of Nephrology

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

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