Health inequities and the inappropriate use of race in nephrology

Abstract

Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race - a socio-political construct that mediates the effect of structural racism - as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.

Fig. 1. The effects of racism on kidney pathophysiology.

Racial and ethnic differences in health conditions and/or outcomes are mainly driven by the effects of structural racism and racial discrimination. Structural racism not only creates debilitating social inequities but also induces biological alterations that contribute to disease development. However, the impact of these important factors varies among individuals of the same racial group and is not reliably captured by race alone. eGFR, estimated glomerular filtration rate; RAAS, renin–angiotensin–aldosterone system.

Fig. 2. Social determinants of creatinine metabolism.

Kidney function is commonly assessed using estimated glomerular filtration rate (eGFR) equations that are derived from blood creatinine levels. However, the generation and secretion of creatinine, and therefore, creatinine-based eGFR, can be influenced by a multitude of social factors that are highly variable among all individuals, including those of Black race.