Interdisciplinary Collaboration Behind Elimination of Race-Based eGFR Adjustment
Being Black in Minnesota might mean having Liberian, Somali or multi-generational African American heritage.
“The Black population in Minnesota is very diverse,” said Kristina Krohn, MD, assistant professor in the University of Minnesota Medical School’s Department of Medicine and Division of General Internal Medicine. “These are people with very different genetic histories, family histories and exposure histories.”
But until recently, a medical calculation of kidney health, called estimated glomerular filtration rate (eGFR), used a race-based adjustment for Black patients, despite the great individual diversity that exists across all racial groups. This meant that there were different care guidelines for Black and non-Black patients, even though race is a social construct, not a biological one.
“Every time there’s a study, it’s important to understand how race is identified,” Dr. Krohn said. “Was race self-determined or physician-decided, and could somebody be biracial? There are all sorts of social and environmental factors that could also be at play, so it’s unclear what the patient’s race is really measuring.”
Impetus for System-wide Change
Glomerular filtration rate (GFR) is an important factor in determining drug dosage for patients with kidney disease, making referrals to a nephrologist or getting patients listed for a kidney transplant. Despite its importance, it’s difficult and costly to measure directly, and typically, doctors use serum creatinine to estimate GFR using an equation. Serum creatinine is affected by many things, including a patient’s diet, muscle mass, age, height, weight and fitness level. For 20 years, physicians have used creatinine plus sex, age and race (Black vs. non-Black) to calculate eGFR.
“If you have a Black patient and a white patient who are both 50 years old and they both have a creatinine of two, the Black patient is thought to have a higher GFR by a few points than the white patient,” said Adam Bregman, MD, assistant professor in the Department of Medicine’s Division of Nephrology and Hypertension. “That means that if the eGFR is a little bit less than 30, the white patient will be referred to nephrology earlier and might even be referred for transplant and be eligible for listing sooner.”
Karyn Baum, MD, professor in the Department of Medicine’s Division of General Internal Medicine and vice president for system clinical operations at M Health Fairview, asked Dr. Krohn to form a task force to explore the implications of race-based eGFR adjustments. Dr. Krohn sought out Mark Rosenberg, MD, vice dean for education and professor in the Division of Nephrology and Hypertension, Michelle Rheult, MD, associate professor in the Department of Pediatrics and director of the Division of Pediatric Nephrology, Samy Riad, MD, assistant professor in the Division of Nephrology and Hypertension, and an interdisciplinary team of faculty from laboratory medicine and pathology, internal medicine and family medicine to have race-based eGRF adjustments removed from the M Health Fairview system.
The task force also included experts in racism in medicine, including Brooke Cunningham, MD, PhD, assistant professor in the Department of Family Medicine and Community Health, Taj Mustapha, MD, assistant professor in the Division of General Internal Medicine, and Andrea Westby, MD, assistant professor in the Department of Family Medicine and Community Health. Medical School students were also eager for this change and were highly involved throughout the task force’s meetings.
“The task force worked with the Medical Education Reform Student Coalition (MERSC), a recently established student organization advocating for health equity in our preclinical curriculum and in the hospitals where we spend our clinical years,” said Zarin Rahman, a third-year Medical School student involved in the coalition’s work.
In the wake of the murder of George Floyd in May 2020, MERSC and student advocates wrote a letter to faculty with 11 action items to address systemic racism in medical education, which was signed by over 500 students, residents and faculty.
“It was empowering to see students and faculty acknowledge these issues and step up to the plate to help promote change,” said Christopher Johns, a third-year Medical School student. “One particular point was denouncing race-based medicine, which includes racial eGFR metrics. Dr. Krohn was pivotal in getting this work off the ground and provided space for medical students, like myself, to take part in these discussions.”
The decision to eliminate race-based eGFR adjustments also extended into medical education, including lectures to discuss the changes and student body discussions.
“From the beginning, there was a consensus that the way race was used didn’t make sense,” Dr. Krohn said. “We don’t know why researchers found differences in eGFR calculated from creatinine by race in the United States. We couldn’t find quality reasons why there should be a difference, and studies in other countries showed no difference in race.”
While M Health Fairview is certainly not the first in the nation to remove race-based eGFR adjustments, it’s a small step in the right direction.
“Access to transplant, as a whole, has been an issue for Black individuals in this country,” Dr. Bregman said. “For there to be one less roadblock to getting them on a waiting list earlier, at the same time as their white counterparts, is just one inch closer to promoting equity and access to the gift of life that they should be given.”
Eliminating Race in Medical Algorithms
Both Drs. Krohn and Bregman have been involved in educating their peers about racism in medicine and facilitated a discussion around eGFR within the Department of Surgery’s Diversity, Equity and Inclusion Journal Club.
“Racism has been inherent in healthcare for decades and it starts in medical education,” Dr. Bregman said. “Eliminating race-based eGFR adjustments can level the playing field and maybe provide a little bit more equity and access to care.”
While eGFR adjustments are just one example of inequity in healthcare, there are numerous race-based medical algorithms that may exacerbate disparities, including the Vaginal Birth after Cesarean algorithm and STONE score.
“The work done in eGFR is just one part of the 11 action points that student advocates would like to see changed within our curricula,” Johns said. “Although we are moving in the right direction, I can’t stress the importance of having faculty, such as Dr. Krohn, who took the initiative to coordinate and execute this system-wide change.”
At the request of Congress, the U.S. Agency for Healthcare Research and Quality is examining race within medical algorithms to determine how to reduce bias moving forward. While there is still work to be done, multidisciplinary collaboration helped shed light on a pervasive issue and catalyzed action to improve health equity for patients seeking care within the M Health Fairview system.
“In medicine, we often hone in on specific things in our field and don’t include other experts,” Dr. Krohn said. “Sociology affects medicine and health so much, and we really need to hear other voices and have interdisciplinary collaboration.”