Why we need to remove race from kidney function equations.

Elise:

In our first conversation, we acknowledged the recent debates over removing race from kidney function equations. You were a strong proponent of that action.

Based on comments we received, our readers want to more deeply understand the context around your position. Can you provide more color for why removing race is so important?

 

Dr. Norris:

APOL1 and eGFR have both been debated. And now race has been removed from the GFR formula. I can provide greater context for why that was done (and why it was a good idea), by explaining the formula’s origin story.

In the past, when clinical data was reviewed, there was “great swing” in the prevalence of kidney disease by racial group. Accordingly, many in the medical profession thought that understanding ‘race’ was critical. Kidney function formulas were developed, all using race as an important data point.

Another faction of the medical community said, we shouldn’t include race in any formula, it’s a social justice issue.

But is it really a social justice issue? Or is it a scientific justice issue?

To answer that question, we need to revisit what “race” is?

Race is a social construct that was created by some people 400+ years ago. They determined that someone either fell in one group or another. The goal was to capture and “name” groups of people.

Now, the sociologists say – race is a social variable – it can’t be used here because these formulas are for understanding biologic differences.

Others say that race has a place in the formulas because there are some genetic variants (APOL1 variant) that do have a racial meaning.

Who is right?

The simplest way to explain it is to say that race is an unordered variable, meaning that it does not have a direct correlation or relationship with health. Nor can race be measured consistently, like BMI, serum creatinine or urine albumin.

The color green is also an unordered variable. Let’s say that we had a group of people that shared ‘green’ as their favorite color. And they all had lower rates of kidney disease and mortality. Would it be right to assume that ‘green’ (as a ‘favorite color’) should be a factor that is fed into a kidney function formula?

This is why social variables cannot be used to determine risk formulas or equations. That would indicate that every person from any one group is the same, and equally different from those in another group. This, of course, is far from the truth.

We can’t, for example, assume that every African American has higher blood pressure than the general population. But we can say, that as an African American, you are a member of group that has higher blood pressure on average than other groups. Because of that, we should delve into more of a patient’s family history and see that patient more often. We can use the group level information to help recommend and prioritize care for this patient who may be at higher risk.

To answer the earlier question of whether or not to use race as a factor in an equation – no. But when thinking about whether or not this is a social justice issue, the answer is also no. This is actually a matter of scientific justice that has arisen during a social justice movement.