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Kidney Disease, Race, and GFR Estimation

Andrew S. Levey, Silvia M. Titan, Neil R. Powe, Josef Coresh and Lesley A. Inker
CJASN August 2020, 15 (8) 1203-1212; DOI: https://doi.org/10.2215/CJN.12791019
Andrew S. Levey
1Division of Nephrology, Tufts Medical Center, Boston, Massachusetts;
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Silvia M. Titan
1Division of Nephrology, Tufts Medical Center, Boston, Massachusetts;
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Neil R. Powe
2Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and University of California, San Francisco, California; and
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Josef Coresh
3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Lesley A. Inker
1Division of Nephrology, Tufts Medical Center, Boston, Massachusetts;
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Abstract

Assessment of GFR is central to clinical practice, research, and public health. Current Kidney Disease Improving Global Outcomes guidelines recommend measurement of serum creatinine to estimate GFR as the initial step in GFR evaluation. Serum creatinine is influenced by creatinine metabolism as well as GFR; hence, all equations to estimate GFR from serum creatinine include surrogates for muscle mass, such as age, sex, race, height, or weight. The guideline-recommended equation in adults (the 2009 Chronic Kidney Disease Epidemiology Collaboration creatinine equation) includes a term for race (specified as black versus nonblack), which improves the accuracy of GFR estimation by accounting for differences in non-GFR determinants of serum creatinine by race in the study populations used to develop the equation. In that study, blacks had a 16% higher average measured GFR compared with nonblacks with the same age, sex, and serum creatinine. The reasons for this difference are only partly understood, and the use of race in GFR estimation has limitations. Some have proposed eliminating the race coefficient, but this would induce a systematic underestimation of measured GFR in blacks, with potential unintended consequences at the individual and population levels. We propose a more cautious approach that maintains and improves accuracy of GFR estimates and avoids disadvantaging any racial group. We suggest full disclosure of use of race in GFR estimation, accommodation of those who decline to identify their race, and shared decision making between health care providers and patients. We also suggest mindful use of cystatin C as a confirmatory test as well as clearance measurements. It would be preferable to avoid specification of race in GFR estimation if there was a superior, evidence-based substitute. The goal of future research should be to develop more accurate methods for GFR estimation that do not require use of race or other demographic characteristics.

  • human
  • Cystatin C
  • creatinine
  • glomerular filtration rate
  • African Americans
  • Public Health
  • Decision Making
  • Shared
  • Body Weights and Measures
  • Renal Insufficiency
  • Chronic
  • Health Personnel
  • Demography
  • Kidney Function Tests
  • Copyright © 2020 by the American Society of Nephrology
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Clinical Journal of the American Society of Nephrology: 15 (8)
Clinical Journal of the American Society of Nephrology
Vol. 15, Issue 8
August 07, 2020
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Kidney Disease, Race, and GFR Estimation
Andrew S. Levey, Silvia M. Titan, Neil R. Powe, Josef Coresh, Lesley A. Inker
CJASN Aug 2020, 15 (8) 1203-1212; DOI: 10.2215/CJN.12791019

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Kidney Disease, Race, and GFR Estimation
Andrew S. Levey, Silvia M. Titan, Neil R. Powe, Josef Coresh, Lesley A. Inker
CJASN Aug 2020, 15 (8) 1203-1212; DOI: 10.2215/CJN.12791019
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  • Article
    • Abstract
    • Introduction
    • Current Recommendations and Limitations
    • GFR Estimating Equations
    • Race Coefficients in GFR Estimating Equations
    • Possible Causes for Race Differences in GFR Estimating Equations
    • Consequences of Eliminating Race from GFR Estimates Using Creatinine
    • Moving Forward
    • Disclosures
    • Funding
    • Acknowledgments
    • Supplemental Material
    • Footnotes
    • References
  • Figures & Data Supps
  • Info & Metrics
  • View PDF

More in this TOC Section

  • Integrating Patient Priorities with Science by Community Engagement in the Kidney Precision Medicine Project
  • Risk Factors for CKD Progression
  • NephroTalk Multimodal Conservative Care Curriculum for Nephrology Fellows
Show more Features

Cited By...

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  • The FDA Metformin Label Change and Racial and Sex Disparities in Metformin Prescription among Patients with CKD Injury
  • Precision in GFR Reporting: Lets Stop Playing the Race Card
  • Improving Equity in Medication Use through Better Kidney Function Measurement
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Keywords

  • human
  • Cystatin C
  • creatinine
  • glomerular filtration rate
  • African Americans
  • Public Health
  • Decision Making
  • Shared
  • Body Weights and Measures
  • Renal Insufficiency
  • Chronic
  • Health Personnel
  • Demography
  • Kidney Function Tests

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