A key driver in the work of many faculty, staff, and trainees at UAB is to eradicate health disparities in the Southeast. A major component of structural racism in the U.S. is the racial disparity in health care. Such disparities are caused by intersecting factors, including socioeconomic barriers and historical exclusion from many opportunities and resources, such as preventive care and processes of disease testing.
In the Heersink School of Medicine, we are consistently taking inventory of our research environments and clinical practices to ensure barriers to equitable care are removed.
A factor contributing to health disparities
Across the country, many specialties have used race as a variable in clinical decision-making, particularly in assessing organ function. An area where the use of race has drawn considerable attention is in the assessment of kidney function.
In tandem with institutions across the country, Heersink and UAB Medicine are working to reduce kidney health disparities by adopting a new formula to assess kidney function—one that no longer includes race as a variable—effective Thursday, Sept. 1.
Who carries the burden of kidney disease?
The decision to adopt a race-neutral test will have a ripple effect across the country. The tremendous burden of kidney disease in the U.S. currently impacts an estimated 37 million adults, or 15% of the population. This astounding rate of chronic kidney disease (CKD) is carried by a disproportionate number of underserved minorities.
Black/African American individuals have much higher rates of progressive CKD and End Stage Kidney Disease than non-Black individuals.
History of variables and calculations
Over the past few decades, several variables have been used to estimate kidney function called estimated glomerular filtration rate (eGFR), including age, gender, and race. The most widely used formula, released in 1999, considered over 20 variables but found that age, gender, and race best approximated GFR.
However, the use of race has now been cited as a potential contributor to kidney-related disparities, including delayed diagnosis of CKD and a much lower referral for kidney transplantation in populations of color.
Historically, eGFR formulas that used race and creatinine, a breakdown product from muscle and muscle metabolism, calculated kidney function to be higher in Black/African American individuals.
“Because of that, there were delays in getting Black individuals seen by nephrologists and delays in getting them referred for transplantation,” explained Claretha Lyas, M.D., assistant professor in the Division of Nephrology.
These delays likely contribute to the racial disparity in kidney health. "Black individuals have a greater likelihood of developing progressively worsening kidney function and go on to need dialysis, and are less likely to get a kidney transplant even when on dialysis,” she explained. “One of the ideas, then, is if race is removed, the disparity in referrals and transplantation might be mitigated."
New guidelines increase equity
In September 2021, a national task force, made up of experts from the National Kidney Foundation and the American Society of Nephrology, recommended that all laboratories and institutions adopt a race-neutral formula—a more equitable way to assess kidney function. As of July 2022, the Organ Procurement Transplant Network, which provides policies to transplant centers, has made the same recommendation.
The race-neutral method of eGFR does not disproportionately affect any single group of individuals and is designed to provide greater equity in managing kidney disease.
“This is being done out of equity to help more African Americans get early access to nephrology care and transplantation services. This will decrease that disparity, as well as the numbers who are on dialysis,” Lyas said. “We want to do things that decrease disparities and increase equity.”
Lyas said that medical students and trainees interested in nephrology were a significant driver in seeing this change happen quickly at UAB.
"Part of the push to change this goes back to 2020 when there was so much social media outcry from medical students and trainees, which got the attention of the nephrology community to look at this and make a change."
Changes at UAB
As one of the largest providers of kidney care and kidney transplantation, UAB is committed to addressing disparities and will transition to the race-neutral method of assessing kidney function.
"This will be a tremendous step forward in managing all patients with kidney disease and will help populations of color receive more equitable care," said Lyas. For UAB specifically, this change will impact Alabamians and neighbors in all regions of the Deep South.
"As a top five kidney transplant center, to say we want to have a more equitable way of providing transplant services speaks volumes and shows that UAB is committed to addressing disparities."
Timelines for each institution across the country vary, but UAB is in alignment with national recommendations and peer institutions.
Efforts like this one help create a more equitable health landscape.