Progress on kidney health equity will be a focus at NKF meeting
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A national reckoning with racism in 2020, amplified by COVID-19 and stark economic and structural inequities, galvanized the nephrology community to address the role of racism in producing multi-decade kidney health disparities.
Despite decades of intervention, kidney disease continues to be emblematic of some of the most strikingly stark health inequalities, including that Black individuals in the United States have had a twofold to fourfold higher incidence of end-stage kidney disease vs. white individuals. The pursuit of true kidney health equity will require thoughtful attention to the multifaceted ways in which racially structured inequities in individuals’ social contexts and experiences contribute to disparities, as well as nuanced approaches to understanding risk in the context of race and racism.
I will be presenting on the topic of race-conscious equity at the upcoming National Kidney Foundation Annual Meeting serving California on Sept. 30. For more information visit https://tinyurl.com/NKFsym54.
Multiple contributors
Although transformative discoveries, including APOl1 high-risk polymorphisms, have been critical to disentangling the multifactorial contributors to racial inequalities, genetic explanations alone have not fully elucidated or explained the disproportionate burden of advanced kidney disease among underrepresented groups.
Further, because race is a sociopolitical and not biologic/genetic variable, race cannot be equated with genetic risk. The root causes of this and other racial inequalities in kidney disease are complex, and the role of structural racism in generating these disparities warrants further attention. Structural or institutionalized racism refers to the ways in which “racialized differential access to resources, opportunities, and services are codified in law, policy, practices and norms, such that a single identifiable perpetrator is often not visible.”
This form of inequity may manifest across a range of health-influencing domains (eg, housing; economic opportunity, including jobs and education; and via disproportionate exposure to kidney-harming environmental factors, including medications/pollutants).
Structural racism requires urgent attention because of its often-modifiable influence across the spectrum of kidney disease. For instance, patients of underrepresented groups experience less pre-dialysis care in part because of racial residential segregation/ disinvestment in minoritized communities, resulting in delayed and disproportionately limited access to nephrology providers.
Recognizing socio-structural, often racialized barriers to kidney health promotion is essential to addressing stark inequities, including in access to transplantation whereby bias in the process of evaluation/implementation of criteria for placing patients on the transplant waitlist may also influence transplant equity.
Race essentialism
In addition to addressing structural barriers to kidney health equity, understanding race essentialism and its influence in clinical algorithms is essential to achieving kidney health equity. Race essentialism describes a belief that race captures biologic distinctions, and it has allowed for the categorization of large biologically/genetically heterogenous groups of individuals as the same. The evolution of eGFR science has been influenced significantly by the sociopolitical construct of race, whereby different eGFR algorithms were used for estimating the kidney functions of Black individuals compared with white individuals and individuals from other racial groups.
The 2021 creatinine eGFR estimates GFR based on serum creatinine. Equations using creatinine and/or serum cystatin C without a race coefficient/correction factor offer an important opportunity to advance kidney health equity and precision in kidney function estimation, while avoiding the faulty paradigm of race essentialism.
Understanding the history of how this construct of race infiltrated the science of GFR estimation is also essential to fully appreciate the history and future of kidney function estimation, as well as future targets for addressing racialized practices in including clinical algorithms (eg, Kidney Donor Profile Index) and other tools used to determine risk and diagnostic reasoning, which continue to embed race coefficients without clear considerations of equity. The significant lessons learned from interrogation of race-based clinical algorithms in kidney function estimation have allowed us to better pursue an equity-focused, race-conscious paradigm, and by doing so, renewed hope for a more equity-oriented, scientifically rigorous future.
Racial inequities
The last 2 decades enabled the nephrology community an opportunity to contextualize long-standing racial inequities in the burden of kidney disease, and more specifically to debunk the fallacy that race equals genetics/risk. As we pursue equitable outcomes for all the patients we serve, we must embed an equity lens in all that we do, thus reframing racial disparities within the context of racism-mediated structural inequities patients may be experiencing (eg, housing and transportation/food security challenges).
This contextualization of patient experiences, including adherence, is essential and a key component of embedding structural competency into our clinical care and practice. Moreover, the nephrology community has paved a path to challenge race essentialism as a threat to rigorous science. As demonstrated by the careful interrogation of the race coefficient in kidney function estimation, it is imperative that we continue our efforts to distinguish between race, racism, genetics and ancestry in our clinical care and research, carefully defining each term and its intent/reason for inclusion. Through sustained efforts to incorporate race-conscious anti-racist frameworks into our science and clinical practice, we can better elucidate how social and genetic factors may interact to manifest as differential kidney disease risk and outcomes, while tackling critical socio-contextual barriers to kidney health equity.
- For more information:
- Dinushika Mohottige, MD, is a nephrologist and assistant professor in the division of nephrology at Duke University Hospitals.
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