Nephrology reckons with racism

By Brenna Miller | January 31, 2023

As Black History Month kicks off, we’re covering issues in health equity and ways that the medical field is turning inwards to address them. Up first: nephrology and kidney disease.

Racism and Kidney Transplants

Black Americans are nearly four times as likely as white Americans to develop kidney failure. Theories for why include higher rates of hypertension, diabetes, and diminished access to healthcare. In other words, it’s believed to be the long-term effects of weathering structural racism.

However, racism embedded within our medical system, through practices like race-based algorithms, also lead to disparities in treatment. An algorithm is a tool used by doctors to help them decide which treatment is right for patients based on their health conditions and other characteristics. The algorithm that determines when and where someone makes it onto the kidney transplant list is based on the assumption that Black Americans have higher baseline creatinine levels, making it appear that their kidneys are functioning better than they actually are. The algorithm is so flawed that the Organ Procurement and Transplantation Network board unanimously approved dropping it last summer. Some hospitals, like the University of Maryland Medical Center, are ending the use of the algorithm in efforts to improve health equity.

“For a number of years, some eGFR calculations have included a modifier for patients identified as Black. This practice has led to a systemic underestimation of kidney disease severity for many Black patients.“
-Organ Procurement and Transplantation Network, June 2022

Restoring Justice in Nephrology

Eliminating the faulty algorithm was step one in restoring equity and justice to kidney medicine. This past month, the Board of Directors of the Organ Procurement and Transplantation Network approved a waiting-time adjustment to retroactively fix previously calculated qualifying dates for Black kidney candidates. The board also set a one-year deadline, indicating their interest in immediate action.

For decades, an antiquated test overestimated kidney function in Black patients, masking the severity of disease & resulting in late diagnosis & delayed transplant referrals. Now, a waiting time adjustment for Black transplant candidates has been approved. https://t.co/NO0H3guZo5
— uché blackstock, md (@uche_blackstock) January 27, 2023

Dr. Uché Blackstock, who hosted our 2022 Shkreli Awards, shares the news of the waiting time adjustment

Keeping the momentum going

Outdated race-based algorithms like the one used for kidney transplants are still being used within medicine, impacting Black Americans across the country and diminishing the quality and timeliness of care they receive. In dermatology, the lack of dark-skinned representation in training and materials has resulted in missed diagnoses of conditions like melanoma. In cardiology, race as a factor in the Heart Failure Risk Score can affect recommendations for admission. Obstetrics recently abandoned race-based algorithms that resulted in Black women being told they were less likely to successfully deliver vaginally after previous cesarean sections.

New calculations will be needed to equitably rate risk and determine the best course of healthcare action. We need some way to incorporate the adverse health impacts of structural racism and the effects of shifting social determinants of health while maintaining equity for all. There are plenty of places to start.

This analysis of California’s state budget from 2007 to 2018 finds that to ensure the long-term health of the state, California needs to eliminate health care waste and direct the savings toward increased funding for programs that improve community conditions—like public education, public health, housing assistance, food assistance, and income support.