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Review
. 2020 Aug 7;15(8):1203-1212.
doi: 10.2215/CJN.12791019. Epub 2020 May 11.

Kidney Disease, Race, and GFR Estimation

Andrew S Levey  1 , Silvia M Titan  1 , Neil R Powe  2 , Josef Coresh  3 , Lesley A Inker  1
Affiliations
Review

Kidney Disease, Race, and GFR Estimation

Andrew S Levey et al. Clin J Am Soc Nephrol. .

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.

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

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Figures

Figure 1.
Figure 1.
Clinical decisions can be affected by accuracy of GFR assessment among blacks. Data from 2601 black participants from the Chronic Kidney Disease Epidemiology Collaboration development and internal validation sample were used in this plot (28). We computed eGFR from serum creatinine (eGFRcr) values with (blue) and without (red) the application of the black coefficient and removed values below and above the 2.5 and 97.5 percentiles of these distributions, leaving 2463 participants for the analysis. The model plotted represents generalized additive models for eGFRcr (milliliters per minute per 1.73 m2) on the difference between eGFRcr and measured GFR (mGFR) (milliliters per minute per 1.73 m2). We truncated the horizontal axis to eGFRcr values from 15 to 105 ml/min per 1.73 m2, excluding 190 participants from the plot. The colored areas along the line represent 95% confidence intervals of the estimate. Upper boxes represent hypothetical situations of eGFRcr values for the same mGFR, with numbers in blue representing the eGFRcr with the black coefficient and the numbers in red representing the eGFRcr without the black coefficient. AA, black; BSP, bisphosphonate; SGLT2, sodium-glucose transport protein 2. Modified from ref. , with permission.
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