Did you know that for 20 years, doctors have been estimating how fast the kidneys are filtering the blood (the glomerular filtration rate or GFR) using an equation that includes a “Black race correction”? According to researchers who developed the equation, which is based upon a simple blood test called creatinine, Black people’s kidney function is roughly 20% higher than everyone else’s for a given creatinine result. So, when a 50-year-old Black man’s creatinine is 3.3, his estimated GFR is 24. But for a 50-year-old White, Asian, Indigenous or Hispanic man with the same creatinine of 3.3, the estimated GFR is 20. The White, Asian, Indigenous or Hispanic man is eligible to be added to the kidney transplant waiting list, while the Black man is not and probably won’t be for another 2 years. Time on the waiting list is one of the biggest determinants of when a patient gets a kidney from someone who has died. And since 13 people die every day waiting for a kidney transplant, every day inappropriately delaying a patient getting on that list is essentially gambling with their life.
https://www.niddk.nih.gov/health-information/professionals/advanced-search/explain-kidney-test-results
I first became aware of the rationale behind this “Black race correction” in 2007, on the first day of my nephrology fellowship. The race multiplier, it was explained, was a short-cut for muscle mass, because, according to the researchers who developed the equation, “Black people have higher muscle mass than White people.” My questioning the validity of this statement—(I mean, the suggestion that all Black people have higher muscle mass than everyone else, doesn’t even sound right)—was dismissed. It wasn’t until I was working on my book and came across sociologist Dorothy Robert’s 2016 TED talk, “The Problem with Race-Based Medicine,” in which she talked about GFR equations that I first felt validated. I was like, “See, I told y’all!” and went on to discuss it the following year as part of my own TED talk (ok it was a TEDx San Francisco salon on a much smaller stage, but still a pretty big damn deal).
Not that singling Black people out is new. It goes back to when the concept of “race” was invented and during American slavery when physicians set out to scientifically prove Black people are biologically distinct from and inferior to White people, mostly to help justify slavery. One of the most well-known and respected physicians at the time who engaged in such work was pro-slavery physician Samuel Cartwright. In his 1851 “Report on the Disease and Physical Peculiarities of the Negro Race,” he claimed, “The darkness of the Negro’s skin pervaded his membranes, muscles, tendons, fluids and secretions, including his blood and bile...” and like other physicians of the time, had “discovered” that the “…kidneys, and glands [of Black people] were larger and more active than Caucasian counterparts, and their skin threw off heat more rapidly than that of Whites.
But the issue of race correction in GFR estimation didn’t get widespread attention until the last couple of years when medical students started making noise. They were like, “Why are y’all teaching us how to be racist doctors?” After mostly student-led efforts at several institutions around the country that were notoriously met with resistance—especially from nephrologists, the National Kidney Foundation and the American Society of Nephrology convened a joint task force in August 2020 to provide guidance to the medical community about if it was ok to estimate—and, therefore, base clinical decisions upon—Black people’s kidney function differently than everyone else’s.
Given that the task force was led by some of the most outspoken critics of removing the race correction, I braced myself for the bullshit. But, to my surprise, last week—after eight months of debates, petitions, news articles, medical journal publications, oral testimony, written testimony and tweets from thousands of medical students and physicians around the country— the task force released a statement of their decision: medical institutions should stop using GFR equations that called for a “race correction.”
Advocates have been rejoicing in the win, but I am having a bit of trouble reconciling the fact that:
· it took 8 months for the task force to make a no-brainer decision
· it took nearly 20 years for the issue to be addressed
· Black race was included in the equation in the first damn place
But especially that:
· I could count on one hand the number of nephrologists that supported removing race correction from the start— even though a vetted and better alternative already existed—but I have yet to hear nary a critic acknowledge that they were on the wrong side of history.
I come from a long line of Grubbs’ who don’t let go of shit until a person displays the appropriate contrition. So, this will not never, ever be forgotten without it.
But more importantly, removing race from GFR estimation was supposed to be the “low hanging fruit” in the quest to divorce all medical specialties from the notion that race has biological meaning beyond superficial groupings around skin color, hair texture, and facial features. That it has instead required extra-tall ladders, is not only revealing of how some folks’ clinging to the status quo looks to be much more about power, ego, and legacy than getting the science right and treating patients equitably; but also of how deeply wedded we are to continuing the lie that Black people are inherently different than all other humans, in spite of all evidence to the contrary. At the very least, I hope the fuckery displayed here will serve as a cautionary tale for the next specialty we advocates for eliminating race-based medicine approach.
Stay tuned.