From Equation to Equity: How Health Systems Are Implementing Race-Free eGFR

In this National Kidney Foundation (NKF) panel, moderator Andrew Bzowyckyj, PharmD, BCPS, CDCES, senior scientific director and learning consultant at NKF, talks with 3 clinicians from different practice settings:

• Michelle Estrella, MD, a nephrologist, professor of medicine at the University of California, San Francisco, and renal section chief at the San Francisco VA Medical Center;
• Venita Schandorf, DNP, ARNP, a board-certified family nurse practitioner at MultiCare Covington Family Practice in Washington State’s Puget Sound area;
• and Mark Loafman, MD, MPH, a family medicine physician and systems chair for family and community medicine at Cook County Health in Chicago, Illinois.

The 2021 CKD-EPI equation removed race as a variable, but health systems have adopted it unevenly. The panelists discuss the structural and operational barriers they ran into while putting it in place.

Estrella explained her institution adopted the race-free equations readily. The harder work was explaining the change to primary care and nephrology colleagues and preparing them to talk with patients, since even small shifts in reported kidney function can make patients who track their trends anxious. Her institution chose to report all 3 race-free equations: Creatinine only, cystatin C only, and combined creatinine–cystatin C. That required educating clinicians and getting buy-in from laboratory partners.

At MultiCare, Schandorf took a step-by-step approach after the NKF–American Society of Nephrology (ASN) Joint Task Force recommendations came out. She worked first with the system’s diversity, equity, and inclusion committee and laboratory sciences, then got agreement from nephrology, endocrinology, lab leadership, and emergency medicine, and finally went to several medical executive committees. MultiCare adopted the CKD-EPI 2021 creatinine equation and lets clinicians add cystatin C at their discretion. Pharmacy leadership initially pushed back over concerns about medication dosing.

At Cook County Health, where most patients are Black or Latino, Loafman said nobody opposed the change because it was clearly correcting a racial injustice. Still, it led to some difficult conversations with patients who were newly told they had chronic kidney disease. His team presented the change as a correction for patients who had previously been underrepresented. Adding cystatin C testing meant weighing costs, because 20% to 30% of the system’s patients pay for their own care. On health systems whose point-of-care analyzers can’t easily be updated from the older equations, Loafman and Schandorf recommended treating point-of-care results as a workaround. They advised sending samples to the lab for formal serum testing at least once a year and adding cystatin C when it fits the patient’s clinical factors.

Learn more about the National Kidney Foundation at kidney.org and at this link.