Student advocacy prompts health system and lab to exclude race from kidney function screening
Thanks to the advocacy of a group of students at the Virginia Tech Carilion School of Medicine, a common laboratory test to measure kidney function has been updated and will no longer include what has been found to be an unsubstantiated adjustment for race introduced over 20 years ago.
Currently, many physicians and health systems use a formula called estimated glomerular filtration rate (eGFR) to measure a patient’s kidney function. The value is used to determine treatment plans, including diet changes, dialysis, and/or recommendation for a kidney transplant. The commonly used formula includes submitting if the patient is “Black” or “non-Black,” with Black patients’ scores being impacted.
The race-based adjustment was introduced in 1999 to correct an underestimation of the GFR in African Americans, and it was updated in 2009 to improve accuracy. However, adjusting the equation based upon the dichotomous definition of race (as Black or non-Black) ignores the large amount of genetic diversity present in patients who identify as Black and can lead to erroneous decisions affecting Black patients.
“You could have two patients – one Black woman and one white woman – with all the same stats, including serum creatinine levels. However, because one woman is charted as Black, her GFR estimation is higher. She is not recommended for transplant, and she will instead stay on dialysis for years and years. In this example, that's a social determinant of health,” said Kenneth Young, a second-year VTCSOM student.
As the science of medicine evolves, physicians are using more refined and better indicators to diagnose and treat their patients. In the instance of eGFR, race-based indicators, which may have been the norm 100, 50, even 20 years ago are being replaced with more accurate, evidence-based tests that rely on biological markers.
This past summer, Young, along with fellow second-year students Sarah Yosief and Chukwuemeka Uwakaneme, presented a list of items for the school to consider during a VTCSOM community-wide forum organized by Dean Lee Learman following the killings of Breonna Taylor, Ahmaud Arbery, and George Floyd.
“We came up with a statement that we shared in the school’s community forum with action items for change that we wanted to see from our administration to support students of color and support diversity and inclusion efforts,” Yosief said.
Among the items for consideration, the students proposed asking Carilion Clinic to take race out of its kidney function formula. The recommendation was based on evidence and noted a few other health systems like the University of Washington and Massachusetts General who recently made a similar change.
“As a member of the Black community, it’s of unique interest to me because race has no biological constraints. It is a social construct,” Young said. “As physicians, or a future physician in my case, formulas like this include race as a variable in clinical research as if it were measurable by underlying biology, but that’s not the case. Why are we using it for clinical measures?”
Other students reviewed the list of action items from Young, Yosief, and Uwakaneme. Second-year students Alyssa Dewyer and Madeline D’Aquila looked for a way to contribute.
“To us, this recommendation was extremely actionable and blatantly incorrect, as is including race in many medical algorithms and testing functions,” D’Aquila said. “You have to start somewhere and it was really a simple task of finding the right person within Carilion to help.”
“Our role in this was trying to figure out who needed to be presented with the information already gathered by our classmates,” Dewyer said. “This was just a small thing that we could do when our classmates are doing an incredible job leading. From all of their ideas, the least we can do is send emails out and get the ball rolling.”
They found success after floating the idea to Jon Sweet, professor of medicine at VTCSOM and interim chief of hospital medicine at Carilion. “Dr. Sweet contacted his colleagues in many different disciplines that this would affect and asked for their input, with a strong recommendation to support the change,” D’Aquila said.
Sweet was able to usher the recommended change through a couple of committees within the health system and laboratories for approval.
“By highlighting this issue, VTCSOM students did their best to address an important example of unintended systemic racism in medicine. All due credit goes to the students for advocating for change to make our healthcare systems better and more equitable,” Sweet said.
Technology services will implement the change through the computer system in the near future.
“Without our classmates’ initiative and perseverance in promptly putting forth action items and copious supporting research to our community, this eGFR change would not be possible,” D’Aquila said. “We cannot begin to imagine the immense amount of work, time, and energy they have dedicated to this cause while balancing schoolwork and the emotional toll of both pandemics [Black Lives Matter movement and COVID-19 health pandemic],” Dewyer added.
“This is where the next generation of physician scientists makes its mark,” said Learman. “Asking the difficult ‘why’ questions and pushing us to rethink common approaches. I’m proud of the work they are doing.”
This initiative is just one piece of the suggestions provided by Young, Yosief, and Uwakaneme. Following the community forum in early June, Learman formed the InclusiveVTCSOM Task Force to join these good suggestions with others and the development of additional initiatives to support the medical school’s work in diversity, equity, and inclusion. One area they will investigate includes looking at other ways race is used clinically and whether if its use is valid or harms certain communities.
Young, Yosief, and Uwakaneme hope to keep seeing progress moving forward in many arenas, but particularly in regards to how diversity, inclusion, and equity impact the practice of medicine. “Treating race as a proxy for genetics – biological rather than the social construct it is – actively harms Black, Brown, and Indigenous communities,” Young said. “Physicians have played a role in that, through practices that promote bias. Ultimately, racism doesn’t help anyone.”