Removal of eGFR Adjustment for Race in Ontario
References
1. Dryden O, Nnorom O. Time to dismantle systemic anti-black racism in medicine in Canada. CMAJ 2021 January 11; 193:E55-57. doi:10.1503/cmaj.201579
2. Levey AS, Stevens LA, Scmid CH et al A new equation to estimate glomerular filtration rate Ann Intern Med 2009; 150:604-12.
3. Tangri N, Stevens LA, Griffith J et al. A predictive model for progression of chronic kidney disease to kidney failure. JAMA 2011; 305:1553-9.
4. Multi-care Kidney Clinics. Ontario Renal Network. Available 2021 https://www.ontariorenalnetwork.ca/en/kidney-care-resources/clinical-tools/advanced-kidney-disease/multi-care-kidney-clinic-best-practices (accessed 2021, March 21)
5. Taji L, Thomas D, Oliver MJ et al. COVID-19 in patients undergoing long term dialysis in Ontario CMAJ 2021 Feb 22;193(8):E278-284 doi: 10.1503/cmaj.202601.
Dryden and Nnorom argue strongly that anti-Black racism remains pervasive in medicine1. This is particularly important in chronic kidney disease (CKD), where Black people have a higher risk of end-stage kidney disease (ESKD) than most other racial and ethnic groups. Estimated glomerular filtration rate (eGFR) is a commonly used measure of renal function and is calculated with a formula that includes an adjustment applied only to people of Black race2. This adjustment is based on limited evidence that Black people in the United States have greater muscle mass than their non-Black counterparts and it raises their eGFR by about 16%.
The Ontario Renal Network (ORN) manages province-wide services for people with CKD and ESKD. Trillium Gift of Life Network (TGLN) supports organ transplant activity in Ontario hospitals. Both are now part of Ontario Health, the agency that coordinates the province’s health care system.
eGFR measurements are used by ORN and TGLN as a trigger for action at three crucial referral timepoints. First, referral from primary care to nephrologists is recommended for people with eGFR less than 30 ml/min/1.73 m2. Second, referral to specialized multidisciplinary pre-ESKD clinics, called Multi-Care Kidney Clinics in Ontario, is recommended for people with high-risk CKD, defined by eGFR less than 15 ml/min/1.73m2 or estimated 2-year risk of ESKD of at least 10% based on a formula driven partly by eGFR3,4; of people attending these clinics 4.1% are reported to be Black, compared to 7.4% of people on dialysis, suggesting under-referral5. Third, referral of people with a potential living kidney donor for transplant evaluation is recommended if eGFR is under 15 ml/min/1.73m2 or estimated 2-year risk of ESKD is 25% or more. However, because the race adjustment inflates the eGFR in Black people, it delays referral at these three key transition points in kidney care.
In 2020 the ORN, after broad consultation which included its Patient and Family Advisory Council, decided to discontinue adjusting eGFR for race. TGLN has recently made the same decision. We believe that these decisions give Black people increased access to CKD care in Ontario. There are of course other systemic barriers to kidney care for many groups including indigenous and Black people that need to be addressed.