Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Health inequities and the inappropriate use of race in nephrology

Nature Reviews Nephrology volume 18, pages 84–94 (2022)Cite this article

Subjects

Abstract

Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race — a socio-political construct that mediates the effect of structural racism — as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.

Key points

  • Race and ethnicity are socio-political constructs that are inextricably tied to health outcomes for individuals from racial and ethnic minority groups worldwide.

  • Historically, science has developed and relied on racial frames to artificially organize people into presumed homogeneous and genetically distinct racial groups, to suggest that inherent biological differences exist between the groups.

  • The use of race coefficients in estimated glomerular filtration rate equations reinforces flawed assumptions of race essentialism and potentially perpetuates health inequities for Black individuals with kidney disease.

  • Valid and race-free methods of kidney function estimation should be used to promote high-quality science, guide clinical management decisions and decrease racial bias.

Access through your institution
Buy or subscribe

This is a preview of subscription content, access via your institution

Access options

Access through your institution

Buy this article

  • Purchase on SpringerLink
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: The effects of racism on kidney pathophysiology.
Fig. 2: Social determinants of creatinine metabolism.

Similar content being viewed by others

References

  1. Jones, C. P. Confronting institutionalized racism. Phylon 50, 7–22 (2003).

    Google Scholar 

  2. Williams, D. R. & Mohammed, S. A. Racism and health I: pathways and scientific evidence. Am. Behav. Sci. 57, 1152–1173 (2013).

    Google Scholar 

  3. Williams, D. R. & Mohammed, S. A. Racism and health II: a needed research agenda for effective interventions. Am. Behav. Sci. 57, 1200–1226 (2013).

    Google Scholar 

  4. Gee, G. C. & Ford, C. L. Structural racism and health inequities: old issues, new directions. Du. Bois Rev. 8, 115–132 (2011).

    PubMed  PubMed Central  Google Scholar 

  5. Wilkinson, E., Brettle, A., Waqar, M. & Randhawa, G. Inequalities and outcomes: end stage kidney disease in ethnic minorities. BMC Nephrol. 20, 234 (2019).

    PubMed  PubMed Central  Google Scholar 

  6. Garcia-Garcia, G. & Jha, V. CKD in disadvantaged populations. Kidney Int. 87, 251–253 (2015).

    PubMed  Google Scholar 

  7. Moosa, M. R. & Norris, K. C. Sustainable social development: tackling poverty to achieve kidney health equity. Nat. Rev. Nephrol. 17, 3–4 (2021).

    CAS  PubMed  Google Scholar 

  8. Ogedegbe, G. et al. Assessment of racial/ethnic disparities in hospitalization and mortality in patients with COVID-19 in New York City. JAMA Netw. Open 3, e2026881 (2020).

    PubMed  PubMed Central  Google Scholar 

  9. Krishnan, L., Ogunwole, S. M. & Cooper, L. A. Historical insights on coronavirus disease 2019 (COVID-19), the 1918 influenza pandemic, and racial disparities: illuminating a path forward. Ann. Intern. Med. 173, 474–481 (2020).

    PubMed  Google Scholar 

  10. World Health Organization. WHO’s Contribution to the World Conference against Racism, Racial Discrimination, Xenophobia and Related Intolerance: Health and freedom from discrimination (2001).

  11. Crews, D. C. & Wesson, D. E. Persistent bias: a threat to diversity among health care leaders. Clin. J. Am. Soc. Nephrol. 13, 1757–1759 (2018).

    PubMed  PubMed Central  Google Scholar 

  12. Norris, K. C. et al. Hemodialysis disparities in African Americans: the deeply integrated concept of race in the social fabric of our society. Semin. Dialysis 30, 213–223 (2017).

    Google Scholar 

  13. Crews, D. C., Liu, Y. & Boulware, L. E. Disparities in the burden, outcomes, and care of chronic kidney disease. Curr. Opin. Nephrol. Hypertens. 23, 298–305 (2014).

    PubMed  PubMed Central  Google Scholar 

  14. Crews, D. C., Bello, A. K. & Saadi, G. Burden, access, and disparities in kidney disease. Kidney Int. 95, 242–248 (2019).

    PubMed  Google Scholar 

  15. Nicholas, S. B., Kalantar-Zadeh, K. & Norris, K. C. Racial disparities in kidney disease outcomes. Semin. Nephrol. 33, 409–415 (2013).

    PubMed  PubMed Central  Google Scholar 

  16. National Kidney Foundation. Statement on racial violence and disparities in America. kidney.org https://www.kidney.org/news/statement-racial-violence-and-disparities-america (2020).

  17. American Society of Nephrology. ASN statement against racism. asn-online.org https://www.asn-online.org/news/item.aspx?ID=173 (2020).

  18. Mohottige, D., Diamantidis, C. J., Norris, K. C. & Boulware, L. E. Time to repair the effects of racism on kidney health inequity. Am. J. Kidney Dis. https://doi.org/10.1053/j.ajkd.2021.01.010 (2021).

  19. Csete, J. et al. Public health and international drug policy. Lancet 387, 1427–1480 (2016).

    PubMed  PubMed Central  Google Scholar 

  20. Banys, P. Mitigation of marijuana-related legal harms to youth in California. J. Psychoact. Drugs 48, 11–20 (2016).

    Google Scholar 

  21. Chandra, A., Frakes, M. & Malani, A. Challenges to reducing discrimination and health inequity through existing civil rights laws. Health Aff. 36, 1041–1047 (2017).

    Google Scholar 

  22. Bailey, Z. D., Feldman, J. M. & Bassett, M. T. How structural racism works — racist policies as a root cause of U.S. Racial health inequities. N. Engl. J. Med. 384, 768–773 (2020).

    PubMed  Google Scholar 

  23. White House. Executive Order on advancing racial equity and support for underserved communities through the federal government. whitehouse.gov https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/ (2021).

  24. The report of the Commission on Race and Ethnic Disparities. UK Government publications https://www.gov.uk/government/publications/the-report-of-the-commission-on-race-and-ethnic-disparities (2021).

  25. Hall, Y. N. Social determinants of health: addressing unmet needs in nephrology. Am. J. Kidney Dis. 72, 582–591 (2018).

    PubMed  Google Scholar 

  26. Norton, J. M. et al. Social determinants of racial disparities in CKD. J. Am. Soc. Nephrol. 27, 2576–2595 (2016).

    PubMed  PubMed Central  Google Scholar 

  27. Nicholas, S. B., Kalantar-Zadeh, K. & Norris, K. C. Socioeconomic disparities in chronic kidney disease. Adv. Chronic Kidney Dis. 22, 6–15 (2015).

    PubMed  PubMed Central  Google Scholar 

  28. Bailey, Z. D. et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet 389, 1453–1463 (2017).

    PubMed  Google Scholar 

  29. Bruce, M. A. et al. Social environmental stressors, psychological factors, and kidney disease. J. Investig. Med. 57, 583–589 (2009).

    PubMed  PubMed Central  Google Scholar 

  30. Braun, L., Wentz, A., Baker, R., Richardson, E. & Tsai, J. Racialized algorithms for kidney function: erasing social experience. Soc. Sci. Med. 268, 113548 (2021).

    PubMed  Google Scholar 

  31. Linnaeus, C. Systema naturae 10th edn (1758).

  32. Harawa, N. T. & Ford, C. L. The foundation of modern racial categories and implications for research on black/white disparities in health. Ethn. Dis. 19, 209–217 (2009).

    PubMed  Google Scholar 

  33. Bunyavanich, S., Grant, C. & Vicencio, A. Racial/ethnic variation in nasal gene expression of transmembrane serine protease 2 (TMPRSS2). JAMA 324, 1–2 (2020).

    PubMed Central  Google Scholar 

  34. Kalinowski, L., Dobrucki, I. T. & Malinski, T. Race-specific differences in endothelial function: predisposition of African Americans to vascular diseases. Circulation 109, 2511–2517 (2004).

    PubMed  Google Scholar 

  35. Cardillo, C., Kilcoyne, C. M., Cannon, R. O. 3rd & Panza, J. A. Racial differences in nitric oxide-mediated vasodilator response to mental stress in the forearm circulation. Hypertension 31, 1235–1239 (1998).

    CAS  PubMed  Google Scholar 

  36. No Authors Listed. ASHG denounces attempts to link genetics and racial supremacy. Am. J. Hum. Genet. 103, 636 (2018).

    Google Scholar 

  37. Marshall, E. DNA studies challenge the meaning of race. Science 282, 654–655 (1998).

    CAS  PubMed  Google Scholar 

  38. Ford, C. L. & Harawa, N. T. A new conceptualization of ethnicity for social epidemiologic and health equity research. Soc. Sci. Med. 71, 251–258 (2010).

    PubMed  PubMed Central  Google Scholar 

  39. Hoffman, K. M., Trawalter, S., Axt, J. R. & Oliver, M. N. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc. Natl Acad. Sci. USA 113, 4296–4301 (2016).

    CAS  PubMed  PubMed Central  Google Scholar 

  40. Schulman, K. A. et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N. Engl. J. Med. 340, 618–626 (1999).

    CAS  PubMed  Google Scholar 

  41. No Authors Listed. US Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (eds Smedley, B. D. et al.) (US National Academies Press, 2003).

  42. Egede, L. E. Race, ethnicity, culture, and disparities in health care. J. Gen. Intern. Med. 21, 667–669 (2006).

    PubMed  PubMed Central  Google Scholar 

  43. Oppenheimer, G. M. Paradigm lost: race, ethnicity, and the search for a new population taxonomy. Am. J. Public Health 91, 1049–1055 (2001).

    CAS  PubMed  PubMed Central  Google Scholar 

  44. Office of Management and Budget. Standards for the classification of federal data on race and ethnicity. Fed. Regist. 59, 29831–29835 (1994).

  45. Office of Management and Budget. Revisions to the standards for the classification of federal data on race and ethnicity. Fed. Regist. 62, 58781–58790 (1997).

    Google Scholar 

  46. Wallman, K. K., Evinger, S. & Schechter, S. Measuring our nation’s diversity: developing a common language for data on race/ethnicity. Am. J. Public Health 90, 1704–1708 (2000).

    CAS  PubMed  PubMed Central  Google Scholar 

  47. US Census Bureau. data.census.gov https://data.census.gov/cedsci/profile?q=United%20States&g=0100000US (2021).

  48. Yudell, M., Roberts, D., DeSalle, R. & Tishkoff, S. Science and society. Taking race out of human genetics. Science 351, 564–565 (2016).

    CAS  PubMed  Google Scholar 

  49. Isabel Wilkerson. America’s Enduring Caste System. Nytimes.com https://www.nytimes.com/2020/07/01/magazine/isabel-wilkerson-caste.html (2020).

  50. Williams, D. R. & Collins, C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 116, 404–416 (2001).

    CAS  PubMed  PubMed Central  Google Scholar 

  51. Chen, J. T. et al. Mapping and measuring social disparities in premature mortality: the impact of census tract poverty within and across Boston neighborhoods, 1999–2001. J. Urban. Health 83, 1063–1084 (2006).

    PubMed  PubMed Central  Google Scholar 

  52. Plantinga, L. C., Johansen, K. L., Schillinger, D. & Powe, N. R. Lower socioeconomic status and disability among US adults with chronic kidney disease, 1999–2008. Prev. Chronic Dis. 9, E12 (2012).

    PubMed  Google Scholar 

  53. Zimmerman, F. J. & Anderson, N. W. Trends in health equity in the United States by race/ethnicity, sex, and income, 1993–2017. JAMA Netw. Open 2, e196386 (2019).

    PubMed  PubMed Central  Google Scholar 

  54. Powe, N. R. Let’s get serious about racial and ethnic disparities. J. Am. Soc. Nephrol. 19, 1271–1275 (2008).

    PubMed  Google Scholar 

  55. Rodriguez, R. A. et al. Geography matters: relationships among urban residential segregation, dialysis facilities, and patient outcomes. Ann. Intern. Med. 146, 493–501 (2007).

    PubMed  Google Scholar 

  56. Gostin, L. O. Politics and public health: the flint drinking water crisis. Hastings Cent. Rep. 46, 5–6 (2016).

    PubMed  Google Scholar 

  57. White, B. M., Bonilha, H. S. & Ellis, C. Jr Racial/ethnic differences in childhood blood lead levels among children <72 months of age in the United States: a systematic review of the literature. J. Racial Ethn. Health Disparities 3, 145–153 (2016).

    PubMed  Google Scholar 

  58. Tessum, C. W. et al. Inequity in consumption of goods and services adds to racial-ethnic disparities in air pollution exposure. Proc. Natl Acad. Sci. USA 116, 6001–6006 (2019).

    CAS  PubMed  PubMed Central  Google Scholar 

  59. Krieger, N. Shades of difference: theoretical underpinnings of the medical controversy on black/white differences in the United States, 1830–1870. Int. J. Health Serv. 17, 259–278 (1987).

    CAS  PubMed  Google Scholar 

  60. Link, E. P. The civil rights activities of three great negro physicians (1840–1940). J. Negro Hist. 52, 169–184 (1967).

    CAS  PubMed  Google Scholar 

  61. Smith, J. M. On the fourteenth query of Thomas Jefferson’s notes on Virginia. Anglo-Afr. Mag. 1, 225–238 (1859).

    Google Scholar 

  62. Du Bois, W. E. B. The Philadelphia Negro: A Social Study (University of Pennsylvania, 1899).

  63. DuBois, W. E. The health and physique of the Negro American. 1906. Am. J. Public Health 93, 272–276 (2003).

    PubMed  PubMed Central  Google Scholar 

  64. Zuberi, T. Thicker Than Blood: How Racial Statistics Lie (University of Minnesota Press, 2001).

  65. Steele, C. M. & Aronson, J. Stereotype threat and the intellectual test performance of African Americans. J. Pers. Soc. Psychol. 69, 797–811 (1995).

    CAS  PubMed  Google Scholar 

  66. Aronson, J., Burgess, D., Phelan, S. M. & Juarez, L. Unhealthy interactions: the role of stereotype threat in health disparities. Am. J. Public Health 103, 50–56 (2013).

    PubMed  PubMed Central  Google Scholar 

  67. Williams, M. V. et al. Inadequate functional health literacy among patients at two public hospitals. JAMA 274, 1677–1682 (1995).

    CAS  PubMed  Google Scholar 

  68. Boulware, L. E., Cooper, L. A., Ratner, L. E., LaVeist, T. A. & Powe, N. R. Race and trust in the health care system. Public Health Rep. 118, 358–365 (2003).

    PubMed  PubMed Central  Google Scholar 

  69. Abdou, C. M., Fingerhut, A. W., Jackson, J. S. & Wheaton, F. Healthcare stereotype threat in older adults in the health and retirement study. Am. J. Prev. Med. 50, 191–198 (2016).

    PubMed  Google Scholar 

  70. Greenwood, B. N., Hardeman, R. R., Huang, L. & Sojourner, A. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc. Natl Acad. Sci. USA 117, 21194–21200 (2020).

    CAS  PubMed  PubMed Central  Google Scholar 

  71. Ford, C. L. & Airhihenbuwa, C. O. Commentary: just what is critical race theory and what’s it doing in a progressive field like public health? Ethn. Dis. 28, 223–230 (2018).

    PubMed  PubMed Central  Google Scholar 

  72. Delgado, R. S. J. Critical race theory and criminal justice. Hum. Soc. 31, 133–145 (2007).

    Google Scholar 

  73. Vyas, D. A., Eisenstein, L. G. & Jones, D. S. Hidden in plain sight — reconsidering the use of race correction in clinical algorithms. N. Engl. J. Med. 383, 874–882 (2020).

    PubMed  Google Scholar 

  74. Ford, C. L. & Airhihenbuwa, C. O. Critical race theory, race equity, and public health: toward antiracism praxis. Am. J. Public Health 100 (Suppl 1), S30–S35 (2010).

  75. McEwen, B. S. Stress, adaptation, and disease. Allostasis and allostatic load. Ann. N. Y. Acad. Sci. 840, 33–44 (1998).

    CAS  PubMed  Google Scholar 

  76. Geronimus, A. T., Hicken, M., Keene, D. & Bound, J. “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States. Am. J. Public Health 96, 826–833 (2006).

    PubMed  PubMed Central  Google Scholar 

  77. Ong, A. D. & Williams, D. R. Lifetime discrimination, global sleep quality, and inflammation burden in a multiethnic sample of middle-aged adults. Cultur. Divers. Ethn. Minor. Psychol. 25, 82–90 (2019).

    Google Scholar 

  78. Brown, K. M. et al. Social regulation of inflammation related gene expression in the multi-ethnic study of atherosclerosis. Psychoneuroendocrinology 117, 104654 (2020).

    CAS  PubMed  PubMed Central  Google Scholar 

  79. Portha, B., Grandjean, V. & Movassat, J. Mother or father: who is in the front line? Mechanisms underlying the non-genomic transmission of obesity/diabetes via the maternal or the paternal line. Nutrients 11, 233 (2019).

    CAS  PubMed Central  Google Scholar 

  80. Sales, V. M., Ferguson-Smith, A. C. & Patti, M. E. Epigenetic mechanisms of transmission of metabolic disease across generations. Cell Metab. 25, 559–571 (2017).

    CAS  PubMed  PubMed Central  Google Scholar 

  81. van Steenwyk, G., Roszkowski, M., Manuella, F., Franklin, T. B. & Mansuy, I. M. Transgenerational inheritance of behavioral and metabolic effects of paternal exposure to traumatic stress in early postnatal life: evidence in the 4th generation. Environ. Epigenet. 4, dvy023 (2018).

    PubMed  PubMed Central  Google Scholar 

  82. Jiang, W. et al. Prenatal famine exposure and estimated glomerular filtration rate across consecutive generations: association and epigenetic mediation in a population-based cohort study in Suihua China. Aging 12, 12206–12221 (2020).

    CAS  PubMed  PubMed Central  Google Scholar 

  83. Olson, D. M. et al. Allostatic load and preterm birth. Int. J. Mol. Sci. 16, 29856–29874 (2015).

    CAS  PubMed  PubMed Central  Google Scholar 

  84. Yao, Y. et al. Ancestral exposure to stress epigenetically programs preterm birth risk and adverse maternal and newborn outcomes. BMC Med. 12, 121 (2014).

    PubMed  PubMed Central  Google Scholar 

  85. Christiaens, I., Hegadoren, K. & Olson, D. M. Adverse childhood experiences are associated with spontaneous preterm birth: a case-control study. BMC Med. 13, 124 (2015).

    PubMed  PubMed Central  Google Scholar 

  86. Saran, R. et al. US Renal Data System 2019 Annual Data Report: epidemiology of kidney disease in the United States. Am. J. Kidney Dis. 75, (1 Suppl 1), A6–A7 (2020).

  87. Hounkpatin, H. O. et al. Ethnic minority disparities in progression and mortality of pre-dialysis chronic kidney disease: a systematic scoping review. BMC Nephrol. 21, 217 (2020).

    PubMed  PubMed Central  Google Scholar 

  88. Johns, T. S. et al. Neighborhood socioeconomic status, race, and mortality in young adult dialysis patients. J. Am. Soc. Nephrol. 25, 2649–2657 (2014).

    PubMed  PubMed Central  Google Scholar 

  89. Volkova, N. et al. Neighborhood poverty and racial differences in ESRD incidence. J. Am. Soc. Nephrol. 19, 356–364 (2008).

    PubMed  PubMed Central  Google Scholar 

  90. Kurella-Tamura, M., Goldstein, B. A., Hall, Y. N., Mitani, A. A. & Winkelmayer, W. C. State medicaid coverage, ESRD incidence, and access to care. J. Am. Soc. Nephrol. 25, 1321–1329 (2014).

    PubMed  PubMed Central  Google Scholar 

  91. Evans, K. et al. Race differences in access to health care and disparities in incident chronic kidney disease in the US. Nephrol. Dial. Transpl. 26, 899–908 (2011).

    Google Scholar 

  92. Krop, J. S. et al. A community-based study of explanatory factors for the excess risk for early renal function decline in blacks vs whites with diabetes: the Atherosclerosis Risk in Communities study. Arch. Intern. Med. 159, 1777–1783 (1999).

    CAS  PubMed  Google Scholar 

  93. Perneger, T. V., Whelton, P. K. & Klag, M. J. Race and end-stage renal disease. Socioeconomic status and access to health care as mediating factors. Arch. Intern. Med. 155, 1201–1208 (1995).

    CAS  PubMed  Google Scholar 

  94. Cobb, R. J., Thorpe, R. J. & Norris, K. C. Everyday discrimination and kidney function among older adults: evidence from the Health and Retirement Study. J. Gerontol. Ser. A Biol. Sci. Med. Sci. 75, 517–521 (2020).

    CAS  Google Scholar 

  95. Beydoun, M. A. et al. Perceived discrimination and longitudinal change in kidney function among urban adults. Psychosom. Med. 79, 824–834 (2017).

    PubMed  PubMed Central  Google Scholar 

  96. Camelo, L. V. et al. Racial disparities in renal function: the role of racial discrimination. The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). J. Epidemiol. Commun. Health 72, 1027–1032 (2018).

    Google Scholar 

  97. Santos, E. M. D. et al. Association between estimated glomerular filtration rate and sodium excretion in urine of African descendants in Brazil: a population-based study. J. Bras. Nefrol. 40, 248–255 (2018).

    PubMed  PubMed Central  Google Scholar 

  98. Stewart, D. L., Harshfield, G. A., Zhu, H. & Hanevold, C. D. Stress and salt sensitivity in primary hypertension. Curr. Hypert. Rep. 17, 2 (2015).

    Google Scholar 

  99. Centers for Disease Control and Prevention. Diabetes Report Card 2019 (Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2020).

  100. Genovese, G. et al. Association of trypanolytic ApoL1 variants with kidney disease in African Americans. Science 329, 841–845 (2010).

    CAS  PubMed  PubMed Central  Google Scholar 

  101. Olaniran, K. O. et al. Kidney function decline among black patients with sickle cell trait and sickle cell disease: an observational cohort study. J. Am. Soc. Nephrol. 31, 393–404 (2020).

    CAS  PubMed  Google Scholar 

  102. Datta, S. et al. Kidney disease-associated APOL1 variants have dose-dependent, dominant toxic gain-of-function. J. Am. Soc. Nephrol. 31, 2083–2096 (2020).

    CAS  PubMed  PubMed Central  Google Scholar 

  103. Gutiérrez, O. M. et al. APOL1 nephropathy risk variants and incident cardiovascular disease events in community-dwelling black adults. Circ. Genom. Precis. Med. 11, e002098 (2018).

    PubMed  PubMed Central  Google Scholar 

  104. Tang, H. et al. Genetic structure, self-identified race/ethnicity, and confounding in case-control association studies. Am. J. Hum. Genet. 76, 268–275 (2005).

    CAS  PubMed  Google Scholar 

  105. Micheletti, S. J. et al. Genetic consequences of the transatlantic slave trade in the Americas. Am. J. Hum. Genet. 107, 265–277 (2020).

    CAS  PubMed  PubMed Central  Google Scholar 

  106. Nadkarni, G. N. et al. Worldwide frequencies of APOL1 renal risk variants. N. Engl. J. Med. 379, 2571–2572 (2018).

    PubMed  PubMed Central  Google Scholar 

  107. Wudil, U. J. et al. Apolipoprotein-1 risk variants and associated kidney phenotypes in an adult HIV cohort in Nigeria. Kidney Int. 100, 146–154 (2021).

    CAS  PubMed  Google Scholar 

  108. Cerdeña, J. P., Tsai, J. & Grubbs, V. APOL1, black race, and kidney disease: turning attention to structural racism. Am. J. Kidney Dis. 77, 857–860 (2021).

    PubMed  Google Scholar 

  109. Yan, G. et al. The associations between race and geographic area and quality-of-care indicators in patients approaching ESRD. Clin. J. Am. Soc. Nephrol. 8, 610–618 (2013).

    PubMed  PubMed Central  Google Scholar 

  110. Zarkowsky, D. S. et al. Racial/ethnic disparities associated with initial hemodialysis access. JAMA Surg. 150, 529–536 (2015).

    PubMed  Google Scholar 

  111. Mehrotra, R. et al. Racial and ethnic disparities in use of and outcomes with home dialysis in the United States. J. Am. Soc. Nephrol. 27, 2123–2134 (2016).

    PubMed  Google Scholar 

  112. Eneanya, N. D. et al. Longitudinal patterns of health-related quality of life and dialysis modality: a national cohort study. BMC Nephrol. 20, 7 (2019).

    PubMed  PubMed Central  Google Scholar 

  113. Purnell, T. S. et al. Association of race and ethnicity with live donor kidney transplantation in the United States from 1995 to 2014. JAMA 319, 49–61 (2018).

    PubMed  PubMed Central  Google Scholar 

  114. Reese, P. P. et al. Racial disparities in preemptive waitlisting and deceased donor kidney transplantation: ethics and solutions. Am. J. Transplant. 21, 958–967 (2021).

    PubMed  Google Scholar 

  115. Zelnick, L. R., Leca, N., Young, B. & Bansal, N. Association of the estimated glomerular filtration rate with vs without a coefficient for race with time to eligibility for kidney transplant. JAMA Netw. Open 4, e2034004 (2021).

    PubMed  PubMed Central  Google Scholar 

  116. Delanaye, P., Mariat, C., Maillard, N., Krzesinski, J. M. & Cavalier, E. Are the creatinine-based equations accurate to estimate glomerular filtration rate in African American populations? Clin. J. Am. Soc. Nephrol. 6, 906–912 (2011).

    PubMed  Google Scholar 

  117. Porrini, E. et al. Estimated GFR: time for a critical appraisal. Nat. Rev. Nephrol. 15, 177–190 (2019).

    CAS  PubMed  Google Scholar 

  118. Levey, A. S., Titan, S. M., Powe, N. R., Coresh, J. & Inker, L. A. Kidney disease, race, and GFR estimation. Clin. J. Am. Soc. Nephrol. 15, 1203–1212 (2020).

    CAS  PubMed  PubMed Central  Google Scholar 

  119. Levey, A. S. et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann. Intern. Med. 130, 461–470 (1999).

    CAS  PubMed  Google Scholar 

  120. Levey, A. S. et al. A new equation to estimate glomerular filtration rate. Ann. Intern. Med. 150, 604–612 (2009).

    PubMed  PubMed Central  Google Scholar 

  121. Cohn, S. H. et al. Body elemental composition: comparison between black and white adults. Am. J. Physiol. 232, E419–E422 (1977).

    CAS  PubMed  Google Scholar 

  122. Harsha, D. W., Frerichs, R. R. & Berenson, G. S. Densitometry and anthropometry of black and white children. Hum. Biol. 50, 261–280 (1978).

    CAS  PubMed  Google Scholar 

  123. Worrall, J. G., Phongsathorn, V., Hooper, R. J. & Paice, E. W. Racial variation in serum creatine kinase unrelated to lean body mass. Br. J. Rheumatol. 29, 371–373 (1990).

    CAS  PubMed  Google Scholar 

  124. Levey, A. S., Tighiouart, H., Titan, S. M. & Inker, L. A. Estimation of glomerular filtration rate with vs without including patient race. JAMA Intern. Med. 180, 793–795 (2020).

    PubMed  PubMed Central  Google Scholar 

  125. Schwartz, S. The fallacy of the ecological fallacy: the potential misuse of a concept and the consequences. Am. J. Public Health 84, 819–824 (1994).

    CAS  PubMed  PubMed Central  Google Scholar 

  126. Eneanya, N. D., Yang, W. & Reese, P. P. Reconsidering the consequences of using race to estimate kidney function. JAMA 322, 113–114 (2019).

    PubMed  Google Scholar 

  127. Subramanian, S. V., Jones, K., Kaddour, A. & Krieger, N. Revisiting Robinson: the perils of individualistic and ecologic fallacy. Int. J. Epidemiol. 38, 342–360 (2009). author reply 370–343.

    CAS  PubMed  PubMed Central  Google Scholar 

  128. Levey, A. S. et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann. Intern. Med. 145, 247–254 (2006).

    CAS  PubMed  Google Scholar 

  129. Sika, M. et al. Baseline characteristics of participants in the African American Study of Kidney Disease and Hypertension (AASK) Clinical Trial and Cohort Study. Am. J. Kidney Dis. 50, 78–89 (2007). 89.e71.

    CAS  PubMed  Google Scholar 

  130. Kochhar, R. and Cilluffo, A. Appendix A: Income distributions of whites, blacks, Hispanics and Asians in the U.S., 1970 and 2016. pewresearch.org https://www.pewsocialtrends.org/2018/07/12/appendix-a-income-distributions-of-whites-blacks-hispanics-and-asians-in-the-u-s-1970-and-2016/ (2018).

  131. DeNavas-Walt, C., Proctor B. D. & Smith J. C. Income Poverty and Health Insurance Coverage in the United States: 2011 (U.S Census Bureau, 2011).

  132. Diskin, C. J. Creatinine and glomerular filtration rate: evolution of an accommodation. Ann. Clin. Biochem. 44, 16–19 (2007).

    CAS  PubMed  Google Scholar 

  133. Nair, S. et al. Effect of a cooked meat meal on serum creatinine and estimated glomerular filtration rate in diabetes-related kidney disease. Diabetes Care 37, 483–487 (2014).

    CAS  PubMed  Google Scholar 

  134. Inker, L. A. et al. Estimating glomerular filtration rate from serum creatinine and cystatin C. N. Engl. J. Med. 367, 20–29 (2012).

    CAS  PubMed  PubMed Central  Google Scholar 

  135. Anderson, A. H. et al. Estimating GFR among participants in the Chronic Renal Insufficiency Cohort (CRIC) Study. Am. J. Kidney Dis. 60, 250–261 (2012).

    PubMed  PubMed Central  Google Scholar 

  136. Eneanya, N. D., Kostelanetz, S. & Mendu, M. M. Race-free biomarkers to quantify kidney function: health equity lessons learned from population-based research. Am. J. Kidney Dis. 77, 667–669 (2021).

    PubMed  Google Scholar 

  137. Rule, A. D. & Teo, B. W. GFR estimation in Japan and China: what accounts for the difference? Am. J. Kidney Dis. 53, 932–935 (2009).

    PubMed  PubMed Central  Google Scholar 

  138. Ma, Y. C. et al. Modified glomerular filtration rate estimating equation for Chinese patients with chronic kidney disease. J. Am. Soc. Nephrol. 17, 2937–2944 (2006).

    PubMed  Google Scholar 

  139. Matsuo, S. et al. Revised equations for estimated GFR from serum creatinine in Japan. Am. J. Kidney Dis. 53, 982–992 (2009).

    CAS  PubMed  Google Scholar 

  140. Teo, B. W. et al. GFR estimating equations in a multiethnic Asian population. Am. J. Kidney Dis. 58, 56–63 (2011).

    PubMed  Google Scholar 

  141. Barcellos, R. C., Matos, J. P., Kang, H. C., Rosa, M. L. & Lugon, J. R. Comparison of serum creatinine levels in different color/race categories in a Brazilian population. Cad. Saude Publica 31, 1565–1569 (2015).

    PubMed  Google Scholar 

  142. Zanocco, J. A. et al. Race adjustment for estimating glomerular filtration rate is not always necessary. Nephron Extra 2, 293–302 (2012).

    PubMed  PubMed Central  Google Scholar 

  143. Eastwood, J. B. et al. Assessment of GFR by four methods in adults in Ashanti, Ghana: the need for an eGFR equation for lean African populations. Nephrol. Dial. Transplant. 25, 2178–2187 (2010).

    PubMed  PubMed Central  Google Scholar 

  144. Bukabau, J. B. et al. Performance of creatinine- or cystatin C-based equations to estimate glomerular filtration rate in sub-Saharan African populations. Kidney Int. 95, 1181–1189 (2019).

    CAS  PubMed  Google Scholar 

  145. van Deventer, H. E., George, J. A., Paiker, J. E., Becker, P. J. & Katz, I. J. Estimating glomerular filtration rate in black South Africans by use of the modification of diet in renal disease and Cockcroft-Gault equations. Clin. Chem. 54, 1197–1202 (2008).

    PubMed  Google Scholar 

  146. Flamant, M. et al. Performance of GFR estimating equations in African Europeans: basis for a lower race-ethnicity factor than in African Americans. Am. J. Kidney Dis. 62, 182–184 (2013).

    PubMed  Google Scholar 

  147. Stevens, P. E. & Levin, A. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann. Intern. Med. 158, 825–830 (2013).

    PubMed  Google Scholar 

  148. Miller, W. Perspective on new equations for estimating glomerular filtration rate. Clin. Chem. 67, 820–822 (2021).

    PubMed  Google Scholar 

  149. Schmidt, I. M. & Waikar, S. S. Separate and unequal: race-based algorithms and implications for nephrology. J. Am. Soc. Nephrol. 32, 529–533 (2021).

    PubMed  Google Scholar 

  150. Beasley, J. M., Firestone, M. J., Popp, C. J., Russo, R. & Yi, S. S. Age and racial/ethnic differences in dietary sources of protein, NHANES, 2011–2016. Front. Nutr. 7, 76 (2020).

    PubMed  PubMed Central  Google Scholar 

  151. Crews, D. C. et al. Race/ethnicity, dietary acid load, and risk of end-stage renal disease among US adults with chronic kidney disease. Am. J. Nephrol. 47, 174–181 (2018).

    CAS  PubMed  Google Scholar 

  152. Baumgartner, R. N., Chumlea, W. C. & Roche, A. F. Bioelectric impedance phase angle and body composition. Am. J. Clin. Nutr. 48, 16–23 (1988).

    CAS  PubMed  Google Scholar 

  153. Inker, L. A. C. S. & Tighiouart, H. et al. A new panel estimated GFR, including B2-microglobulin and B-trace protein and not including race, developed in a diverse population. Am. J. Kidney Dis. 77, 673–683.e1 (2020).

    PubMed  Google Scholar 

  154. Robinson, W. S. Ecological correlations and the behavior of individuals. Int. J. Epidemiol. 38, 337–341 (2009).

    CAS  PubMed  Google Scholar 

  155. Ahmed, S. et al. Examining the potential impact of race multiplier utilization in estimated glomerular filtration rate calculation on African-American care outcomes. J. Gen. Intern. Med. 36, 464–471 (2021).

    PubMed  Google Scholar 

  156. Cleveland Manchanda, E., Couillard, C. & Sivashanker, K. Inequity in crisis standards of care. N. Engl. J. Med. 383, e16 (2020).

    PubMed  Google Scholar 

  157. Schmidt, H., Roberts, D. E. & Eneanya, N. D. Rationing, racism and justice: advancing the debate around ‘colourblind’ COVID-19 ventilator allocation. J. Med. Ethics https://doi.org/10.1136/medethics-2020-106856 (2021).

    Article  PubMed  Google Scholar 

  158. Rappoport, N. et al. Comparing ethnicity-specific reference intervals for clinical laboratory tests from EHR Data. J. Appl. Lab. Med. 3, 366–377 (2018).

    PubMed  Google Scholar 

  159. Huria, T. et al. Reported sources of health inequities in indigenous peoples with chronic kidney disease: a systematic review of quantitative studies. BMC Public Health 21, 1447 (2021).

    PubMed  PubMed Central  Google Scholar 

  160. Elwyn, G. et al. Shared decision making: a model for clinical practice. J. Gen. Intern. Med. 27, 1361–1367 (2012).

    PubMed  PubMed Central  Google Scholar 

  161. FitzGerald, C. & Hurst, S. Implicit bias in healthcare professionals: a systematic review. BMC Med. Ethics 18, 19 (2017).

    PubMed  PubMed Central  Google Scholar 

  162. Roberts, D. E. Abolish race correction. Lancet 397, 17–18 (2021).

    PubMed  Google Scholar 

  163. Norris, K. C., Eneanya, N. D. & Boulware, L. E. Removal of race from estimates of kidney function: first, do no harm. JAMA 325, 135–137 (2021).

    PubMed  Google Scholar 

  164. Diao, J. A. et al. Clinical implications of removing race from estimates of kidney function. JAMA 325, 184–186 (2021).

    PubMed  Google Scholar 

  165. Shin, J. I. et al. The FDA metformin label change and racial and sex disparities in metformin prescription among patients with CKD. J. Am. Soc. Nephrol. 31, 1847–1858 (2020).

    CAS  PubMed  PubMed Central  Google Scholar 

  166. Walther, C. P., Winkelmayer, W. C. & Navaneethan, S. D. Black race coefficient in GFR estimation and diabetes medications in CKD: national estimates. J. Am. Soc. Nephrol. 32, 1319–1321 (2021).

    PubMed  Google Scholar 

  167. Sehgal, A. R. Race and the false precision of glomerular filtration rate estimates. Ann. Intern. Med. 173, 1008–1009 (2020).

    PubMed  Google Scholar 

  168. Miller, W. G. Uncertainty in estimated glomerular filtration rate is much larger than the race adjustment term. Clin. Chem. 36, 464–471 (2021).

    Google Scholar 

  169. Lentine, K. L. et al. KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Transplantation 101, S1–S109 (2017).

    PubMed  Google Scholar 

  170. Mandelbrot, D. A. et al. KDOQI US Commentary on the 2017 KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Am. J. Kidney Dis. 75, 299–316 (2020).

    CAS  PubMed  Google Scholar 

  171. Chen, T. K., Knicely, D. H. & Grams, M. E. Chronic kidney disease diagnosis and management: a review. JAMA 322, 1294–1304 (2019).

    CAS  PubMed  PubMed Central  Google Scholar 

  172. Duggal, V., Thomas, I. C., Montez-Rath, M. E., Chertow, G. M. & Kurella Tamura, M. National Estimates of CKD prevalence and potential impact of estimating glomerular filtration rate without race. J. Am. Soc. Nephrol. 32, 1454–1463 (2021).

    PubMed  Google Scholar 

  173. Peralta, C. A. et al. Race differences in prevalence of chronic kidney disease among young adults using creatinine-based glomerular filtration rate-estimating equations. Nephrol. Dial. Transplant. 25, 3934–3939 (2010).

    PubMed  PubMed Central  Google Scholar 

  174. El-Khoury, J. M. et al. Is it time to move on? Reexamining race in glomerular filtration rate equations. Clin. Chem. 67, 585–591 (2021).

    PubMed  Google Scholar 

  175. Collins, F. S. What we do and don’t know about ‘race’, ‘ethnicity’, genetics and health at the dawn of the genome era. Nat. Genet. 36, S13–S15 (2004).

    CAS  PubMed  Google Scholar 

  176. Purnell, T. S. et al. Reduced racial disparity in kidney transplant outcomes in the United States from 1990 to 2012. J. Am. Soc. Nephrol. 27, 2511–2518 (2016).

    PubMed  PubMed Central  Google Scholar 

  177. Grubbs, V. Precision in GFR reporting: let’s stop playing the race card. Clin. J. Am. Soc. Nephrol. 15, 1201–1202 (2020).

    PubMed  PubMed Central  Google Scholar 

  178. Powe, N. R. Black kidney function matters: use or misuse of race? JAMA 324, 737–738 (2020).

    PubMed  Google Scholar 

  179. Boulware, L. E., Purnell, T. S. & Mohottige, D. Systemic kidney transplant inequities for black individuals: examining the contribution of racialized kidney function estimating equations. JAMA Netw. Open 4, e2034630 (2021).

    PubMed  Google Scholar 

  180. Delgado, C. et al. Reassessing the inclusion of race in diagnosing kidney diseases: an interim report from the NKF-ASN task force. J. Am. Soc. Neprhol. 32, 1305–1317 (2021).

    CAS  Google Scholar 

  181. Delgado, C. et al. A unifying approach for GFR estimation: recommendations of the NKF-ASN task force on reassessing the inclusion of race in diagnosing kidney disease. J. Am. Soc. Nephrol. https://doi.org/10.1681/asn.2021070988 (2021).

    Article  PubMed  Google Scholar 

  182. Inker, L. A. et al. New creatinine- and cystatin C-based equations to estimate GFR without race. N. Engl. J. Med. https://doi.org/10.1056/NEJMoa2102953 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  183. Mendu, M. L. et al. Measuring quality in kidney care: an evaluation of existing quality metrics and approach to facilitating improvements in care delivery. J. Am. Soc. Nephrol. 31, 602–614 (2020).

    PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

N.D.E. is supported by NIH research grant K23DK114526. R.J.T. is supported in part by NIH research grants U54MD000214, K02AG059140 and R01AG054363. M.A.B. is supported in part by NIH Grants K02AG059140, R25HL126145 and P30AG059298. K.C.N. is supported in part by NIH research grants UL1TR001881 and P30AG021684.

Author information

Authors and Affiliations

  1. Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Nwamaka D. Eneanya & Peter P. Reese

  2. Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA

    L. Ebony Boulware

  3. Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA

    Jennifer Tsai

  4. Program for Research on Faith, Justice, and Health, Department of Behavioral and Social Sciences, University of Houston College of Medicine, Houston, TX, USA

    Marino A. Bruce

  5. Center for the Study of Racism, Social Justice & Health, Fielding School of Public Health, University of California, Los Angeles, CA, USA

    Chandra L. Ford

  6. VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California, Los Angeles, CA, USA

    Christina Harris & Keith C. Norris

  7. Division of General Internal Medicine, University of Washington, Seattle, WA, USA

    Leo S. Morales & Michael J. Ryan

  8. Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Peter P. Reese

  9. Program for Research on Men’s Health, Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Roland J. Thorpe Jr.

  10. Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Michelle Morse

  11. Department of Paediatrics, Ohio State University College of Medicine, Columbus, OH, USA

    Valencia Walker

  12. Department of Medicine, Obafemi Awolowo University, Ile-Ife, Nigeria

    Fatiu A. Arogundade

  13. Clinical Epidemiology and Evidence-Based Medicine Unit of the Edgard Santos University Hospital and Department of Internal Medicine, Federal University of Bahia, Salvador, Brazil

    Antonio A. Lopes

Authors
  1. Nwamaka D. Eneanya
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. L. Ebony Boulware
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Jennifer Tsai
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Marino A. Bruce
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Chandra L. Ford
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Christina Harris
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Leo S. Morales
    View author publications

    You can also search for this author inPubMed Google Scholar

  8. Michael J. Ryan
    View author publications

    You can also search for this author inPubMed Google Scholar

  9. Peter P. Reese
    View author publications

    You can also search for this author inPubMed Google Scholar

  10. Roland J. Thorpe Jr.
    View author publications

    You can also search for this author inPubMed Google Scholar

  11. Michelle Morse
    View author publications

    You can also search for this author inPubMed Google Scholar

  12. Valencia Walker
    View author publications

    You can also search for this author inPubMed Google Scholar

  13. Fatiu A. Arogundade
    View author publications

    You can also search for this author inPubMed Google Scholar

  14. Antonio A. Lopes
    View author publications

    You can also search for this author inPubMed Google Scholar

  15. Keith C. Norris
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

N.D.E., L.E.B. and K.C.N. researched data for the article, made substantial contributions to discussions of the content and wrote the article. All authors reviewed or edited the manuscript before submission.

Corresponding author

Correspondence to Nwamaka D. Eneanya.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Peer review information

Nature Reviews Nephrology thanks P. Delanaye, M. Hoenig and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Glossary

Chronic Renal Insufficiency Cohort eGFR equation

An eGFR equation developed among the Chronic Renal Insufficiency Cohort that is largely restricted to research investigations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Eneanya, N.D., Boulware, L.E., Tsai, J. et al. Health inequities and the inappropriate use of race in nephrology. Nat Rev Nephrol 18, 84–94 (2022). https://doi.org/10.1038/s41581-021-00501-8

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41581-021-00501-8

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing