The case of the kidney killers

Usually, kidneys aren’t sexy.Not to me, anyway. Sorry, nephrology and urology and everyone else who loves kidneys!Unless patients are unconscious, I’m not screaming for stat bloodwork and an IV, and even then, I find it best to stay calm and let the nurses and phlebotomists do their work.I guess kidneys are more the strong, silent type, doing the work to keep us alive without demanding attention. Kind of like some people we know, and bless you for it.Today, though, I met a pathologist and lab director who had instituted the CKD-EPI 2021 calculation for eGFR. A family doctor personally thanked him because the previous guidelines had discriminated against Black patients.Say whaaaaat?Read: Dr. Melissa Yuan-Innes: Dr. BullyThey both explained, and this is what I understood: The prior CKD-EPI 2009 calculation included a race-based modifier that yielded different eGFR results for Black people than Caucasians.The use of a modifier was based on the premise that mean serum creatinine concentrations are greater in Black people attributable, controversially, to their greater average muscle mass.The CKD-EPI 2009 equation gives Black people higher eGFR results compared with Caucasians for the same creatinine measurements. Sounds innocuous, right? I love getting As, and they’re getting better results on their lab tests.Actually, it’s terrible because these results are not accurate. Artificially pumping up the results means that Black people aren’t necessarily getting the preventative care they need to treat renal insufficiency early on. They have also been deemed ineligible for kidney transplants because their renal function looks too good!This shocked me.Imagine how many people suffer, not getting the health they need, and die prematurely, all because of a messed-up calculation.I use the present tense because not all hospitals have switched to the current calculation. Ontario hospitals were supposed to switch over by April 2024, but at least one major hospital system in the region probably won’t until the end of the year.I understand bureaucracy and the difficulty of switching over.Read: Dr. Melissa Yuan-Innes: Just for pun: Some much-needed humour in medicineBut it sounded like we’re overhauling the system based on a study published in 2018. I, personally, would not want my kidneys failing over the past six years while the hospital wheels grind along.I think of the worst creatinine (and therefore lowest eGFR) I’ve ever seen, in a patient who was starting to go into altered mental status. Not the first time this had happened. The partner began to panic, and frankly, I wasn’t too far behind as I called nephrology and said, “What do I do?”Answer: Transfer to nephrology for emergency dialysis at another hospital. Hallelujah and transfer completed. I don’t know if a kidney transplant followed.In retrospect, my patient’s race probably wasn’t a coincidence in that case.You may think, well, they’re fixing the equation now, no big deal, but please stop and think. This is a big deal. That could be you or your loved one with the wrong calculation dragging on until the end of 2024. That could be the history of medicine reaching forward to harm your patients here and now.When we swear to do no harm, it’s not only in our day-to-day interactions. We have to recognize systemic biases, not only in how we act but also those baked into our tools. We have to think about our research, overturning previous theories, and opening ourselves up to new and better data. We have to fund research, including basic science.And then maybe we can build a healthier and more just society.

The case of the kidney killers

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Dr. Melissa Yuan-Innes

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