A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease
The American Society of Transplantation (AST) welcomes the National Kidney Foundation (NKF)/American Society of Nephrology (ASN) Task Force recommendations. We agree that race modifiers should be excluded from equations used to estimate kidney function. We understand the rationale behind these recommendations, grounded on the fact race is a social and not a biological construct and applying race to clinical algorithms is not medically sound and contributes to health disparities.
We support the adoption of the new 2021 CKD-EPI creatinine estimated glomerular filtration rate (eGFR) equation that is refit to estimate kidney function without a race modifier. It uses already collected demographic and lab values and should be easy to implement at all laboratories across US. The 2021 CKD-EPI creatinine equation would allow standardized reporting of eGFR across all racial and ethnic groups, including in individuals of mixed race, helping to facilitate uniform and consistent clinical practice.
We agree with the recommendation for national efforts to facilitate increased, routine, and timely use of cystatin C, especially to confirm eGFR in adults for clinical decision-making. The CKD-EPI creatininecystatin C eGFR equation that combines both creatinine and cystatin C filtration markers is more accurate than either marker alone and would support better clinical decision making. However, in a recent survey of staff at adult kidney transplant centers in the United States conducted by the AST KPCOP Policy workgroup, only 62% of respondents reported access to cystatin C testing at their hospitals (CJASN 2021 | PMID: 34620650). In the near term, widespread use of cystatin C will be difficult to achieve. We also agree with the recommendation that research on GFR estimation with new endogenous filtration markers and on interventions to eliminate race and ethnic disparities should be encouraged and funded.
We highlight the following settings where there may be unintended consequences with the use of the 2021 CKD-EPI equation where more accurate assessment of kidney function should be considered: 1) Evaluation of potential living donors; 2) Evaluation of post-donation kidney function; 3) Evaluation of preemptive kidney transplant candidates and multi-organ transplant candidates; 4) Evaluation of kidney disease progression in organ transplant recipients especially during the transition to 2021 CKD-EPI equation; 5) Evaluation of eligibility for participation in clinical trials.
As mentioned by the Task Force, these recommendations are advisory only, and are not clinical guidelines, do not define a standard of care, and do not constitute the practice of medicine. The recommendations should be appropriately applied considering the needs of individual patients, available resources, and limitations unique to an institution or type of practice.
AST remains committed to elimination of all causes of racial and ethnic disparities in access to transplant and health care and supports the need for further research and appropriate policy and regulatory measures to achieve this objective.
Approved by the AST Board of Directors on December 2, 2021
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