Q&A with Nwamaka Eneanya, MD, MPH, on Advancing Health Equity and Removing Race from Assessment of Renal Function — a Driver of Disparities in Timely Access to Care
Two female patients with advanced kidney disease walk into a physician’s office. Their heights and weights are equal, their ages the same, their laboratory reports identical. They are alike in almost every way, yet only one qualifies for a transplant list. The other does not — because she is Black.
For the last two decades, a clinical laboratory test called eGFR — which stands for estimated glomerular filtration rate — has been used to evaluate how efficiently a person’s kidneys remove creatinine, a waste product they filter out of blood. The eGFR equation reports a score based on measured creatinine levels while also considering a patient’s age, gender, and race. Nephrologist Nwamaka Eneanya, MD, MPH, an assistant professor in Epidemiology and in Renal-Electrolyte and Hypertension at the Perelman School of Medicine, is working to eliminate race from the formula. She has lobbied extensively for this change, including in a wave-making 2019 Journal of the American Medical Association paper that helped propel the issue to a national stage.
How does race affect a person’s eGFR?
The researchers who developed these equations discovered that Black study participants had higher creatinine levels compared to white study participants — despite having similar kidney function. The researchers proposed that the reasons for their findings were due to Black people having more muscle mass than white people. Since people with more muscle mass make more creatinine, they concluded that Black patients’ eGFR scores should be adjusted with a multiplication factor. Clinicians have been performing this “race correction” for more than 20 years, so Black patients are routinely assigned higher kidney function than those of other races.
Why is this race multiplier problematic?
Human genome studies have shown there are no inherent biological differences between races. Those studies reporting that Black people had greater muscle mass were flawed, but no one questioned them. Patients’ eGFR scores inform many clinical decisions; guidelines recommend a chronic kidney disease diagnosis at less than 60, a specialist referral at less than 30, and placement on a transplant list at less than 20. If we “correct” Black patients’ scores, we refer them for care too late. This is a big deal because Black people are disproportionately affected with more advanced stages of kidney disease — they are also known to progress more quickly than others to needing dialysis and transplant.
If the multiplier can cause harm, why do physicians continue using it?
Not everyone approaches medicine with a health equity lens. Many clinicians are not aware of existing disparities — how Black patients do not get referred to nephrology as early as white patients and do not have sufficient access to transplant [procedures]. In medicine, the tendency is to say, “This is what a study showed, so this is what we should do,” focusing on biomarkers and statistical tests without examining issues of ethics or health equity.
How can physicians make sure Black patients are getting proper care?
I sit on a joint American Society of Nephrology-National Kidney Foundation task force that is revising formal eGFR reporting guidelines to exclude racial bias. Many physicians across the country, including some at Penn, have stopped using the race multiplier already. And while the eGFR is a frontline test for kidney function, there are other tests that don’t incorporate race. When there is any doubt about the accuracy of an eGFR score, other confirmatory tests that do not use race should be performed.
You serve as director of Health Equity, Anti-Racism, and Community Engagement in the Renal Electrolyte and Hypertension Division. What does that role entail?
Internally, I focus on diversity, inclusion, and relationship-building among staff, faculty, and trainees. Our division employs many individuals from minority racial and ethnic backgrounds, and I make sure they feel seen, heard, and valued. For example, in the dialysis unit, we are putting up a board with everyone’s pictures and names, because colleagues feel unseen if you don’t know them by name. We also recently held an inaugural staff awards ceremony, which was a big success.
There’s more to the job than staff initiatives. I’m currently looking into creating endowments for racial/ethnic minority student research pipeline programs, so our division can support them perpetually. And out in the community, we have a kidney disease awareness and screening program that’s run completely by undergraduate students — I’m helping them apply for a grant to incorporate food insecurity into their screenings.
Penn has done a great thing in appointing diversity and inclusion directors for every department and allowing them to implement changes that are reformative, not performative. We all need to work harder to advance equity — and here, I am empowered to do that.
— Interview by Karen Brooks