Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
Division of Nephrology, Stanford University School of Medicine, Stanford, California.
J Am Soc Nephrol. 2021 Jun 1;32(6):1454-1463. doi: 10.1681/ASN.2020121780. Epub 2021 May 6.
The implications of removing the adjustment for Black race in equations to eGFR on the prevalence of CKD and management strategies are incompletely understood.
We estimated changes in CKD prevalence and the potential effect on therapeutic drug prescriptions and prediction of kidney failure if race adjustment were removed from the CKD-EPI GFR estimating equation. We used cross-sectional and longitudinal data from adults aged ≥18 years in the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2016, and the Veterans Affairs (VA) Health Care System in 2015. In the VA cohort, we assessed use of common medications that require dose adjustment on the basis of kidney function, and compared the prognostic accuracy of the Kidney Failure Risk Equation with versus without race adjustment of eGFR.
The prevalence of CKD among Black adults increased from 5.2% to 10.6% in NHANES, and from 12.4% to 21.6% in the VA cohort after eliminating race adjustment. Among Black veterans, 41.0% of gabapentin users, 33.5% of ciprofloxacin users, 24.0% of metformin users, 6.9% of atenolol users, 6.6% of rosuvastatin users, and 5.8% of tramadol users were reclassified to a lower eGFR for which dose adjustment or discontinuation is recommended. Without race adjustment of eGFR, discrimination of the Kidney Failure Risk Equation among Black adults remained high and calibration was marginally improved overall, with better calibration at higher levels of predicted risk.
Removal of race adjustment from CKD-EPI eGFR would double the estimated prevalence of CKD among Black adults in the United States. Such a change is likely to affect a sizeable number of drug-dosing decisions. It may also improve the accuracy of kidney failure risk prediction among higher-risk Black adults.
在 eGFR 方程中去除对黑人种族的调整对 CKD 的流行程度和管理策略的影响尚不完全清楚。
我们估计如果从 CKD-EPI GFR 估算方程中去除种族调整，CKD 的流行率会发生怎样的变化，以及这对治疗药物处方的潜在影响和对肾衰竭的预测。我们使用了 2015 年至 2016 年全国健康和营养调查（NHANES）中年龄≥18 岁的成年人的横断面和纵向数据，以及 2015 年退伍军人事务部（VA）医疗保健系统的数据。在 VA 队列中，我们评估了根据肾功能需要调整剂量的常用药物的使用情况，并比较了在有无种族调整 eGFR 的情况下，肾衰竭风险方程的预测准确性。
在 NHANES 中，黑人成年人的 CKD 患病率从 5.2%上升到 10.6%，在 VA 队列中从 12.4%上升到 21.6%，在去除种族调整后。在黑人退伍军人中，41.0%的加巴喷丁使用者、33.5%的环丙沙星使用者、24.0%的二甲双胍使用者、6.9%的阿替洛尔使用者、6.6%的瑞舒伐他汀使用者和 5.8%的曲马多使用者被重新归类为较低的 eGFR，需要调整剂量或停药。在没有种族调整 eGFR 的情况下，肾衰竭风险方程在黑人成年人中的区分度仍然很高，整体校准略有改善，在较高的预测风险水平上校准效果更好。
从 CKD-EPI eGFR 中去除种族调整将使美国黑人成年人中 CKD 的估计患病率增加一倍。这样的变化可能会影响相当数量的药物剂量决策。它也可能提高高风险黑人成年人肾衰竭风险预测的准确性。
