Beyond the Equation: A Call for Sustained Equity in Chronic Kidney Disease Care for Black Communities

The recent Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 equation which removes race adjustment from estimated glomerular filtration rate (eGFR) calculation, represents an important step on the road to equity in nephrology. ¹ In both the United States and Canada, this shift has been driven by the need to address longstanding inequities in chronic kidney disease (CKD) care—particularly for Black communities.^2-4 There has been uptake of the CKD-EPI 2021 equation in some Canadian jurisdictions including Ontario, Quebec, and Nova Scotia,^2,5-7 signaling a growing commitment to equitable kidney care across the country. For too long, the use of scientifically invalid race-adjusted equations has contributed to delays in the diagnosis and treatment of CKD in Black populations.^3,4,8,9 If we are serious about improving kidney health outcomes for black communities in Canada, we must recognize that removing the race “correction” is only a starting point. Many of the disparities in diagnosis, access to care, and treatment are unrelated to the equation itself and require focused, sustained action to address longstanding systemic barriers and anti-Black racism in the health care system. We discuss the disparities in kidney disease and its care faced by Black Canadians, their potential underlying reasons, and propose additional specific measures to address these gaps, highlighting ongoing initiatives in Ontario.

Compared with White persons, Black individuals in Canada have higher rates of CKD, often developing at younger ages. They are referred for kidney care later, are less likely to receive home dialysis or a kidney transplant, and experience poorer outcomes across the care continuum compared with white patients with CKD.^9-13 They also report greater psychosocial distress while living with CKD. ¹³ Social and structural factors such as higher rates of poverty, psychosocial stress, experiences with anti-Black racism, and limited health literacy significantly undermine their ability to manage these chronic conditions.

The disparities observed in CKD outcomes among Black individuals in Canada reflect a complex set of systemic and structural influences that extend beyond the misclassification concerns introduced by the prior eGFR equation that used race. ¹⁴ Race is a socially constructed category shaped by historical, cultural, and political contexts, with no biological basis.^8,15,16 In fact, greater genetic variation often exists within racial groups than between them. Long-standing patterns of disadvantage, including the enduring effects of anti-Black racism, continue to influence access to care, allocation of health resources, and engagement with the health care system.^15,16 These influences operate across individual, institutional, and structural levels. Even where biological factors such as specific genetic variants are more common, the extent to which they are studied or addressed remains shaped by broader systemic priorities.

Central to advancing equity in kidney care is the need for high-quality, disaggregated data on the racialized status of individuals whose health or health care participation is being studied. For decades, health systems in Canada have operated without consistently collecting or reporting outcomes by race or ethnicity, allowing disparities to remain unrecognized and unaddressed. ¹⁶ Accurate, self-identified race data—linked with other sociodemographic variables ¹⁶ such as income, education, language, religion, gender, and immigration history—are critical to identifying inequities, designing appropriate interventions, evaluating outcomes, and ensuring accountability in care delivery. Ontario Health has issued guidance on the collection and use of sociodemographic data for analysis of equity gaps, outlining foundational practices to support this work. ¹⁷ Without disaggregated data and a critical lens, equity cannot be measured—let alone achieved. In addition, improved data collection must be coupled with a broader shift toward embedding equity in clinical care and research. Integration with initiatives such as Ontario Health’s Provincial Genetics Program and Equity, Inclusion, Diversity and Anti-Racism (EIDA-R) framework^18,19 will be essential to ensure that new tools (eg, genomic or proteomic markers) do not replicate old biases, but instead identify and support at-risk populations with precision and cultural competence.

Ontario has taken initial steps to address these gaps. Through Ontario Health, the province introduced the Black Health Plan to improve outcomes for Black populations across the health system. ²⁰ As part of this effort, the Ontario Renal Network (ORN) established the Black Health CKD Working Group in September 2023 to identify disparities in kidney care and co-develop evidence-informed policy and practice recommendations. This group brings together patients, caregivers, clinicians, researchers, and community leaders to examine data, review literature, and share lived experiences. In community consultations, participants have described feeling overlooked in clinical settings, facing uncertainty about the kidney care process, and expressing concern about whether services are designed to meet their needs. These narratives, alongside quantitative data, underscore the need for improved engagement, communication, and culturally appropriate care models.

Trust-building in health care requires more than consultation. It involves sharing power, ensuring transparency, and embedding equity into how care is planned, delivered, and evaluated. The ORN Working Group has embraced this approach by involving stakeholders with a range of experiences and perspectives as equal partners. By prioritizing Black voices, drawing on community experience, and using disaggregated data, the initiative is developing a scalable framework aligned with the province’s broader health equity strategy. This approach supports system-wide improvements across programs and pathways.

Looking ahead, a broader shift toward social accountability is needed across health care institutions, professional and research communities, education systems, and related sectors. This includes standardized collection of race-based and sociodemographic data, as well as the integration of genomic and proteomic markers to more precisely identify and support at-risk populations. Targeted and culturally appropriate interventions will be necessary to address identified gaps. In addition, increasing representation of diverse individuals in leadership roles across health care, education, and research will help ensure that system-level decisions reflect the needs of the communities they serve.