Table 1.

Potential implications of the removal of race from the 2009 CKD-EPI eGFR equation

Clinical implication	eGFR threshold (ml/min/ 1.73 m2)	Estimated impacta	Additional considerations	Warranted future research
CKD diagnosis	<60	~ 1 million Black adults will be newly diagnosed with CKD	Potential for closer monitoring for CKD progression in a high-risk group	Racial disparities in early CKD diagnosis among Black adults
Referral to nephrologist	<30	An additional ~68,000 Black patients will have increased specialty evaluation	More aggressive control of cardiac and kidney failure risk factors	Time to referral for Black adults before and after removing the race coefficient
Eligibility for kidney transplant waiting list	≤20	An additional ~37,000 Black patients will have timely access to transplant evaluation	Timely access to optimal treatment for a high-risk population	Trends in proportion of transplants received among Black adults with kidney failure before and after removal of the race coefficient Time to transplant listing for Black adults before and after removal of the race coefficient
Health insurance coverage for medical nutrition therapy	13–50	An additional ~170,000 Black individuals will have access to quality nutritional education	Increased access to optimal nutritional education and/or information in a high-risk population	Effect of using an eGFR race coefficient on eligibility to access medical nutrition services Black patient perspectives regarding new access to medical nutrition services
Health insurance coverage for kidney disease education	15–29	An additional ~47,000 Black individuals will have access to kidney failure education	Increased timely access to education about CKD and kidney failure in a high-risk population	Effect of using an eGFR race coefficient on kidney disease education referral rates and timing
Limited access to clinical tests (for example, imaging procedures with contrast agents)	<60	Many of these patients might not receive testing with contrast	Potentially protective for some Black individuals given their high risk of incident kidney failure86	Effect of using an eGFR race coefficient on eligibility for contrast imaging studies and subsequent benefits (for example, detection of illness) and risks (for example, development of contrast agent-induced acute kidney disease)
Possible dose reduction for ACE inhibitors, ARBs, aldosterone antagonists and direct renin inhibitorsb	<60	Of 717,000 at-risk individuals, the number of patients who might need dose adjustments is unknown	Dose reduction should be based on blood pressure levels and the presence of hyperkalaemia	Contribution of race coefficient to changes in doses of pertinent medications and associated outcomes (for example, progression of CKD, adverse events)
Possible dose adjustments for other medications (for example, opioids, β-blockers, macrolides, warfarin, and low-molecular-weight heparins)c	<60	Of 717,000 at-risk individuals, the number of patients who might need dose adjustments is unknown	Most patients are treated for clinical endpoints and consideration for dosing is usually limited to change in CKD stage	Contribution of race coefficient to changes in doses of pertinent medications and associated outcomes (for example, pain management and proportion of inadequately treated infections)
Impact on patient-centred outcomes and health equity	NA	NA	At the patient level: potential adverse impact on life insurance from a new diagnosis At the provider level: more aggressive care due to lower reported eGFR At the society level: reduced implicit and explicit racial biases in the clinical encounter; increased awareness of the legacy of racism in medicine; reconciliation towards rebuilding trust with patients and communities who have been marginalized	Patient awareness and perspectives regarding the use of race in eGFR equations Provider understanding of the impact of the race coefficient on health equity and other clinical outcomes Implicit bias among clinicians and impact on kidney care quality metrics183 for the treatment of Black adults with and at risk of kidney disease

ACE, angiotensin-converting enzyme; ARBs, angiotensin receptor blockers; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; NA, not applicable. The table is based on data from a cohort of 9,522 non-pregnant Black adults derived from the National Health and Nutrition Examination Survey 2001–2018; the proportions and confidence intervals are adjusted to be representative of the US population using the National Health and Nutrition Examination Survey weights and design, and US census data. ^aBased on data from Diao et al.¹⁶⁴. ^bRecommendations from Kidney Disease: Improving Global Outcomes for eGFR <45 ml/min/1.73 m²: dose reduction for ACE inhibitors, ARBs, aldosterone antagonists and direct renin inhibitors. ^cRecommendations from Kidney Disease: Improving Global Outcomes for eGFR <30 ml/min/1.73 m²: contraindication for metformin, sodiumglucose co-transporter 2 inhibitors, cisplatin and NSAIDs; dose reduction for β-blockers, macrolides, warfarin and low-molecular-weight heparins.