Introducing a Special Series: Addressing Racial and Ethnic Disparities in Kidney Disease

It has been more than a year and a half since the murder of George Floyd precipitated our ongoing national discussion on racial and ethnic inequity. This has been a difficult and at times polarizing conversation, but there is widespread recognition that addressing racial and ethnic inequity is as urgent as ever. Differences in health, access to health care, and life expectancy provide some of the most blatant measures of racial and ethnic inequity. We, as health care providers, need to continue to confront the contribution of poor health care to persistent inequality and work to remedy it. We must also recognize the adverse societal conditions that lead to inequalities of health and be willing to lend our efforts to eliminate them. These conditions have been heightened in the coronavirus disease 2019 pandemic, but they are not new. What is new is increased recognition of the broad contribution of structural racism,¹ amplified by attention to the consequent failure of our health care system to deliver optimum care to people of color. The American Medical Association guidelines on structural racism represent an important step.²

JASN readers are very familiar with the grim facts about the burden of kidney disease in the United States on people of color. Much higher incidence of kidney failure^3,4; ineffective care as exemplified by impaired access to nephrology care, permanent vascular access, transplantation,⁵ or hospice care⁶; and worse long-term transplant outcomes⁵ illustrate the inequities Black Americans face. They are shocking in magnitude and persistent. Indeed, these inequities affect others in our communities, including members of indigenous communities and other disadvantaged people. The facts and pleas for getting serious have been known for decades and well documented in our pages.⁷ We must move beyond accepting these facts as the status quo. We must instead recognize the urgency to eliminate these inequities in kidney disease and its treatment. They are neither normal nor acceptable.

The JASN editorial team has resolved to contribute to the ongoing discussion and to use our platform to make sure this renewed attention results in beneficial change for patients with and at risk for kidney disease. We are inviting a series of articles in which we ask the authors to focus on actionable factors. Although continued discovery and documentation of disparities are important, it is clearly not enough because it has not resulted in significant improvement. Hence, we are inviting submission of perspectives and editorials that take on the challenge of proposing strategies that will make a difference, and we are calling upon funding agencies to support testing of these proposed strategies.

Where must we look for change? Certainly, progress will require attention to delivery of care and reimbursement issues. Two powerful essays in this issue kick off the conversation. In one essay, Taylor and Crews⁸ present a forceful exposition of how policies of the Centers for Medicare & Medicaid Services (CMS), intended to improve value and quality, actually penalize dialysis facilities serving predominantly Black communities.

Another area where we must be advocates for change is by promoting policies that affect the physical environment—the places we live, the effect of decades of racial redlining, and the persistent economic and social segregation. In the second article, Nigra and Navas-Acien⁹ explain how lead in drinking water provides a compelling demonstration of persistent environmental injustice. The accompanying study provides striking data showing how impaired kidney function results in increased vulnerability; levels of lead below those considered safe in the Lead and Copper Rule of the US Environmental Protection Agency nevertheless worsen anemia in patients with advanced CKD.¹⁰ As advocates for our patients, we must not wait on the doorsteps of our institutions for patients to present with problems and disease. We must learn to identify and address the upstream environmental and societal stressors that lead to the disease burden in our patients.

However, this is just a start. One immediate issue for nephrology is the need to estimate kidney function without incorporating race into the estimation tools. JASN is proud, together with the American Journal of Kidney Disease, to have published the interim National Kidney Foundation–American Society of Nephrology Task Force Report on this topic,¹¹ and we anticipate participating in the next steps as we move collectively and in an evidence-based fashion to establish and implement optimum racefree approaches to estimate kidney function.

We expect to publish a robust series of additional perspectives that will propose research into solutions. We think it is critical to emphasize the need for interventional research, including randomized, control trials and quasiexperimental designs.¹² As health care providers, we can do better, and evidence must lead the way. Well-meaning policy changes sometimes do not have the intended effects; CMS policies on quality improvement or hospital readmissions are oft-cited examples of policies with unanticipated adverse effects.¹³ Taylor and Crews⁸ identify others. We will welcome discussion of the best research approaches to create the evidence needed for wise changes including newer implementation science methods, such as cluster randomized, control trials; step-wedge designs; sequential multiple assignment trials; adaptive designs; and mixed quantitative and qualitative methods. There are many topics amenable to study. They include new models of care delivery, use of indigenous community health workers, enhancing interpersonal interactions between patients and providers, addressing the implicit biases inherent in medical decision making, improving communication, and addressing persistent mistrust.

We also recognize the need for attention to our own processes at JASN. We have a diverse team of editors and editorial fellows, but we are intensifying attention to augmenting the diversity of reviewers and our editorial board. We believe the perspective of diverse editors and reviewers is critical to making wise and balanced decisions about the content of JASN.

Finally, in this dialogue, we need to explicitly acknowledge that race is a social construct, and its relation to ancestry is complex.¹² We, as journal editors, have a shared responsibility for a focus on biologic differences that have resulted in neglect of the dominant role of societal factors in causing disease burden—and hence, we ultimately have a shared responsibility in correcting it.

Disclosures

J.P. Briggs reports scientific advisor or membership as a scientific advisor to the Executive Directo of Patient-Centered Outcomes Research Institute (PCORI) and other interests/relationships with PCORI as the Interim Executive Director (November 2019 through April 2020) and as the Editor-in-Chief of JASN. D. Wesson reports consultancy agreements with Tricida; honoraria from Brigham, Medscape, and Women’s Hospital; and scientific advisor or membership via the American Journal of Nephrology Editorial Board, the CJASN Editorial Board, Deputy Editor of JASN, the Journal of Renal Nutrition Editorial Board, and the Kidney International Editorial Board.