A doctor performs a renal ultrasound examination of the kidneys on a young, Black, female patient. Photo by sofiko14 via Adobe Stock.
Maria Sukarets is double majoring in Public Health and Neuroscience and she is a 2024-25 health care ethics intern at the Markkula Center for Applied Ethics at Santa Clara University. Views are her own.
At any given time almost 90,000 people in the United States are waiting for a kidney transplant, and every day 11 die waiting for one. Of these people, 35% are Black patients receiving dialysis for renal failure.
Despite making up only 13% of the U.S. population, Black people are three times more likely than white people to develop End Stage Renal Failure/Disease (ESRD). Similarly, despite accounting for more than 35% of all patients in the U.S. receiving dialysis for kidney failure, Black patients are also significantly less likely than white patients to receive a live-donor kidney transplant. This glaring disparity highlights health care inequality within the United States, and drives us to investigate the factors leading to such tangible harm within this population.
How Does This Happen?
Race-Based GFR Calculation
Until recently, standard nephrological practice included a troubling component in the calculation of kidney function. The estimated glomerular filtration rate (eGFR) which measures how well kidneys filter blood, historically applied "race correction" factors that assumed fundamental biological differences between Black and non-Black patients.
In 1999 when this adjustment was first introduced, it operated under the unfounded assumption that Black people have a higher average muscle mass. Adjusting for Black race using the MDRD (Modification of Diet in Renal Disease) and CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equations accounted for an approximate 18% and 16% increase in eGFR. The consequences to this metric inflation were severe. Black patients' kidney function was dramatically overestimated, delaying referrals to specialists, kidney transplant eligibility, and crucial early interventions.
While this practice has been abandoned by all major health care organizations since 2022, the fact that it was allowed to continue unquestioned for over 20 years points to the glaring level of racial disparity in modern renal care. If this racial coefficient had been eliminated, 300,000 more Black patients would have been allowed to receive specialist referrals and 31,000 more would have been considered for transplant list evaluations.
Disparities in Disease Management and Diagnosis
The disproportionate prevalence of ESRD among Black Americans is largely the product of unmanaged diabetes and hypertension. Both of these conditions disproportionately affect Black people in the US, and are uncoincidentally the two leading causes of kidney failure.
Early-stage kidney disease often presents without tangible symptoms, which makes it difficult to diagnose. Despite this, stage I CKD can still be detected through the use of urine, blood, and imaging tests. Timely diagnosis at stages I and II of CKD is essential to halting kidney deterioration. Despite this, physicians are failing to diagnose the early stages of CKD in the Black population, which leads to an irreversible progression of CKD in the community with the highest prevalence of risk factors for the condition.
When CKD progresses to the later stages without appropriate treatment, patients begin dialysis to either supplement or completely replace their renal function. However, dialysis comes with its own set of complications for patients of color. Black and Hispanic patients have been found to have the highest rate of staph bloodstream infections. Black patients are also most prone to premature AV (arteriovenous) graft failure, requiring more surgical intervention and almost always requiring an additional CVC (Central Venous Catheter) placement.
The path to kidney failure is often paved with missed opportunities for intervention, and serves as a poignant example of racial disparity in health care. In 2023, African American adults were 20% more likely to have diagnosed hypertension, and were 1.4 times more likely to be diagnosed with diabetes than white adults. Despite both conditions being the prime risk factors for CKD, the early stages remain least diagnosed throughout the Black community.
Systemic Barriers
Figure: Chart depicting the barriers patients face when seeking a kidney transplant from "Racial disparities in preemptive waitlisting and deceased donor kidney transplantation: Ethics and solutions," Reese, Peter P. et al, American Journal of Transplantation, Volume 21, Issue 3, 958 - 967a.
It is important to understand that these outcomes in Black patients are not proof of predisposition to worse health, but rather the outcome of racial discrimination in numerous areas of life. Social determinants of health; including access to care, education, employment, health literacy, food security, and stable housing all influence a patient's ability to manage their health and wellbeing.
Structural racism in this country presents itself as discrimination that stems from pivotal historical events and trickles into our current lives as harmful policy. Renal care or not, Black patients are consistently the group most affected by health problems due to structural racism. Racist policies are the root of U.S. racial health disparities; how we see this in kidney care is only one piece of the puzzle.
Legal Troubles
In recent years, numerous lawsuits have been filed against the United Network for Organ Sharing (UNOS), alleging racial bias in transplant allocation policies. Similarly, major dialysis companies have faced legal challenges for providing substandard care in facilities serving predominantly minority communities and for steering patients toward dialysis rather than transplantation.
During my year and a half working for one of these companies, I witnessed several of the factors contributing to health care disparity in dialysis firsthand. As a dialysis tech, I worked through cycles of questionable staffing and time card readjustments, cockroach and gnat infestations, power outages, inaccessible language line services, and constantly back-ordered supplies. While this company was holding itself to a subpar standard, our patients were terrified to formally voice their complaints for fear of being labeled as noncompliant with treatment–potentially jeopardizing their transplant status.
Ethical Issues
The Ethics of Race-Based Medicine
The race-based eGFR calculation represents a troubling example of race-based medicine. Using race as a proxy for biological differences reinforces the disproved notion that race represents meaningful genetic or biological differences rather than a social construct. This practice perpetuates harmful stereotypes while potentially delaying critical care for an already vulnerable population.
Autonomy and Informed Consent
Many patients have been unaware that their race directly influenced their kidney disease diagnosis and treatment plan. This lack of transparency undermines patient autonomy and informed consent—core principles of medical ethics. When patients don't understand how their race affects their treatment and transplantation options, how can we consider their consent to be truly informed?
Potential Solutions
Moving Beyond Race-Based Medicine
In 2021, several medical institutions began abandoning the race-based eGFR calculation in favor of race-neutral alternatives. The National Kidney Foundation and American Society of Nephrology Task Force recommended the adoption of the new eGFR-CKD EPI 2021 equation, which estimates kidney function without a race coefficient. This transition represents a positive step forward, but changing an equation doesn't address all systemic inequities.
Addressing Social Determinants of Health
Addressing the underlying social determinants of health is necessary to achieve significant improvements in renal health equity. This includes:
- Expanding access and funding to Medicare/Medicaid
- Creating targeted programs for diabetes and hypertension management in underserved communities
- Increasing health literacy on diabetes, hypertension, and CKD
- Reducing food deserts, providing access and education on healthy diets
Reform in Transplantation Policy
Reform of the organ transplantation system is necessary to address inequities. This includes:
- Revising allocation algorithms to address systematic disadvantages
- Improving outreach to minority communities regarding living donation options
- Providing better financial support for donors to remove economic barriers
Diversifying the Nephrology Workforce
The nephrology workforce does not reflect the diversity of their patients. Increasing representation of Black physicians, nurses, and researchers in nephrology would improve cultural competence, build trust with communities, and bring informed perspectives to research and policy development.
Conclusion
The disparities in renal care are the poster child of health care inequality in the United States. From biased diagnostic tools to unequal access to treatment options, the system has failed Black Americans at every step of kidney disease.
The recent movement away from race-based eGFR calculations represents an important first step, but true equity will require more comprehensive changes. It is clear this population's trust in American health care has been broken time after time. Repairing that relationship is essential to keeping Americans in good health. Only then can we uphold the medical profession's commitment to beneficence, and ensure that care is provided based on need rather than on factors that perpetuate division and discrimination.