A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease
A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease
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DOI：
10.1681/asn.2021070988
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发表时间：
2021-12-01
影响因子：
13.6
通讯作者：
Powe, Neil R.
中科院分区：
文献类型：
--
作者：
Delgado, Cynthia;Baweja, Mukta;Powe, Neil R.
美国国家肾脏基金会和美国肾脏病学会的一个工作组提出了重新评估在美国GFR估计中纳入种族的建议。工作组建议在所有实验室中立即实施慢性肾脏病流行病学协作肌酐方程修正，不包括种族变量，因为计算不包括种族，它在其开发中包括多样性，其潜在的不良后果不会不成比例地影响任何一个群体，并且它立即可用于所有实验室。第二项建议呼吁国家努力促进增加，常规和及时使用胱抑素C，特别是在成人中确认eGFR，以供临床决策。第三个建议鼓励研究GFR估计与新的内源性滤过标记物和干预措施，以消除种族和ethnicdisparity.Background在响应国家呼吁重新评估种族在临床算法中的使用，美国国家肾脏基金会（NKF）和美国肾脏病学会（ARF）成立了一个工作组，重新评估在美国GFR估计中纳入种族及其对诊断和管理患有或有风险的患者的影响，工作组在10个多月的时间里分阶段组织了活动，以（1）澄清美国eGFR方程的问题和证据（先前在中期报告中描述），并在本最终报告中，（2）评价在GFR估计中使用种族的方法，（3）提供建议。我们确定了26种估计GFR的方法，这些方法考虑或不考虑种族，并将我们的重点缩小到其中的5种方法。我们从六个方面对每种方法进行了全面评估：检测方法的可用性和标准化;实施;方程开发中的人群多样性;与测量的GFR相比的性能;对临床护理、人群跟踪和研究的影响;以及以患者为中心。为了得出一个统一的方法来估计GFR，我们整合了来自许多来源的信息和证据，评估了每种方法的优点和缺点，认识到受影响的黑人和非黑人成年人的数量。（>85%的患者肾功能正常），我们建议立即实施CKD-在美国所有实验室中，EPI肌酐方程重新拟合，不包含人种变量，因为计算中不包括人种，报告，包括其发展的多样性，立即提供给美国的所有实验室，并具有可接受的性能特征和潜在的后果，不会不成比例地影响任何一组个人。(2)我们建议国家努力促进增加，常规和及时使用胱抑素C，特别是在有CKD风险或患有CKD的成人中确认eGFR，因为联合滤过标志物（肌酐和胱抑素C）更准确，并且比单独使用任何一种标志物更能支持更好的临床决策。如果正在进行的证据支持可接受的性能，CKD-EPI eGFR？胱抑素C（eGFR cys）和eGFR肌酐？除确证性检测外，应采用不含人种变量的cystatin C（eGFRcr-cys_R）改装，提供另一种一线检测。(3)应鼓励和资助使用新的内源性滤过标志物估计GFR的研究以及消除种族和民族差异的干预措施。在科学上的投资是需要新的方法，产生准确的，公正的，精确的GFR测量和估计，而不包括种族，促进健康公平，不产生不同的care.Implementation这种统一的方法，没有种族的规格，应在美国各地采用。应通过高度优先和多方利益攸关方的努力实施这一解决办法。
Significance Statement A Task Force from the National Kidney Foundation and American Society of Nephrology developed recommendations for reassessing inclusion of race in the estimation of GFR in the United States. The Task Force recommends immediate implementation of the Chronic Kidney Disease Epidemiology Collaboration creatinine equation refit without the race variable in all laboratories because the calculation does not include race, it included diversity in its development, its potential adverse consequences do not disproportionately affect any one group, and it is immediately available to all laboratories. A second recommendation calls for national efforts to facilitate increased, routine, and timely use of cystatin C, especially to confirm eGFR in adults for clinical decision making. A third recommendation encourages research on GFR estimation with new endogenous filtration markers and interventions to eliminate racial and ethnic disparities.Background In response to a national call for re-evaluation of the use of race in clinical algorithms, the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) established a Task Force to reassess inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and management of patients with, or at risk for, kidney diseases.Process & Deliberations The Task Force organized its activities over 10 months in phases to (1) clarify the problem and evidence regarding eGFR equations in the United States (described previously in an interim report), and, in this final report, (2) evaluate approaches to address use of race in GFR estimation, and (3) provide recommendations. We identified 26 approaches for the estimation of GFR that did or did not consider race and narrowed our focus, by consensus, to five of those approaches. We holistically evaluated each approach considering six attributes: assay availability and standardization; implementation; population diversity in equation development; performance compared with measured GFR; consequences to clinical care, population tracking, and research; and patient centeredness. To arrive at a unifying approach to estimate GFR, we integrated information and evidence from many sources in assessing strengths and weaknesses in attributes for each approach, recognizing the number of Black and non-Black adults affected.Recommendations (1) For US adults (>85% of whom have normal kidney function), we recommend immediate implementation of the CKD-EPI creatinine equation refit without the race variable in all laboratories in the United States because it does not include race in the calculation and reporting, included diversity in its development, is immediately available to all laboratories in the United States, and has acceptable performance characteristics and potential consequences that do not disproportionately affect any one group of individuals. (2) We recommend national efforts to facilitate increased, routine, and timely use of cystatin C, especially to confirm eGFR in adults who are at risk for or have CKD, because combining filtration markers (creatinine and cystatin C) is more accurate and would support better clinical decisions than either marker alone. If ongoing evidence supports acceptable performance, the CKD-EPI eGFR?cystatin C (eGFRcys) and eGFR creatinine?cystatin C (eGFRcr-cys_R) refit without the race variables should be adopted to provide another first-line test, in addition to confirmatory testing. (3) Research on GFR estimation with new endogenous filtration markers and on interventions to eliminate race and ethnic disparities should be encouraged and funded. An investment in science is needed for newer approaches that generate accurate, unbiased, and precise GFR measurement and estimation without the inclusion of race, and that promote health equity and do not generate disparate care.Implementation This unified approach, without specification of race, should be adopted across the United States. High-priority and multistakeholder efforts should implement this solution.