Last month, a federal judge in New Jersey reviewed the plea of an inmate who claimed his kidney problems made Covid-19 particularly dangerous for him. The man, Maurice McPhatter, 49, was one of more than 20,000 federal inmates who have requested early release during the pandemic. Thousands have been liberated through that process.
Mr. McPhatter, who was serving a 10-year sentence for drug trafficking, explained in a handwritten letter that he was born with only one kidney and now had a large kidney stone. Results of a blood test scored Mr. McPhatter as low.
But then the judge, Kevin McNulty, did something that lowered Mr. McPhatter on parole did drop. The prison’s medical records contain instructions that kidney test scores for African Americans should be adjusted, using a decades-old formula that distinguished between races. mr. McPhatter is black, and the resulting “race adaptation” placed his score on the healthy side of a commonly used threshold for chronic kidney disease.
“He is not at particular risk of a dangerous Covid infection,” the judge concluded in his March 23 decision, rejecting Mr McPhatter’s application.
But the formula Judge McNulty used to make his decision has been rejected by a growing number of healthcare facilities and experts who say it could lead to misdiagnosis and unequal care for black patients.
The American Society of Nephrology recommended replacing it with a race-blind formula last year. LabCorp, the diagnostic lab company, has already made the switch, as have the Department of Veterans Affairs and numerous major hospital systems.
But during the pandemic, the older formula gained unexpected importance in at least one setting: federal courtrooms where the race-adjusted kidney score is still used to help judges decide whether to grant medical release to black inmates.
It is unclear how many cases have been decided on the basis of the old formula. But this week, lawyers for a black inmate at the Hazelton federal prison complex in West Virginia, Jonte Robinson, filed a lawsuit in federal court in Washington, DC, demanding that the Bureau of Prisons stop adjusting black kidney function scores. prisoners. It also demands that the agency re-evaluate the scores of thousands of black inmates using a newer race-free formula.
“Jonte is demanding that the Bureau of Prisons stop using the race-based formula and take steps to repair the damage suffered by black individuals,” his attorney, Juyoun Han, said in a statement. Adjusting the kidney function scores of black inmates amounts to “racial discrimination,” she added. A spokeswoman for the Bureau of Prisons, Randilee Giamusso, declined to comment on the lawsuit. But she said the Bureau of Prisons is “migrating” to the newer, race-blind formula. “We expect the transition to be completed in the coming months.”
The kidney formula debate is part of a broader reckoning about the role of race in medicine. The race of patients is included in a series of formulas that doctors use to evaluate data on everything from lung function to recommending cesarean sections.
The history of these formulas – and how race crept into them – is varied. Some can be traced back to an obvious racist origin. Others began as well-intentioned attempts to incorporate data from black patients into diagnostic formulas.
For decades, the kidney function formula has involved measuring blood levels of creatinine – a waste product produced by muscles. Higher creatinine levels suggest that the kidneys are struggling, which translates to a lower renal function score.
One of the early kidney formulas was based on data from 249 white men. Then, in 1999, a group of researchers proposed a new formula that would include data from black patients, men and women.
The group’s data — like some subsequent studies — indicated that African-American adults tended to have higher creatinine levels than white Americans — even if actual kidney health is comparable. There are theories as to why. Some researchers speculate that variation in diet or muscle mass could explain the higher levels. Others pointed to demographics: Many of the black participants in a key study were poor and in poor health.
Armed with this data, the researchers created a new formula that called for multiplying the kidney function scores of black patients by a factor of 1.2. They reasoned that the resulting higher renal function score would be more accurate and reduce the chances of overdiagnosing kidney disease in black people.
The medical establishment largely agreed and the formula became standard for many lab companies and hospitals.
But critics said the higher kidney function scores masked actual kidney disease in Black patients, delaying referrals to nephrologists or preventing patients from getting on kidney transplant lists.
In recent years, that criticism has grown louder as a younger generation of doctors and kidney experts have argued that the race-based formula perpetuates a history of racism in medicine. They have said that focusing on a patient’s race obscures the socioeconomic, environmental and genetic factors that can contribute to disease.
“Races should not be used to draw biological inferences about individuals,” a group of doctors wrote in a scientific journal last year about the kidney formula, which they believe could contribute to racial stereotypes and health inequalities.
Using race to score kidney function is particularly fraught because kidney disease disproportionately affects African Americans, who are more than three times more likely than white Americans to have kidney failure and need dialysis or a transplant. That’s partly because diabetes and hypertension — which African Americans suffer greatly — can increase the risk of kidney disease.
Still, some kidney specialists have defended the controversial formulas that use race adjustments, saying they tend to give more accurate measurements of kidney function than those that are race-blind. These specialists argue that ignoring higher baseline creatinine levels in many black Americans will lead to overdiagnosis of kidney disease in them, limiting treatment options for other diseases. Patients with low renal function scores are also often ineligible for, or receive lower doses of, certain life-saving medications, including antibiotics, chemotherapy, and diabetes medications. That’s because certain drugs may be too harmful to a patient’s kidneys, among other dangers.
Despite some disagreement, there is a growing medical consensus that adjusting kidney function scores based on a patient’s race no longer makes sense when other formulas are available that do not contain race.
“It’s just become unacceptable now to have race in the equation,” noted Dr. Neil Powe, who co-chaired the task force of the National Kidney Foundation and the American Society of Nephrology, which recently recommended replacing the race-based algorithm with the new race-blind.
This debate seems to have barely reached the federal judges who have been inundated with inmates’ requests for early medical release because of Covid-19 over the past two years. Given the overcrowded conditions and limited access to medical care in prisons, the stakes were high.
A review of medical release cases suggests that many judges ruled based on blotchy medical records — sometimes not much more than a few blood tests — and often without input from doctors who may have examined the inmate. Medical records before detention were often unavailable.
To make decisions, many judges turned to the Centers for Disease Control and Prevention website, where they found a long list of comorbidities that made Covid-19 particularly dangerous, including diabetes, obesity and chronic kidney disease. Sometimes their statements were partly about whether an inmate had any of these risk factors.
It is unclear exactly how many of these prison cases involved the issue of kidney disease. But a lawyer’s investigation into federal release orders indicated that kidney disease was a dozen occurrences. The CDC estimates that approximately 37 million Americans have chronic kidney disease, and most are unaware of it.
In the case involving Mr. Robinson, the inmate who filed the lawsuit Wednesday, a race-adjusted kidney function score was clearly a factor in the judge’s assessment. Mr Robinson has served 17 years of a 25-year sentence for crimes including complicity in a double murder.
“Where I’m stuck and concerned is whether Mr. Robinson does indeed have chronic kidney disease,” Randolph D. Moss, a federal judge in Washington, DC, said during a telephone hearing last year.
Mr. Robinson’s raw renal function scores ranged from 56 to 58, and a cutoff point of 60 is commonly used to diagnose kidney disease. A nurse who worked in the federal prison system told the judge that because Mr. Robinson is black, his score had to be revised upwards, which would put him above the threshold.
Judge Moss refused to release Mr Robinson, now 40. In a decision written in April 2021, he acknowledged that the Bureau of Prison’s use of the race-based adjustment “may be the subject of dispute.” But he said he wasn’t clear on whether Mr. Robinson even had kidney disease.
“In the absence of further evidence, the Court cannot rely solely on the CDC’s caution regarding chronic kidney disease (which Robinson may or may not have),” the judge wrote.
In an appeal filed last year, Mr. Robinson’s attorney pointed to the racial implications of the old formula: “If Mr. Robinson were white, his medical records would indicate he suffered from chronic kidney disease.”
He lost the appeal.