Nephrologist and former Chief Transformation Officer at Emory Healthcare made life-saving changes
Dr. Amaka Eneanya did not set out to change federal policy. She set out to serve her patients. As a physician executive, nephrologist, and former Chief Transformation Officer at Emory Healthcare, Eneanya spent her career identifying the places where medicine causes harm and doing the hard work of repairing them. She sat down with Rolling Out Health IQ to talk about racialized algorithms, what Black communities need to know about kidney disease, and where the healthcare system still falls short.
Your career spans clinical medicine, public health, and executive leadership. What connects all of it for you?
I just have done what has been passionate for me in my life. I’ve always tried to use my power for good and do the right thing, in particular for Black patients. My career started off with clinical training, then a research fellowship focused on supporting patients with chronic kidney disease in their decision making, and why we saw racial inequities between Black patients and other racial groups. A controversy I was involved in hit the national stage, and that is what led me to executive and administrative careers, because I saw so many injustices baked into clinical medicine that I wanted to be a part of fixing the system and making it more equitable.
What are racialized algorithms in nephrology and how have they harmed Black patients?
Your kidneys filter your blood of waste and extra fluid. In nephrology, we developed a mathematical equation in 1999 to quickly predict kidney function. It is called an EGFR equation, estimated glomerular filtration rate. You are diagnosed with chronic kidney disease when your EGFR is less than 60.
For a long time, there were two equations. One for Black people and one for everybody else. That equation made Black people appear to have 16 to 21% better kidney function than any other racial group. So a doctor would say to a Black person, your kidneys are fine, you don’t meet the threshold for chronic kidney disease, come back as needed. That is really harmful because national guidelines say you should see a nephrologist when your EGFR is less than 60, and you can be listed for a kidney transplant, the only cure for chronic kidney disease, when your EGFR is equal to or less than 20.
For two decades, Black people had to wait longer to see a specialist and longer to get listed for transplant. We already had racial gaps in care, and that equation just widened them.
How did race-based calculations get embedded in kidney care in the first place?
When they developed the equation, they found Black individuals appeared to have better kidney function. They should have asked why, because there is no racial biology. The things that actually cause differences in kidney function are social determinants of health like food, insurance, and the ability to control blood pressure and diabetes.
One biomarker used was creatinine, a byproduct of muscle breakdown. They found Black people had higher creatinine levels and said it must be because Black people have more muscle mass. As a former D1 athlete, there is no way anyone is born with more muscle mass without vigorous physical activity. That was completely made up, and it goes back to the assumption that Black bodies are different, which comes from racism.
What does health inequity look like for Black patients in the kidney disease system today?
The number one cause of chronic kidney disease in the United States is diabetes, and number two is high blood pressure. Both of those conditions are disproportionate in the Black community for a variety of reasons related to social drivers of health, the types of food you are exposed to, pollution, and many other contributing factors. Black people are more likely to progress to kidney failure, which is the stage where you need dialysis or a transplant.
They are less likely to see a specialist, less likely to have their diabetes and high blood pressure controlled, and kidney disease is very silent until you reach the point of needing dialysis. There are now FDA-approved medications that can slow the progression of chronic kidney disease, and Black people are less likely to be on those medications. The inequities stack on top of each other at every level of care.
You helped change national standards. What did that process actually take?
It was a multi-year process and I am writing a book about it. When I got to the University of Pennsylvania, my colleagues said we have to write about race in the EGFR equation. Medical students at Harvard Medical School had already removed it from one of their hospitals in 2017. When we published, I became an overnight national expert and started speaking nationally about why it needed to go.
There was massive resistance. People called it woke medicine and reverse racist. The bullying was real. I was an assistant professor without much power, so we took it to social media. I made a TikTok video that got 30,000 views on Twitter, caught the attention of Grey’s Anatomy and the Roland Martin show, and suddenly it became not cool to keep the equation. At least 17 hospitals removed it. The American Society of Nephrology and National Kidney Foundation created a task force, and I was honored to sit on it. We developed a new race-neutral equation published in the New England Journal of Medicine. At the end of the day, we won.
That led to three federal policies. The first said you could never use a race-based equation to list a patient for transplant. The second, which I call the reparations policy, moved Black patients up the waitlist because the old equation had made them wait longer. Twenty-three thousand Black people have been moved up and about 9,800 have received transplants with adjusted wait times. My father was one of those recipients in January of this year, after waiting about seven or eight years in Philadelphia. The third policy removed another racialized algorithm causing organs from Black donors to be discarded more often than those from other racial groups.
How does digital health help or hurt Black patients depending on how it is built?
AI tools are essentially statistical equations that predict things. Everyone at AI conferences is focused on statistical accuracy, just the numbers. The caveat is if you do not think through what variables you are putting in those equations, you can cause real harm. Are you putting race into something that predicts biology? You should not. We also have to go back and update these tools, retrain them, and make sure they are not causing harm. We used the EGFR equation for two decades without asking whether it still applied to a population that had changed.
What do Black communities need to know about kidney disease and when to advocate for themselves?
The new EGFR equation was recommended in 2021. About 70% of hospital systems have made that change but at least 30% have not. If you see an EGFR value, especially if you have diabetes and hypertension, ask which equation your clinic is using. Is it the 2021 race-neutral equation?
Also ask how your kidneys are doing and whether you need a specialist. Between the 60 and 30 EGFR values is where people fall through the gap. Ask about medications that could slow your kidney disease from getting worse. The majority of people do not get to dialysis. You cannot reverse kidney disease but you can slow it down. Control your diabetes, control your blood pressure, daily use of Advil, Motrin, ibuprofen, naproxen, and Aleve can harm your kidneys. If you have chronic kidney disease, go to Tylenol instead, which is safe for the kidneys though not safe for the liver, not to be used with alcohol.
How far are we from a healthcare system that truly serves Black patients well?
It is going to take some time. A lot of implicit bias training happens at academic medical centers, not every clinic. One of the main reasons Black people are not referred for transplant is clinician bias. They are just not referring Black patients.
I am excited about HBCUs that train the majority of Black physicians. I am a Meharry grad, very proud class of 2008, and the investment in HBCU medical schools is something I am hopeful about. But we have a ways to go, and so we have to put it back on the community and patients themselves to advocate for their health.