The state of Georgia has one of the highest levels of chronic kidney disease (CKD) diagnostic inequity. According to Daryl O Crenshaw, MD, FACP, FASN, FASH, “That means if we were able to bridge that gap, 10,000 more Black patients would be diagnosed with CKD.” he pointed out. “I understand this more and more. I want to highlight that part of this diagnostic inequity is even [that] some physicians don’t have the wherewithal or the skill [to diagnose CKD].”
Dr. Crenshaw, a nephrologist who practices in Thomasville, GA, presented at NephCure’s 2025 Health Equity Conference and reminded us of the sobering statistics within our community: Black Americans account for 32% of kidney disease in the United States and are four times more likely to develop kidney disease than white Americans. Hypertension and diabetes comprise the majority of CKD cases in our community, but other conditions such as lupus nephritis can also result in CKD.
But there are also genetic causes, Dr Crenschaw continued. “And now we appreciate APOL-1 mediated kidney disease, particularly people of African descent.”
He broke down the stages of CKD and the levels at which the kidneys function as follows:
Stage 1: 90% or higher
Stage 2: 60-89 % mild kidney disease
Stage 3a: 59-45 Stage 3b:44%-30%
Stage 4: 29% to 15% severe kidney dysfunction
Stage 5: Less than 15% end-stage kidney disease
“Unfortunately, when I see a patient, perhaps 70% of the time, I see a patient in my office, by the time they see me, they are already at stage four chronic kidney disease,” Dr. Crenshaw said. “In other words, that functions of 29% or less, and people of color that comprises about 90% of those individuals, highlighting this level of CKD diagnostic inequity.”
“Lastly, stage five kidney disease is known as end-stage kidney Disease,” Dr. Crenshaw said. “These are individuals that have function less than 15% and also, these are individuals that qualify for the need of what we call kidney replacement therapy. In other words, this is when the individuals need dialysis.”
Dr. Crenshaw points out that we rarely talk about the psychological toll on patients with kidney disease. He pointed to a study of 1,000 patients where 67% experienced symptoms of depression. 36% could not take care of themselves due to mental health problems. An additional 27% contemplated self-harm or suicide. There were 68% that were not offered mental health support, and 53% admitted to finding it hard to speak up about their mental health.
Dr. Crenshaw pointed out, “We’re going to see a significant amount of psychological and psychiatric detriment as a result of these individuals because they have underlying kidney disease and, unfortunately, were not diagnosed at an appropriate time.”
What are the Symptoms of Kidney Failure?
Dr. Crenshaw highlighted some of the warning signs of kidney failure:
- severe fatigue
- nausea and vomiting
- swelling
- a loss of appetite
- itching
Dr. Crenshaw points out that because we are underdiagnosed for CKD in our community, or diagnosed later. Many people have CKD and do not know it.
“In the southeastern part of the United States, there is a high death rate that is affiliated with kidney disease,” Dr. Crenshaw reminds us. “As I just said, 10,000 extra people in Georgia. If there was a bridge in the gap of CKD equity, in other words, the diagnostic inequity, that gap could be bridged. We will see here that we can mitigate even the death rate of kidney disease in this country.”
It is not just the underserved that go undiagnosed. Dr. Crenshaw notes, “I gave a talk to a church about five days ago, a very educated population, and in that population, there were 70% of those individuals, perhaps that were under diagnosed with chronic kidney disease.”
The APOL-1 Connection
“People who identify as Black, African American, African, Afro Carribbean, Hispanic or Latino, have an increased chance of certain genetic forms of kidney disease. Everyone with a gene in their DNA is called APOL-1. Many people from Western or Central African ancestry carry either one of two specific genetic changes or risk alleles in the APOL-1 gene. These APOL-1 risk alleles originated 1000s ago from people from Sub Saharan Africa,” Dr Crenshaw explained.
“If a person’s DNA has these two AOL-1 risk alleles, they have a one in five chance of developing a kidney disease. Doctors call this genetic form of kidney disease, APOL-1 mediated kidney disease,” he continued. “APOL-1 mediated kidney disease can manifest in different ways in different people. Sometimes, it shows up as chronic kidney disease that is misattributed to hypertension. Other times, the disease can cause rapid progression of high levels of protein and urine and is referred to as FSGS (Focal Segmental Glomerulosclerosis).”
Dr. Crenshaw said that it is estimated that about half of Black Americans have at least one APOL-1 risk allele and that 1 in 10 of us are at risk for kidney disease because we have two copies. However, the only way to find out is through genetic testing.
For more resources on APOL-1, check out the resources at NephCures.
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