Race-Free Equations and Cardiovascular Risk Assessment: Much Ado About Something

Estimated glomerular filtration rate (eGFR) is central to kidney-function assessment and cardiovascular risk prediction. The equations long used to compute it incorporated a race coefficient that artificially raised values in people of African descent. Because race is a sociocultural construct rather than a biological variable, a 2021 consensus statement recommended adoption of race-free eGFR equations-paralleling cardiology's move from the race-based 2013 Pooled Cohort Equations to the race-free PREVENT equations. Whether removing race meaningfully alters cardiovascular risk stratification has remained largely untested in diverse populations outside North America. The HELIUS study addresses this gap, examining 21,617 Amsterdam adults from six ethnic groups, collapsed into non-African descent, African Surinamese, and Ghanaian categories. Replacing the 2009 race-corrected equation with the 2021 race-free equation lowered eGFR by roughly 9-10 mL/min/1.73 m² in the African Surinamese and Ghanaian groups, while estimates changed little in the non-African descent group. Agreement for composite chronic kidney disease (CKD) classification was near-perfect (Cohen's κ 0.94-0.99), though driven largely by albuminuria, which is unaffected by the eGFR equation; isolating the eGFR component showed the prevalence of eGFR <60 mL/min/1.73 m² roughly doubling in Ghanaian and rising about three-quarters in African Surinamese participants, while falling in those of non-African descent. Within the SCORE2 CKD add-on model, equation choice did not materially change median risk or categorization at the population level. These reassurances are bounded by the cohort's youth (mean age 44 years) and low burden of impaired function (1.2% with eGFR <60). As a cross-sectional study without events, HELIUS demonstrates classificational concordance but cannot establish equal predictive performance, and may not generalize to older or higher-risk populations. HELIUS nonetheless indicates that race-free estimation preserves risk categories without altering management in this low-risk cohort, while underscoring the need for rigorous, longitudinal, event-based validation across diverse global populations.