Impact of Adopting the Race/Ethnicity-Free 2021 CKD-EPI Equation on Cardiovascular Risk Stratification in a Multiethnic European Population: Results from the HELIUS Study

Aim: To assess the impact of the race-free 2021 CKD-EPI equation compared with the 2009 CKD-EPI equation (with/without race correction) on chronic kidney disease (CKD) detection and cardiovascular (CV) risk categorization in a multiethnic European population. Methods: This cross-sectional analysis included 21,617 participants of the Healthy Life in an Urban Setting (HELIUS) study in Amsterdam: Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish, and Moroccan adults aged 18–70 years. Estimated glomerular filtration rate (eGFR) was calculated using the 2009 CKD-EPI equation (with/without race coefficient) and the race-free 2021 CKD-EPI equation. CKD was defined as eGFR <60 mL/min/1.73 m2 and/or urinary albumin-to-creatinine ratio ≥3 mg/mmol. CV risk was assessed using SCORE2 and SCORE2 CKD Add-on models. Results: Compared with the 2009 equation, the 2021 equation yielded lower eGFR values in African Surinamese and Ghanaian participants and marginally higher values in other groups. This led to a modest increase in CKD prevalence among those of African ancestry but did not affect overall CKD classification (Cohen’s κ = 0.94–0.99). Sensitivity, specificity, and C-statistics for CKD detection in risk groups were similar across equations. Integration of CKD modestly increased CV risk estimates, but results were virtually identical across the 2009 and 2021 equations. Conclusion: In this multiethnic European cohort, the race-free 2021 CKD-EPI equation produced different kidney function estimates, but both CKD and CV risk classifications were nearly identical to the 2009 equation. These findings support their clinical interchangeability and endorse adoption of the race-free equation as an equitable and reliable standard for kidney function assessment and CV risk prediction. Lay Summary In this large, multiethnic European cohort, adoption of the race-free 2021 CKD-EPI equation did not meaningfully alter chronic kidney disease (CKD) detection or cardiovascular (CV) risk stratification compared with the 2009 equation. The 2021 CKD-EPI equation lowered estimated glomerular filtration rate (eGFR) in individuals of African descent living in Europe but did not change CKD detection. Agreement between the 2009 and 2021 CKD-EPI equations for CKD classification was almost perfect, and CV risk categorization using SCORE2 and SCORE2 CKD Add-on tools was largely unaffected, indicating that adopting the race-free CKD-EPI equation is unlikely to alter CV risk management at the population level.