Changes Underway May Shorten Black Americans Wait Time for a Kidney Transplant
For some Black Americans living with kidney failure and enduring the long wait for a new kidney, that wait may be getting a little shorter because of an important policy change implemented by the Organ Procurement and Transplantation Network (OPTN). The new policy removes the impact of race-inclusive calculations for estimated glomerular filtration rate (eGFR) which determines the level of kidney function.
“We are acting along with kidney transplant programs nationwide to ensure that any candidates known to have been disadvantaged by a race-inclusive GFR calculation will receive all the waiting time credit for which they qualify, as soon as possible,” said Jerry McCauley, MD, M.P.H., president of the board at OPTN, in a press release about the change.
In 2022, more than 25,000 kidney transplants were performed in the U.S. – a record number. Yet, about 90,000 people are still waiting. Because eGFR can factor into transplant eligibility, using a calculation that took patients’ race into account, may have delayed the starting time for a wait that can last up to five years or more.
“This change has the potential to increase access to transplants, reduce waiting times, and increase equity in the transplant process,” says Carmen A. Peralta, MD, MAS, chief clinical officer at Interwell Health. “By removing the race-based equations from clinical use, we also have the potential to identify persons with advanced disease who could benefit from earlier intervention.”
Looking Back: The Dangers of Including Race When Calculating Kidney Function
Cholesterol levels. Prostrate function. Blood sugar. These have numerical values that signal healthy versus sick, or functioning versus failing.
According to a recent New England Journal of Medicine (NEJM) study however, including race in algorithms may introduce unintended bias, resulting in inaccuracies when estimating presence of disease. The NEJM list identified eight treatment areas potentially impacted, from cardiology to nephrology. Other historic and systemic disparities, such as social determinants of health, were not considered.
“In most cases, using race as a main component in calculating health does not tell the full story of patients in racially diverse communities,” says Melissa Morgan, MHA, CPHQ, Interwell Health’s director of health equity and quality.
Kidney function is estimated using calculations that convert blood creatinine to estimated glomerular filtration rate. These equations have used factors such as age, race, and gender as a strategy to account for non-kidney factors that affect creatinine levels.
Three decades ago, based on the belief that Black people have a higher muscle mass and, therefore, a higher creatinine for the same level of kidney function compared with non-Hispanic whites, clinicians would automatically add points to Black patients’ eGFR scores. This overestimated kidney functioning by as much as 16%, resulting in prolonged waits for care and transplants.
“If organizations continued to use race in the calculations for eGFR rates, Black patients would continue to appear less sick, have poor management of their disease, suffer unnecessary stress, and have worse outcomes,” says Morgan.
By 2017, at least one university health system was actively challenging race-based nephrology care, and others soon followed. The National Kidney Foundation and the American Society of Nephrology started a task force that led to the recommended removal of race from the eGFR equation in 2021.
At one Boston location, nephrologists conducted a clinical study that removed the race multiplier from 2,225 Black patients’ eGFR calculations. Without the race inclusion, approximately 3.1 percent of this patient cohort would have been moved up the queue in the donor waiting list.
In what Dr. Peralta calls a “win for health equity,” the OPTN Board of Directors voted unanimously in 2022 to remove the race inclusion. Dr. Peralta adds: “This policy change shines a light on the potential we have as a community to eliminate the health disparities seen in outcomes of persons living with kidney disease.”
Policy To Practice: The Race-Neutral eGFR Calculation in Action
Starting January 5, 2023, OPTN-member transplant facilities have one year to apply the policy change where it really counts—in real-time patient care. This begins with education for patients, providers, and caregivers.
UNOS Connect, the OPTN learning management system, provides a list of required steps and links to provider and patient education.
Here’s our quick-study snapshot:
- The new policy applies to all eligible dialysis and pre-dialysis candidates, who must now be evaluated or re-evaluated via a race-neutral eGFR equation.
- It applies to all adult patients who register or have registered as Black or African American.
- For patients currently on the transplant waiting list, the waiting times must be retrospectively adjusted to potentially re-position qualified patients in the transplant queue.
- All patients must be informed of the change twice: (1) when they are verified as eligible for a waiting time adjustment and (2) when their waiting time has been modified.
- The OPTN has listed its defined documentation and reporting mandates
Dr. Peralta believes that medical equity involves all stakeholders, and, some day, may be a key component of managed-care and other key quality measures. Peralta concludes: “If payers and providers can work together to share accountability for reducing health disparities, I am very hopeful we can see change.”