The Board of Directors of the Organ Procurement and Transplantation Network (OPTN) has approved a mandatory waiting time adjustment for Black kidney transplant candidates disadvantaged by race-based kidney function estimates. The policy revision, which went into effect on January 5, 2023, is a major step toward kidney transplantation equity.
According to OPTN policy, estimated glomerular filtration rate (eGFR) is one of the factors used to set the date a kidney transplant candidate starts to accrue credit for waiting time. Total waiting time is one of the criteria used to determine priority for a kidney transplant and organ offers. A person can join the kidney transplant waitlist once eGFR reaches 20 mL/min/1.73 m2 or less. Race-based eGFR equations disadvantaged Black adults with chronic kidney disease because they estimated a higher level of kidney function compared with patients of other races with the same age, sex, and serum creatinine or cystatin C levels.
“This action underscores our commitment to equity in access to transplantation for all candidates,” Jerry McCauley, MD, MPH, president of the OPTN board stated in a news release. “We and many other organizations have now prohibited the use of a race-based calculation that has unfairly delayed care for many Black patients with kidney failure. Waiting time for a transplant is a major factor in the priority that kidney candidates receive. Thus, 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.”
Race-free eGFR Equations Increasingly Adopted
The new 2021 race-free CKD-EPI eGFR equations recommended by The National Kidney Foundation/American Society of Nephrology Joint Task Force are more accurate. A report published in JAMA Network Open found that 30.3% of US laboratories surveyed in March 2022 had already adopted the 2021 race-free CKD-EPI creatinine equation, 21.6% planned to adopt the equation by July 2022, 10.7% by December 2022, and 2.2% in 2023 or later. The remaining 58.4% of respondents were unsure of future plans. Adoption of the 2021 race-free CKD-EPI creatinine-cystatin C equation was more limited due to few testing options and costs.
Both LabCorp and Quest Diagnostics have adopted race-free formulas for eGFR calculations. All Veterans Affairs laboratories and transplant hospitals now use race-free formulas.
In addition to laboratory reports, race-free eGFR calculators can be found online.
Revising Kidney Transplant Waiting Times
Starting January 5, 2023, the OPTN requires all kidney transplant programs to identify Black kidney candidates whose current qualifying date for waitlisting was based on the use of a race-based eGFR calculation. The programs have 1 year to determine whether a new race-free eGFR calculation would have qualified the candidate sooner as having kidney function of 20 mL/min/1.73 m2 or less. This revised qualifying date could be prior to transplant registration. Programs must apply to the OPTN for a waiting time modification for such candidates and provide documentation. The OPTN will be providing educational resources for programs and transplant candidates.
“This policy change is a much-needed correction to previously biased estimates of kidney function that disadvantaged Black patients,” Silas Norman, MD, MPH, Board of Trustees Chair Elect of the American Kidney Fund and Co-Medical Director of Kidney and Pancreas Transplantation at the University of Michigan in Ann Arbor, said in an interview. He said he expects many Black patients to accrue additional months of waiting time.
“Since the duration of waiting time is what primarily drives access to kidney transplant, this new policy is incredibly important,” he said. “The tangible effect will be patients being transplanted sooner than before the policy was implemented.”
Dr Norman also highlighted the larger implications for patients and the medical community. “The new policy shows that by recognizing inequities in medicine and making structural changes, we have the opportunity to improve health disparities, and ultimately, patient outcomes.”
OPTN Minority Affairs and Kidney Transplantation Committees. Briefing to the OPTN Board of Directors on modify waiting time for candidates affected by race-inclusive estimated filtration rate (eGFR) Calculations. OPTN website. Accessed on January 10, 2022. https://optn.transplant.hrsa.gov/media/zu4ngiwg/bp_mod-candidate-wait-time-date-aff-by-race-based-egfr-calcs_kidmac.pdf
Genzen JR, Souers RJ, Pearson LN, et al. Reported awareness and adoption of 2021 estimated glomerular filtration rate equations among US clinical laboratories, March 2022. JAMA. 2022;328(20):2060-2062. doi:10.1001/jama.2022.15404
OPTN Board approves elimination of race-based calculation for transplant candidate listing. OPTN; June 28, 2022.
Labcorp implements race-free equation for kidney disease test. Labcorp; March 2, 2022.
CKD-EPI creatinine equation (2021) for creatinine-based eGFR. QuestDiagnostics; April 12, 2022.
VA adopts race-free test to determine kidney health. Veterans Affairs; February 22, 2022.