Changes to waitlist eligibility policies may reduce racial disparities in transplant
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Placing Black patients on the waitlist at “slightly” higher levels of kidney function than the current standard may help mitigate some persisting racial disparities in access to kidney transplantation.
“Currently, most transplant centers in the U.S. do not begin the process of evaluation for kidney transplantation candidacy until estimated GFR (eGFR) is close to 20 mL/min/1.73 m2,” Elaine Ku, MD, of the University of California San Francisco, and colleagues wrote. “However, the transplant candidacy evaluation may take several months between referral and waitlist registration, if appropriate. Thus, the point in the course of disease when an individual is identified as being eligible for transplant evaluation and the rapidity of progression of CKD between GFR of 20 mL/min/1.73 m2 and [end-stage kidney disease] ESKD may be critical factors that influence the time available for living donor identification, waitlist registration and accumulation of additional (preemptive) wait time for transplantation.”
According to the researchers, the fact that eligibility for placement on the waitlist does not occur until eGFR declines to 20 mL/min/1.73 m2 or below may lead to greater adverse consequences for Black patients, as studies have shown these patients frequently experience faster CKD progression compared with white patients.
The purpose of the study was twofold: Ku and colleagues aimed to determine the time between eligibility for the waitlist and ESKD based on race (using a variety of models to assess eGFR) and to evaluate whether getting Black patients access to the waitlist at greater levels of kidney function would confer a benefit to accruable wait time.
“We compared differences in accruable wait time and transplant preparation by CKD-EPI estimating equations in Chronic Renal Insufficiency Cohort participants, based on estimates of kidney function by creatinine (eGFRcr), cystatin C (eGFRcys), or both (eGFRcr-cys),” the researchers explained of the methods. “We used Weibull accelerated failure time models to determine the association between race (non-Hispanic Black or non-Hispanic white) and time to ESKD from an eGFR of [at least] 20 mL/min per 1.73 m2. We then estimated how much higher the eGFR threshold for waitlisting would be required to achieve equity in accruable preemptive wait time for the two groups.”
Patients were included in the study if they had an eGFR between 20 mL/min/m2 and 70 mL/min/1.73 m2 between June 2003 and September 2008.
Findings indicated that, when using eGFRcr, 444 participants were eligible for waitlist registration, but the potential time between eGFR of 20 mL/min per 1.73 m2 or less and ESKD was 32% shorter for Black patients vs. white patients. Similar observations were made using the eGFRcys and eGFRcr-cys equations.
“Regardless of which equation we used to estimate kidney function, Black patients had less potential time available for waitlist registration than white patients,” Ku said in a related press release. “However, we found that use of a higher kidney function threshold to allow for earlier eligibility for waitlisting in Blacks could theoretically reduce the racial disparity in time spent in the advanced stages of chronic kidney disease.”
More specifically, to “equalize time spent in the advanced stages of CKD,” Black patients would need to be able to be registered on the waitlist when their eGFR falls to 24 mL/min/1.73 m2 or 25 mL/min/1.73 m2, with white patients remaining eligible at eGFR 20 mL/min/1.73 m2 or below.
“Our study supports the potential utility of using different thresholds for waitlist registration by race as a means of reducing disparities that could occur in wait time accrual for deceased donor transplantation and pre-dialysis transplant preparation time,” the researchers concluded.
However, they acknowledged the complexity of the matter, contending this is merely one strategy of many that should be considered.
“We believe that racial disparities in access to kidney transplantation are likely multifactorial, and additional factors may need to be addressed including differences in social determinants of health, referring provider practices, racism or perceived racism in the evaluation process, and other considerations beyond the estimation of kidney function,” they wrote.
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