Black patients coded non-Black in GFR estimation wait-listed earlier for kidney transplant
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Black patients categorized as non-Black in GFR estimation were waitlisted earlier, but time to kidney failure with replacement therapy did not change, according to a retrospective cohort study in American Journal of Kidney Diseases.
“Although the race term was motivated by increased precision and decreased statistical bias in GFR estimation, there has been a push to remove race (Black vs. non-Black) from the calculation of eGFR out of concern that the higher eGFR may delay access to various aspects of kidney care such as kidney transplantation, as well as the ethical considerations of using race, which is not a biological construct, in a model that overtly drives clinical decisions,” Chi D. Chu, MD, MAS, of the University of California, San Francisco department of medicine and OptumLabs, and colleagues wrote. “Removal of the race term could lead to earlier activation on the kidney transplant waitlist, allowing Black patients to accrue more waiting time prior to starting dialysis and to have a longer window during which preemptive transplantation could occur, potentially allowing patients to avoid dialysis treatment.”
Chu and colleagues examined data for 52,130 patients (40,042 non-Hispanic white;, 8,519 non-Hispanic Black;, 3,569 Hispanic) between 18 and 75 years of age with an outpatient eGFR no greater than 20 mL/min per 1.73 m2 from Jan. 1, 2008, to Dec. 31, 2018, and who had an eGFR between 20 mL/min per 1.73 m2 and 60 mL/min per 1.73 m2 within the previous 2 years. Using eGFRnon-Black for Black patients, another cohort of 11,269 Black patients met study criteria.
Kidney failure with replacement therapy (KFRT) occurred in 9,401 white patients 3,411 Black patients with eGFRBlack values 3,718 Black patients with eGFRnon-Black values and 1,472 Hispanic patients. Death occurred in 13,532 white patients 1,849 Black patients with eGFRBlack values 2,577 Black patients with eGFRnon-Black values and 490 Hispanic patients.
At 3 years, KFRT risk was higher in Black (eGFRBlack, 36%; eGFRnon-Black, 28.7%) and Hispanic patients (40.9%) than in white patients (20.5%). With multivariable adjustment, KFRT risk was attenuated but still statistically significantly increased for Black (HR 1.28; 95% CI, 1.15 to 1.43) and Hispanic patients (HR 1.66; 95% CI, 1.18 to 2.31).
Based on eGFR slopes, Black patients with eGFRBlack values had a median of 0.5 years delay in transplant eligibility compared with Black patients with eGFRnon-Black values.
Chronic kidney disease progression was slower among white patients (median, –4.2 mL/min per 1.73 m2 per year) than in Black (median, –6.4 mL/min/1.73 m2 per year) and Hispanic patients (median, –7.6 mL/min per 1.73 m2 per year).
While the study covered a large and diverse population with longitudinal lab data, it was limited by inability to exclude patients who would be ineligible for transplant after comprehensive evaluation, potential misclassification of AKI episodes, not accounting for eligibility criteria of individual centers and solely evaluating eligibility with race-based eGFR equations.
“While classifying all patients as non-Black for the purpose of GFR estimation is associated with a substantially earlier waitlist eligibility for many Black patients, a large disparity remained in the window available for preemptive transplantation due to disparities in the rate of CKD progression,” Chu and colleagues wrote. “These disparities are unlikely to be remedied by better eGFR equations. Future work should investigate the role of waitlisting eligibility based on alternative criteria such as kidney failure risk, rather than eGFR, as a means to advance equity in access to kidney transplantation.”
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