Race and Evaluation for a Kidney Transplant

The authors of “Transplant Clinician Opinions on Use of Race in the Estimation of Glomerular Filtration Rate” in this issue of CJASN have written a relevant and profound article regarding how eGFR equations use race as a modifier in the practice of kidney transplantation for preemptive wait time, screening for living donors, and monitoring allograft function post-transplant and after kidney donation (1). Although some transplant centers in this study have considered removing this modifier, the concern lies with being able to find viable alternatives that do not result in unintended consequences (1).

The investigators concluded that in their national survey of US transplant centers, there is a consensus among respondents that extant approaches to eGFR calculations that include a race modifier are unsatisfactory; however, there was a broad range of opinions on what should be the status quo.

As discussed in the article, this method has been under scrutiny as it affects Black patients by assigning a higher value to eGFR, which in turn can affect the care of kidney transplant candidates and potential living donors. Although the Modification of Diet in Renal Disease equation and the Chronic Kidney Disease Epidemiology Collaboration equation have been the standard for measuring eGFR for decades, critics have noted that it “is a poor proxy for individual genetic differences, exacerbates inequities, and may propagate structural racism” (1). However, the survey data also highlight the limited availability of proposed alternatives to racefree modifiers.

As a patient with kidney disease who is engaged in her care, having the proper access to care is really important to me. I have advocated for this within the kidney community as it affects me and my fellow patients with kidney disease in our daily lives. In reading this article, I was surprised to learn about the higher GFR value assigned to Black patients. Higher values indicate better kidney function, which in turn can affect one’s diagnosis and assessment. For patients with kidney disease, this is tantamount to obtaining proper access to care to be treated proactively and to be properly referred to a nephrology consult, which could lead to increased access for preemptive transplants among Black patients.

I have been living with CKD for over 20 years and was first diagnosed at the age of 16. At that time, it was hard for me to comprehend everything that was going on and how it happened so quickly. I was not as educated then as I am now and relied heavily on my physician and clinicians for their expertise and guidance. It was difficult for me to understand my own laboratory values and what my body was going through, and it was further difficult to comprehend the bigger picture of what kidney disease meant and how it would affect me for the rest of my life. However, I had an amazing team that had my best interest in mind; they took the time to explain things to me and taught me how to be my best advocate to obtain the level of care I deserve.

This article helped me to better understand how disparities can lie within health care and how they can bias the decisions of health professionals and clinicians. It also highlighted a need for more innovation in the tools and methodologies used to measure and treat kidney disease. As a member of a minority group, my hope is that there is equity when it comes to treating or saving one’s life. However, in my journey as a patient, I have also come to learn that the progression of kidney disease among Black patients is significantly higher than in non-Black patients. As such, there is a need to diminish health care disparities without doing harm to the people who would be affected.

The data provided in this CJASN article were presented in a thoughtful and thorough manner. The table and supplemental appendix support the overall discussion and add additional insights into transplant-specific eGFR practices, with a focus on patients with Black ancestry. As a patient, it was readable, and the language was easy to understand.

Although there are varying opinions on the method of using serum creatinine–based eGFR for listing candidates, we need to move forward with changing the narrative of disparities in using the current equations to ultimately provide better patient outcomes.

Kidney disease is a global public health issue that affects millions of lives year after year. The burden of kidney disease is affected by many factors that can lead to significant health disparities, especially among those with African ancestry. There is a need for a better framework to be proactive in how kidney disease can be prevented and treated, how to accelerate innovation, and how to drive inclusive care for all patients with kidney disease. I am pleased to know that there is action being taken by the National Kidney Foundation–American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease, “which recommended the elimination of race modifiers in eGFR equations” (2), to provide an understanding of how to close the gap in health care disparities and identify strategic ways to eliminate barriers to determining kidney function in the best way that is advantageous to all patients with kidney disease.

Disclosures

A. Adams is a patient ambassador for the American Association of Kidney Patients. She is also a member of Quality Insights and serves as a subject matter expert for its Patient Advisory Committee.

Funding

None.