Racial Disparities in Eligibility for Preemptive Waitlisting for Kidney Transplantation and Modification of eGFR Thresholds to Equalize Waitlist Time

Elaine Ku; Charles E. McCulloch; Deborah B. Adey; Libo Li; Kirsten L. Johansen

doi:10.1681/ASN.2020081144

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Significance Statement

Under current US national policy, determining a patient’s eligibility for kidney transplantation waitlist registration requires the patient’s GFR to be ≤20 ml/min. Because disease progression is faster for Black versus White patients, this policy may contribute to racial disparities in accruable time on the waitlist before dialysis initiation. The authors used models to determine the association between race and time to ESKD from an eGFR of ≤20 ml/min per 1.73 m², finding this time was shorter for Black versus White patients. They then estimated that allowing registration of Black patients on the transplant waitlist at higher levels of kidney function (as early as an eGFR of 24–25 ml/min per 1.73 m²) had the potential to reduce the observed disparities in accruable wait time.

Abstract

Background Patients may accrue wait time for kidney transplantation when their eGFR is ≤20 ml/min. However, Black patients have faster progression of their kidney disease compared with White patients, which may lead to disparities in accruable time on the kidney transplant waitlist before dialysis initiation.

Methods We compared differences in accruable wait time and transplant preparation by CKD-EPI estimating equations in Chronic Renal Insufficiency Cohort participants, on the basis of estimates of kidney function by creatinine (eGFR_cr), cystatin C (eGFR_cys), or both (eGFR_cr-cys). 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 ≤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.

Results By eGFR_cr, 444 CRIC participants were eligible for waitlist registration, but the potential time between eGFR ≤20 ml/min per 1.73 m² and ESKD was 32% shorter for Blacks versus Whites. By eGFR_cys, 435 participants were eligible, and Blacks had 35% shorter potential wait time compared with Whites. By the eGFR_cr-cys equation, 461 participants were eligible, and Blacks had a 31% shorter potential wait time than Whites. We estimated that registering Blacks on the waitlist as early as an eGFR of 24–25 ml/min per 1.73 m² might improve racial equity in accruable wait time before ESKD onset.

Conclusions Policies allowing for waitlist registration at higher GFR levels for Black patients compared with White patients could theoretically attenuate disparities in accruable wait time and improve racial equity in transplant access.

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