eGFR in Black Patients

According to the United Network for Organ Sharing (UNOS), as of January 2023, Black patients disadvantaged by a race-based measure of kidney function have been eligible to receive modifications to their waiting time, potentially improving their prioritization for a kidney transplant, as stated in a policy passed by the Organ Procurement and Transplantation Network (OPTN) Board. Since 1986, UNOS has managed the nation’s Organ Procurement and Transplantation Network (OPTN) under contract with the federal government.

This policy is intended to address disparities in waiting times faced by Black patients on the kidney transplant waiting list. Some of these patients were potentially disadvantaged by the use of formulas that used race to help estimate kidney function. Since race is a social concept that does not necessary reflect biology or consider diversity even among the same self-identified race, the National Kidney Foundation and American Society of Nephrology task force announced recommendations to remove Black race in the estimated glomerular filtration rate (eGFR) calculation in 2021.

The eGFR measures how slowly or quickly kidneys remove a waste product called creatinine from the blood. According to the National Kidney Foundation, creatinine levels can differ between people. The reason for this difference may not only be related to kidney disease, but it may also be affected by several other factors, such as age, sex, and body weight.

eGFR is one of the key tests for assessing kidney function and diagnosing kidney disease. The earlier kidney disease is detected, the better the chance of managing it or keeping a patient’s condition from getting worse. eGFR results are used in the following ways:

• Confirming that kidney function is normal for a potential living-kidney donor.
• Enrollment in clinical trials that use kidney function as an inclusion or exclusion criteria.
• If and when to plan for dialysis.
• Making sure the right dose of medicine is used.
• Making sure the right type of imaging tests and dyes are used.
• When to refer a patient to a nephrologist or kidney doctor.
• When to start an evaluation for a kidney transplant.

Race was originally included in eGFR calculations because clinical trials demonstrated that people who self-identified as Black could have, on average, higher levels of creatinine in their blood. It was thought that this was due to differences in muscle mass. The inclusion of race in the eGFR calculation did not consider the ancestral diversity among Black people or individuals who self-identify as being of mixed racial background. Since a patient’s race is not always used when laboratory tests are ordered, laboratories used different eGFR calculations for Black and non-Black and included both numbers in their lab results.

This practice may have led to the severity of kidney disease in Black patients being systemically underestimated. It may have also negatively affected when Black patients got added to the national waiting list as race-based testing may overestimate eGFR that resulted in delays for kidney transplant referral as well listing that may have resulted in longer wait time for kidney transplant.

Waiting time for a transplant is a major factor in the priority that kidney candidates receive. At the UPMC Kidney Transplant Program, we are committed to providing equal access to kidney transplants for all candidates. All kidney transplant programs in the United States have been required since January 2024 to assess their waiting lists and correct waiting times for any Black kidney transplant candidates disadvantaged by having their kidney function overestimated due to use of the race-inclusive calculation.

To date, more than 14,000 modifications to waiting time for Black patients waiting for kidney transplants have been completed throughout the United States. In that group, more than 2,300 transplants have already been performed due to the modifications in waiting time. UPMC adjusted waiting times for Black kidney transplant candidates whose waiting times were affected using the eGFR calculation that included race in January 2024. UPMC remains committed to equal access for all patients and continuously works to implement this important policy change. To learn more or refer a patient for a kidney transplant, please contact our team at transplant@upmc.edu.