Several years ago, nephrologists attempted a first-of-its-kind effort: remove race from a key clinical algorithm, and attempt to undo the harms of the race-based equation for those who were still being negatively affected by it.
Until 2021, eGFR, which is used to measure kidney function, was inflated by around 16% to 21% for Black patients — which could mask severe kidney disease and delay urgently needed transplants. Not only was the equation phased out in 2022, but the Organ Procurement and Transplantation Network mandated that transplant programs submit modifications for Black patients waiting for transplants.
A new study found the change had big results, impacting 27% of Black patients and resulting in 5.3 more transplants per 1000 Black candidates.
“These tangible results are not only significant for nationwide efforts to ensure that kidney transplantation in the United States is fair and equitable for all those facing kidney failure, but they are deeply meaningful for the more than 21,000 people who have received wait time modifications since this policy was implemented,” LaVarne A. Burton, president and CEO of the American Kidney Fund, said in a statement in response to the paper, published in JAMA Internal Medicine Monday.
Health services researcher and Boston Medical Center resident physician Rohan Khazanchi, who was one of the paper’s authors, said the group was interested in examining “this type of reparative intervention that’s thinking about the people who were harmed by the fact that this race-based algorithm was in place, and trying to come up with a remedy that actually addresses some of that harm” because it’s “the first time that’s been done on a national scale.”
Removing race from the eGFR was a long process that divided the field of nephrology for years. After a task force for the National Kidney Foundation voted to remove race from the eGFR, health equity advocates hoped it would serve as a model for the rest of the medical field. But dozens of tools still use race as a variable.
“It was a really heated battle to get the powers that be to have a race neutral equation. I was honestly surprised at how much people were fighting this. Some of the folks that were fighting it were saying things like, ‘It’s not going to resolve disparities in kidney disease’ and here we have some evidence of how it does mitigate some of the disparities,” said Vanessa Grubbs, a nephrologist and internist who founded the nonprofit Black Doc Village, and was not affiliated with the study.
To understand the impact of the new OPTN policy, the researchers compared transplant data from before and after the policy was implemented in 2023, which included over 180,000 candidates — 56,000 of whom were Black. Counterintuitively, the study found that non-Black patients did not have lower odds of receiving a transplant over the course of the study. The data is “debunking faulty zero-sum concerns that improving transplant rates for Black individuals could detract from transplant rates for other individuals,” several physicians wrote in an accompanying editorial. (Khazanchi cautioned that this may be a result of more kidneys becoming available in the years after the policy was introduced).
While this new paper suggests the OPTN policy had its intended effect, it does not solve racial disparities in kidney transplantation. Other research has suggested that the adjustment largely helped patients who had regular access to care, and were already on the waitlist — and that the wait time adjustments varied based on where Black candidates received care.
“I think there’s more thinking to be done about what inequities we have addressed with this policy, and what inequities might be actually getting a little bit worse with a policy of this nature that inherently prioritizes people who had consistent access to care or had lab values in the last couple of years leading up to their transplant wait listing, versus those patients who just get really sick really fast and might have a different story that leads to their transplant wait listing,” Khazanchi said.
For Khazanchi, this could mean investigating other inequities in kidney disease, as well as finding other opportunities where policies with the goal of racial equity could be implemented. He has also been advocating for policies that could remediate the effects of race-based lung tests, which impact payouts for worker compensation.