Removal of the Black race coefficient from the estimated glomerular filtration equation improves transplant eligibility for Black patients at a single center

Abstract

Race is a social construct that cannot be measured, can be used imprecisely and may contribute to disparities in kidney transplant access for Black patients. At Beth Israel Deaconess Medical Center, we dropped the Black race coefficient in the estimated glomerular filtration rate (eGFR) report in 2017. We conducted a quality improvement project to examine the impact of this change. Before the change, only 26% of our Black patients were listed for preemptive transplant compared to 70% of White patients.Since the change, we found a steady increase in the percentage of Black patients listed before starting dialysis. The average eGFR at listing prior to 2017 was significantly lower in Black patients but after, there was no longer a significant difference. Nine patients "gained" an average of 457 days of wait time directly related to discarding the Black race coefficient. Increased time on the list prior to dialysis initiation allows for evaluation of potential live donors and improves the possibility of a pre-emptive live or deceased donor transplant and allows for a shorter period on dialysis before transplant. In this single center initiative, we demonstrate the benefit of discarding race from the eGFR report for Black patients awaiting kidney transplantation.

Race‐free renal function estimation equations and potential impact on Black patients: Implications for cancer clinical trial enrollment

“…The 16% decrease in eGFR from the removal of the race coefficient and the resulting higher CKD staging have considerable implications for the delivery of medical care 4,9 . For example, more Black patients may obtain a CKD diagnosis (eGFR < 60 ml/min/1.73 m 2 ) for closer monitoring; gain access to a nephrology referral (eGFR < 30 ml/min/1.73 m 2 ), medical nutrition therapy (eGFR = 13–50 ml/min/1.73 m 2 ), and kidney disease education (eGFR = 15–29 ml/min/1.73 m 2 ); and become eligible for kidney transplantation sooner (eGFR < 20 ml/min/1.73 m 2 ) 2,3 …”

“…The National Kidney Foundation and the American Society of Nephrology (NKF–ASN) have officially recommended excluding race from estimated glomerular filtration rate (eGFR) calculations to ameliorate these issues 1 . The resulting lower eGFR due to the removal of race has considerable implications for the delivery of medical care to Black patients, which range from earlier nephrology referral to increased kidney transplant eligibility 2–4 . However, the impact of removing race from eGFR has not been fully analyzed in the context of cancer care and oncology clinical trial eligibility.…”

The race coefficient in glomerular filtration rate-estimating equations and its removal

“…Thus, more Black Americans may be referred to nephrology care, gain access to Medicare coverage for medical nutrition therapy and kidney disease education [11] and become eligible for transplant evaluation and waitlist inclusion [12]. Earlier access to (preemptive) kidney transplant waitlisting [13,14] has been the particular focus of attention in the lay press (https:// www.nytimes.com/2020/06/17/health/many-medical-decision-tools-disadvantage-black-patients.html; accessed 5 May 2022). As Black Americans are at considerably higher risk for kidney failure, many greatly value these potential benefits, which result from being assigned a lower eGFR value [31].…”

Short Report: Race and Ethnicity Misclassification in Kidney Transplantation Research

“…1 Specifically, contemporary kidney function estimation tools founded on erroneous, historic beliefs that the dichotomization of Black versus non-Black in a correction factor contained meaningful biologic information has led to an underestimation of chronic kidney disease burden among Black patients and contributed to delayed referral and wait listing of Black patients with chronic kidney disease. [2][3][4][5][6] Much of the discourse around race correction in kidney function estimation has focused on social construct definition and the consequences of imprecision. 7 Less commonly addressed, however, is measurement imprecision of race.…”