Race-Neutral eGFR: Policy Boosts Kidney Transplants for Black Candidates

Implementation of a race-neutral equation for estimating glomerular filtration rate (eGFR) appears to be linked to increased kidney transplant rates for Black candidates, according to data published in JAMA Internal Medicine. The shift in calculation, intended to address historical inequities in healthcare, led to wait-time modifications for over 21,000 adults and a notable rise in deceased donor transplants for this population.

Racial Bias in eGFR and Transplant Access

For decades, eGFR – a measure of kidney function – was calculated using equations that included a race-based correction factor. These equations, derived from studies conducted in the 1990s and 2000s, assigned higher eGFR values to Black individuals, based on the assumption that they had greater muscle mass and therefore produced more creatinine, a waste product filtered by the kidneys. However, this assumption has been increasingly challenged, with growing evidence suggesting it contributed to delayed diagnosis of chronic kidney disease (CKD), reduced access to specialist care, and disparities in kidney transplant listings and receipt. Previous research indicated that the utilize of race-based eGFR equations could overestimate kidney function in Black patients, potentially delaying their referral for transplant evaluation.

In 2021, the National Kidney Foundation and the American Society of Nephrology jointly recommended adopting a race-neutral CKD-EPI equation. This change aimed to provide a more accurate assessment of kidney function across all racial groups. The Organ Procurement and Transplantation Network (OPTN) subsequently mandated that transplant centers submit wait-time modifications for Black candidates whose eGFR, calculated using the race-based equation, was greater than 20 mL/min/1.73 m² but would fall below 20 mL/min/1.73 m² using the race-neutral equation.

Study Findings: Wait-Time Modifications and Transplant Rates

Researchers, led by Rohan Khazanchi, MD, MPH, at Boston Medical Center and Brigham and Women’s Hospital, analyzed data from 181,314 adult kidney transplant candidates across 230 transplant centers in the United States. The study examined the impact of these wait-time modifications on transplant rates between 2023 and June 2025. The cohort included a non-Hispanic Black group and a comparison group encompassing individuals of other racial and ethnic backgrounds.

The analysis revealed that 21,119 adults received wait-time modifications, adding a median of 1.7 years to their waitlist time, totaling 51,061 person-years of additional wait time. Importantly, the transplant rate for Black candidates increased by 5.3 kidney transplants per 1,000 listings following the implementation of the policy. This increase was primarily driven by a significant rise in deceased donor kidney transplants (5.6 transplants per 1,000 listings), while living donor transplants did not show a statistically significant increase.

The benefits were also observed among candidates who had not yet started dialysis, with a 12.3 transplant per 1,000 listings increase in deceased donor transplants. For those already on dialysis, the increase was 4 transplants per 1,000 listings. The full study, published in JAMA Internal Medicine, details the methodology and statistical analysis.

Magnitude of Wait-Time Adjustments

“The sheer magnitude of these wait-time modifications stood out to us,” Khazanchi told Healio. “Tens of thousands of Black patients who were previously disadvantaged by race-based equations received years back on the transplant waitlist, and many of them were transplanted faster than they would have been otherwise as of this policy.”

What the Data Doesn’t Tell Us

While the study demonstrates a positive association between the race-neutral eGFR equation and increased transplant rates for Black candidates, it’s important to acknowledge its limitations. The study design does not prove a causal relationship; other factors occurring concurrently could have contributed to the observed changes. For example, broader initiatives to improve access to transplantation or changes in donor availability could have played a role. The study focused solely on wait-time modifications and transplant rates; it did not examine the impact of the policy on other aspects of kidney care, such as earlier diagnosis of CKD or access to nephrology specialists.

The researchers also noted that transplant rates in the comparison cohort remained relatively stable, suggesting that the observed increase in transplant rates among Black candidates was not simply due to overall changes in the transplant landscape. However, the policy had differential effects across different transplant centers or regions, which were not fully captured in the analysis.

Implications for Equity in Kidney Transplantation

These findings underscore the importance of addressing systemic biases in healthcare algorithms and policies. The historical use of race-based eGFR equations perpetuated inequities in kidney transplantation, and the shift to a race-neutral approach represents a significant step towards achieving greater fairness in access to this life-saving treatment. The American Kidney Fund highlights the ongoing need to address disparities in kidney disease awareness, referral, evaluation, and living donation.

LaVarne A. Burton, MA, President and CEO of the American Kidney Fund, emphasized the significance of these results, stating that they demonstrate the effectiveness of policies designed to correct harmful race-based equations. Burton also noted that while the OPTN policy is a crucial step, further efforts are needed to address persistent disparities in earlier detection of kidney disease and access to living donation.

Looking Ahead

Future interventions should focus on ensuring that all eligible candidates receive wait-time modifications and addressing barriers to access for those who did not benefit from the policy. Clinicians should continue to prioritize timely referral for transplant evaluation and work to increase awareness of living donation opportunities. Ongoing evaluation of the race-neutral eGFR equation and its impact on different populations is essential to ensure that it continues to promote equitable access to kidney transplantation. The broader question of whether other race-based equations in medicine should be re-evaluated to remedy prior harms also warrants consideration.