OPTN Policy Gave Back Time, Increased Transplants for Black Kidney Candidates So Why Have Rates Plateaued?

A 2023 national policy restored waitlisting time and saw an increase in 5.3 transplants per 1000 listings for Black kidney transplant candidates marginalized by race-based kidney function equations for decades.1

New data from the Organ Procurement and Transplantation Network (OPTN) pointed out that transplant rates have begun to decline again, with experts suggesting structural barriers remain a looming challenge in getting historically marginalized patients onto transplant lists.1

“The numbers for a long period of time have been stable, and we see this fight between 2023 and 2024 and over the last two years, once again, there has been a flattening of that curve, and that's because what the policy did was to repay a historical debt of inequity, and that has now been restored,” Pranav Garimella, MBBS, MPH, Chief Medical Officer of the American Kidney Fund and an associate professor of medicine at UC San Diego, told HCPLive. “The question now remains, how do we take this forward and improve access to transplantation for people who have historically been marginalized?”

The history of race-based GFR involves distinct values for patients who identified as black compared to other races. These were based on studies published in the 1990s, which found increased serum creatinine levels in black participants, which they attributed to increased average muscle mass, a historic clinical misconception and stereotype. As a result, race-based GFR equations systematically assigned a ~16–18% higher eGFR value to these patients, leading to an underestimation in the severity of kidney disease, thereby delaying treatment at crucial intervention windows.2

In 2021, the National Kidney Foundation and American Society of Nephrology recommended the 2021 CKD-EPI Creatinine Equation, a race-free formula using serum creatinine, age, and sex, removing the variable “black” or “non-black”. The OPTN implemented a national policy in 2022, bolstering the CKD-EPI equation to improve accuracy and fairness in kidney care.

As recently as January 2023, the OPTN implemented a second national policy, which required the review and adjustment of waiting times for Black candidates who had been disadvantaged by the previous equation.2

Despite the gains made by this national policy, barriers to kidney care and transplantation remain for historically marginalized patient populations.

“Even if we provide them with an updated GFR that makes them eligible, there are factors, financial economics, and social determinants that may not allow them to receive a transplant,” Garimella said. “While the policy itself has shown that it can result in meaningfully increased transplant access to patients who get to that transplant list, getting to that transplant list remains the challenge, and again, beyond people who identify as black.”

Another important facet of this data that Garimella points out is the increase in transplants for candidates who identified as Black, which did not reduce transplants from individuals of other races. He emphasizes that correcting this historical injustice does not mean taking away from others.

Editor’s Note: Garimella has relevant disclosures with Otsuka and the PKD Foundation.

References

1. Khazanchi R, Fleishman A, Eneanya ND, et al. Wait Time Modifications for Black Transplant Candidates Affected by Race-Based Kidney Function Estimation. JAMA internal medicine. Published online September 2026:e260001. doi:https://doi.org/10.1001/jamainternmed.2026.0001

2. Uppal P, Benjamin Ira Golden, Panicker A, Khan OA, Burday MJ. The Case Against Race-Based GFR. Delaware Journal of Public Health. 2022;8(3):86-89. doi:https://doi.org/10.32481/djph.2022.08.014

3. Charles K, Mary Jane Lewis, Montgomery E, Reid M. The 2021 Chronic Kidney Disease Epidemiology Collaboration Race-Free Estimated Glomerular Filtration Rate Equations in Kidney Disease: Leading the Way in Ending Disparities. Health equity. 2024;8(1):39-45. doi:https://doi.org/10.1089/heq.2023.0038

‌