How Rewriting Race-Based GFR Equations Changed Kidney Transplant Access, With Pranav Garimella, MBBS, MPH

Implementing wait time modifications for Black transplant candidates who were negatively impacted by race-based GFR equations was associated with an increase in transplant rates, according to new data from a national policy shift.1

The History of Race-Based GFR

"Prior to 2021, lab reports typically reported two GFR values, one for people who identified as Black or African American, and another estimate for everyone else," Pranav Garimella, MBBS, MPH, Chief Medical Officer of the American Kidney Fund and an associate professor of medicine at UC San Diego, told HCPLive. "This was based on studies that found that people who identified as Black have higher levels of creatinine in their blood. What ended up happening was that race-based equations systematically assigned a higher GFR value to Black patients."

In 2023, the Organ Procurement and Transplantation Network (OPTN) implemented a national policy to add wait-time modification for Black candidates who were disadvantaged by eGFR equations with racial coefficients. This policy change sought to correct race-based biological assumptions that had informed clinical decision-making for decades.1

“The decisive action required all transplant centers to review their wait lists and submit wait time modifications to persons who identified as black,” Garimella said. “This was really a restorative policy to bring back some level of equity to the transplant wait lists.”

For almost 4 decades, clinicians utilized different eGFR algorithms to estimate the kidney function of patients who identified as black compared to those who were white or within other racial groups. Two widely used equations, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal Disease Study (MDRD), incorporated 1.159 and 1.210 coefficient factors for black patients, respectively. Ultimately, this led to higher assigned eGFR values for black patients compared to white patients.2,3

The use of higher eGFR values suggested better kidney function in Black individuals than was actually present. This misestimation created barriers to care, including delayed evaluation and specialist referral, ultimately contributing to worse health outcomes. By the time patients presented with kidney failure, delays in referral and evaluation often meant they were listed for transplant later, reducing accrued wait time and delaying transplantation.2,3

New Data on Race-Based Equations

To assess the impact of this policy on transplantation rates, study investigators conducted a quasi-experimental study, analyzing an OPTN database of 181,314 adult kidney transplant candidates who were actively waitlisted. This included 56,344 Black candidates (31.1%) and 124,970 candidates of all other racial and ethnic groups, including American Indian/Alaska Native, Asian, Hispanic/Latino, Native Hawaiian/Other Pacific Islander, White, multiracial, and unknown (68.9%).1

Among these, 21,119 transplant candidates received wait time modifications, which added a median (IQR; range) of 1.7 (0.9-3.0; 0-21.2) years, and a total of 51,061 person-years of waitlist time. In interrupted time series analyses, among Black candidates, policy implementation was associated with an increase of 5.3 transplants per 1000 listings (95% Confience Interval [CI], 3.5 to 7.0), with decreasing transplant rates thereafter (−0.10 transplants per 1000 listings per month; 95% CI, −0.17 to −0.03).1

Among all other candidates, implementation was associated with no significant change in overall transplant (0.6 transplants per 1000 listings; 95% CI, −1.8 to 0.7) and a parallel decreasing trend thereafter (−0.10 transplants per 1000 listings per month; 95% CI, −0.15 to −0.05). In secondary analyses, policy implementation was associated with increased overall and DDKT rates among Black preemptive and postdialysis candidates, no significant changes in LDKT for either group or DDKT for non-Black and/or Hispanic candidates, and a small secular increase in overall transplant rates.1

These findings underscore the need for equitable kidney function assessment practices to ensure timely access to evaluation, transplant listing, and ultimately, improved outcomes.

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. Dinushika Mohottige, Opeyemi Olabisi, L. Ebony Boulware. Use of Race in Kidney Function Estimation: Lessons Learned and the Path Toward Health Justice. Annual review of medicine. 2023;74(1):385-400. doi:https://doi.org/10.1146/annurev-med-042921-124419

3. Schmidt IM, Waikar SS. Separate and Unequal: Race-Based Algorithms and Implications for Nephrology. Journal of the American Society of Nephrology. 2021;32(3):529-533. doi:https://doi.org/10.1681/asn.2020081175