A few years ago, nephrologists tried something unprecedented. It is an attempt to remove race from key clinical algorithms and undo the harms of race-based equations for those who are still adversely affected by them.
Until 2021, eGFR, which is used to measure kidney function, had been raised by about 16 to 21 percent for Black patients, which can mask severe kidney disease and delay urgently needed transplants. Not only was this equation phased out in 2022, but the Organ Procurement and Transplant Network also mandated amendments to transplant programs for Black patients awaiting transplants.
The new study found that this change had major consequences, affecting 27% of black patients and increasing the number of transplants by 5.3 per 1,000 black candidates.
“These concrete results are not only important for the national effort to ensure that kidney transplants in the United States are fair and equitable for all people facing kidney failure, but they are also extremely meaningful for the more than 21,000 people who have seen wait time changes since this policy was implemented,” American Kidney Foundation President and CEO Laverne A. Burton said Monday in JAMA Internal. said in a statement in response to a paper published in Medicine.
One of the study’s authors, health services researcher and resident physician at Boston Medical Center Rohan Kazanchi, said the organization is interested in investigating “this type of restorative intervention that takes into account the people who have been harmed by the fact that we have race-based algorithms in place and actually tries to come up with remedies that address some of that harm” because it is “the first time it’s been done on a national scale.”
Embedded bias: Inside the harrowing fight to remove race from kidney disease calculators
Removing race from eGFR was a long process that divided the field of nephrology for years. After the National Kidney Foundation’s task force voted to remove race from eGFR, health equity advocates hoped it would become a model for other medical fields. However, many tools still use race as a variable.
“It’s been a really hot fight to gain the power to have a race-neutral equation. I was honestly surprised to see so many people fighting. Some of the people fighting were saying things like, ‘We’re not going to solve the kidney disease disparities,’ and here’s evidence that this will alleviate some of the disparities,” said Vanessa Grubbs, a nephrologist and internist who founded the nonprofit Black Dog Village. Along with studying.
To understand the impact of the new OPTN policy, researchers compared transplant data before and after the policy was implemented in 2023. This included more than 180,000 candidates, 56,000 of whom were black. Counterintuitively, the study found that non-black patients were no less likely to receive a transplant during the study period. The data “debunks the false zero-sum concern that increasing transplant rates for Black people may reduce transplant rates for others,” several doctors wrote in an accompanying editorial. (Mr Kazanchi cautioned that this could be a result of more kidneys becoming available in the years after the policy was introduced).
This new paper suggests that the OPTN policy had its intended effect, but it does not resolve racial disparities in kidney transplants. Other research suggests that this adjustment primarily helped patients who were already on the waiting list who were able to receive regular care, and that wait-time adjustments varied depending on where Black candidates received care.
Exploring clinical tools that use race to direct care
“I think we need to think more about what inequalities we’ve been addressing with this policy, and what inequities are actually being exacerbated a little bit by these kinds of policies that essentially prioritize people who have had consistent access to care or had good test scores over the past few years leading up to the transplant waitlist, versus patients who get really sick really quickly and may have a different story that leads them to the transplant waitlist,” Kazanchi said.
For Kazanchi, this could mean examining other inequities in kidney disease and finding other opportunities to implement policies aimed at racial equity. He also advocates for policies that could redress the effects of race-based lung testing on workers’ compensation payments.
