Impact of Race‐Adjusted Glomerular Filtration Rate Estimation on Eligibility for Simultaneous Liver‐Kidney Transplantation

Abstract

Estimated glomerular filtration rate (eGFR) is adjusted for Black race in commonly used formulas. This has potential implications for access to simultaneous liver-kidney transplantation (SLKT) as qualifying criteria rely on eGFR. We performed a retrospective study of United Network for Organ Sharing national transplant registry data between February 28, 2002, and March 31, 2019, to evaluate the proportion of Black patients who would be reclassified as meeting SLKT criteria (as defined per current policies) if race adjustment were removed from 2 prominent eGFR equations (Modification of Diet in Renal Disease-4 [MDRD-4] and Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]). Of the 7937 Black patients listed for transplant during the study period, we found that 3.6% would have been reclassified as qualifying for chronic kidney disease (CKD)-related SLKT with removal of race adjustment for MDRD-4, and 3.0% would have been reclassified with CKD-EPI; this represented 23.7% and 18.7% increases in SLKT candidacy, respectively. Reclassification impacted women more than men (eg, 4.5% versus 3.0% by MDRD-4; P < 0.05). In an exploratory analysis, patients meeting SLKT criteria by race-unadjusted eGFR equations were significantly more likely to receive liver transplantation alone (LTA) compared with SLKT. Approximately 2.0% of reclassified patients required kidney transplantation within 1 year of LTA versus 0.3% of nonreclassified patients. In conclusion, race adjustment in eGFR equations may impact SLKT candidacy for 3.0% to 4.0% of Black patients listed for LTA overall. Approximately 2.0% of patients reclassified as meeting SLKT criteria require short-term post-LTA kidney transplantation. These data argue for developing novel algorithms for glomerular filtration rate estimation free of race to promote equity.

Navigating the road to liver transplantation equity

“…In a retrospective analysis using UNOS data, 3%-4.5% of Black patients would have been reclassified as simultaneous kidney transplantation listing candidates had a race-neutral equation been used. [9] In an important step towards equity, the Organ Procurement and Transplantation Network (OPTN) has eliminated the use of race-based calculations of renal function.…”

“…In addition, Black adults have been less likely to receive concomitant listing for and receipt of simultaneous kidney transplantation partly due to the use of race-based assessments of renal function. In a retrospective analysis using UNOS data, 3%–4.5% of Black patients would have been reclassified as simultaneous kidney transplantation listing candidates had a race-neutral equation been used 9. In an important step towards equity, the Organ Procurement and Transplantation Network (OPTN) has eliminated the use of race-based calculations of renal function.…”

Achieving Equity for Liver Transplantation Recipients With Chronic Kidney Disease

“…Of interest, Black women had a higher percentage of reclassification to ESLD with CKD compared with Black men (P < 0.05). (6) This is not surprising given that women have lower muscle mass compared with men and the impact of eliminating the race variable was greater at lower numerical creatinine values. Similar trends were noted when examining the AKI pathway, but the findings were not statistically significant.…”

“…(5) In this issue of Liver Transplantation, Panchal and colleagues investigated the impact of removing the race variable from the MDRD and CKD-EPI equations on Black patients' eligibility for an SLK transplant. (6) The authors performed a retrospective analysis of all patients listed for either a liver or SLK in the UNOS database and examined whether the likelihood of meeting the criteria for SLK using either the CKD or sustained acute kidney injury (AKI) pathway was higher if race was eliminated from the eGFR equations. For the entire cohort of 7937 Black patients, the median value of the minimum waitlist eGFR was 7 mL/ min/1.73 m 2 lower when race was removed from the MDRD-4 equation.…”

“…By eliminating the race variable in the eGFR equation and reclassifying Black patients with ESLD, the percentage of patients with ESLD and CKD who had received LTA increased by 4.7% to 6.2% and the percentage of patients with SLK transplants decreased by 5.5% to 8.4%. ( 6 ) Furthermore, 1.7% to 2.1% of those reclassified as having CKD by using the eGFR equation without the race variable received a kidney transplantation within 1 year of the liver transplantation, suggesting that patients meeting the safety net criteria could have been identified earlier. These data clearly demonstrate that Black patients would benefit and receive improved level of care if a race‐free equation were used for listing patients for SLK.…”