How One Test Stopped Black Patients from Getting Kidney Transplants

A graphic reads One discriminatory test stopped countless Black patients from receiving life-saving care. Black Health. There is a black-and-white photo of a patient in a hospital gown with brown skin and short black hair.

Black patients have been historically impacted by medical mistreatment, discrimination, racism, and justified mistrust in the health care system. The history of one controversial kidney function test touches all these issues at once.

In this post, we explain the history of the racially modified eGFR kidney function test and detail the policy changes made in 2022 and 2023 that impact this issue.

The history of kidney disease diagnoses in the Black community includes countless instances of patients receiving a diagnoses later than their white counterparts. Often, Black patients also face a longer road to getting on kidney transplant waiting lists–or they aren’t presented with this treatment option at all.

Why is that? For starters, an antiquated kidney function test.

As OPTN explained, the testing of a patient’s GFR (glomerular filtration rate) is critical to the transplant evaluation process, indicating how fast kidneys can remove waste creatine from blood. GFR calculations influence how severe medical providers consider a patient’s kidney disease to be, which may also influence how likely a patient is to qualify for the kidney transplant waiting list.

Traditionally, estimated or “eGFR” calculations include a modifier that changes the results when a patient identifies their race as Black. With that modifier in place, Black patients are more likely to receive a late kidney disease diagnosis or be diagnosed with lower-severity kidney disease compared to the outcome of calculations for a white patient.

When original studies took place to form these calculations, scientists noticed differences between white and Black patients that were almost immediately influenced by racism and bias. While medications or diet could have led certain Black patients to show different creatine levels than other patients in the studies, scientists claimed Black patients had more muscle mass and a higher base level of creatine.

To account for these perceived conclusions, scientists recommended racially modifying eGFR calculations to balance the scales. After all, according to their claims, white patients were at higher risk than Black patients if they shared the same eGFR.

These claims were not rigorously tested or challenged. Instead, they became par for the course in eGFR calculations.

As a result, Black patients who receive racially modified eGFR tests may receive kidney function estimates that are 16% higher than comparable white patients. To put it simply, if a Black patient and a white patient with identical kidney function both received a racially influenced eGFR test, the test would conclude that the Black patient had stronger kidney function than the white patient.

Racially modified eGFR calculations can not only lead to later and less-severe diagnoses of kidney disease in Black patients. They can also negatively impact a patient’s chances of joining the waiting list for a kidney in time to have a shot at the gift of life.

The issue then snowballs: Black patients who join the waiting list will have waited for less time than non-Black patients who were listed sooner, even if their kidney disease severity would be identical without eGFR modifications based on race. That means Black transplant candidates end up waiting longer than white candidates while needing a transplant just as severely to save or improve their lives.

White transplant candidates can amass more “time waited” by joining the transplant list sooner, which could mean they receive a kidney transplant opportunity sooner than Black transplant candidates.

In 2022 and at the start of 2023, OPTN offered two pathways to help close the gap for Black patients.

First, transplant hospitals are now required to use a race-neutral calculation for eGFR.

A requirement since July 27, 2022, this overhaul is intended to increase the accuracy of eGFR estimates for Black patients, increase the availability of transplantation as an option for Black candidates with kidney disease, and enforce the use of the most up-to-date technology possible for these estimates.

Note that this policy change will not specify to transplant hospitals that they must use certain eGFR formulas. It will just prohibit the use of race as a modifying variable in these calculations.

Second, by January 2024, all kidney transplant programs must identify all Black kidney transplant candidates who are on the waiting list to see if their wait time for a kidney has been impacted by the use of racially influenced eGFR calculations.

In each of these cases, the program must determine whether each patient would have joined the kidney transplant waiting list sooner if their need had been assessed using a race-neutral eGFR formula. If they would have joined the list sooner, patients will receive a formal modification to their listed time on the waiting list to account for this discrimination.

Patients will be contacted if they are eligible for a waiting time adjustment under this program.

In truth, even though these policies can have a significantly positive corrective effect for Black kidney patients, they come far too late for many patients and families.

Countless Black patients have passed away waiting for a transplant, never getting a fair shot at the gift of new life. For these patients, and for generations of support communities and loved ones, the damage cannot be undone.

Celebrating and acknowledging Black history and health means accepting that the medical system has left the Black community with deep wounds. The healing process is slow and painful.

We hope for additional legislation changes, announcements, and awareness efforts to right health care wrongs, call out racism and discrimination, and cultivate equity and healing.

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Written by Emily Progin