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Reassess Inclusion of Race in Estimated Glomerular Filtration Rate (eGFR) Equation

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Current policy

The estimated glomerular filtration rate (eGFR) calculation is a tool used by kidney transplant programs to measure a patient’s kidney function. The calculation is also one of the ways that a transplant candidate can qualify for kidney waiting time. Waiting time is an important factor for the order in which kidneys are offered to candidates. Race is a variable that is used in some eGFR calculations, and it can cause kidney function to seem better than it really is for Black kidney candidates. Right now, OPTN policy doesn’t say if this variable should or should not be used. In March 2021, the OPTN formed the Reassess Race in eGFR Workgroup (the Workgroup) to evaluate the impact the Black race in eGFR calculations has on the wait time criteria for kidney transplants.

Supporting media

Presentation

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Requested feedback

The OPTN Minority Affairs and Kidney Transplantation Committees are seeking feedback on the following items to inform a future proposal:

  • For transplant programs:
    • Which method of estimating or measuring GFR is your transplant program currently using? Why?
    • How would using a race-neutral eGFR affect your program?
    • What implementation challenges could use of a race-neutral eGFR present for your transplant program?
    • What resources could assist in facilitating a smooth transition for your program?
    • What potential consequences should be considered during this proposal's development?
  • For patients:
    • Do you support the use of a race-neutral eGFR formula? Why or why not?

Anticipated impact

  • What it's expected to do
    • Gather community feedback to inform a future proposal that aims to make access to kidney transplants more equitable for Black kidney candidates
  • What it won't do
    • This Request for Feedback will not result in a policy change

Themes

  • eGFR calculation
  • Equity in transplantation
  • Wait Time calculation

Terms to know

  • Estimated glomerular filtration rate (eGFR): A tool used to measure how well a patient’s kidneys are functioning.
  • Black Race coefficient: A factor that is used in some eGFR calculations. It was developed based on a study that recent research shows may not be reliable or valid.

Click here to search the OPTN glossary

Provide feedback

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Region 1 | 09/24/2021

The region strongly voiced support of removing the race coefficient in the eGFR calculation. There were many comments about this being important work, and several members mentioned their institutions have already stopped using the race coefficient. One member stated that it might be possible to further level the playing field by allow patients to back date their wait time from an eGFR less than 20 rather than dialysis start, as some patients have better access to care and get referred much earlier to transplant.

American Nephrology Nurses Association (ANNA | 09/23/2021

ANNA supports

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Region 6 | 09/23/2021

Attendees believed using a race-neutral eGFR equation is important to ensure certain populations are not disadvantaged and that the OPTN should have a low tolerance for transplant programs who don’t change their calculation. Two attendees noted their hospitals have eliminated race from their eGFR calculations. An attendee asked these programs for guidance to help other hospitals determine which formula to use. One program responded they simply removed the race variable from their eGFR equation, but noted there could be better formulas.

Region 8 | 09/22/2021

Region 8 generally supported this proposal, with the exception of two members pointing out potential areas to address. Several members stated their support of removing race from eGFR calculations and making the calculations race neutral. A member pointed out that the OPTN is in a position to mandate programs to use a specific formula. He believed that there could be an increase in consistency by mandating formulas. A member asked if the OPTN was looking at other areas of policy where race could be a factor in calculations. A member stated that his institution uses eGFR and cystatin C to determine GFR. He was unsure whether race neutral was an appropriate solution. He thought the goal of reducing disparities was good but inquired whether the bigger issue was with referrals to transplant? The member suggested changing the GFR for African Americans to 23. The member thought that removing race correction will turn down black living donors and believed that eGFR of 20 to obtaining waiting time is arbitrary. He further suggested that to reduce white privilege, waiting time should begin at dialysis to reduce disadvantages from inefficiencies caused by transplant centers. He suggested that Cystatin C based eGFR would be the ideal path forward. A member pointed out that two issues are being confounded in this proposal. He noted that although race is a social construct and not suitable for scientific understanding, the CKD-epi and MDRD equations ARE valid (with the inclusion of race) and have been demonstrated to be more accurate than urine collection for creatinine clearance. He suggested that what is needed is reliable formula(s) without reference to race BEFORE they make such a leap. He cited the need to make a scientific move and that the OPTN should lead the way.

John Maxcy | 09/21/2021

I am a living non-directed kidney donor (Caucasian) who donated to an African American male so I feel I can speak on this subject as a first hand experience. We should absolutely get rid of utilizing the race coefficient when it comes to eGFR. Here is my very simple reasoning. My recipient is a very slim African American male who definitely suffered from an inflated eGFR value because of the race coefficient. He had very little muscle mass, but he had to wait 3 long years before the criteria was met for transplant. The oddest part of all of this is that I am an ultramarathon running Caucasian male who has naturally higher than normal creatinine. I was not eliminated or delayed from being a living donor because of this though. Luckily, I didn't have a race coefficient that would have moved me from the approved donor category to a marginal decision. You cannot take a shotgun approach (race based eGFR coefficient) to a situation (organ transplant) that requires a laser scoped rifle. Minorities already face enough challenges when seeking a transplant, mainly the socioeconomic ones. Please eliminate the race coefficient completely, and give them a fighting chance.

Stephanie L | 09/17/2021

Strongly support. The current system is biased on our African American/Black population is unfair and unjust. While there has been discussion on muscle mass and creatine, one must also think about chronic kidney disease patients and the level of muscle mass on the actual level of creatinine. It's a non-factor. The GFR system needs to be race-neutral in offering the same level of access for all races across the board. I would also be in support and recommend a further discussion on the "20" rule of GFR status and being seen by transplant. More work needs to be done with our minority/racial/ethnic populations and increasing access to transplant, with this being a step in the right direction.

Region 7 | 09/15/2021

Comments: Region 7 was supportive of removing the race coefficient in the eGFR equation. Several attendees expressed that they agreed with this direction and also agreed that the race coefficient should be removed. During the discussion, many regional members agreed and supported removing the race based differentiation and stated that it is limiting and could negatively affect people who are designated as Black/African American. There was also discussion around the creatinine of Black individuals, and that it was believed to be higher based on body mass. One attendee commented that, there was probably determination early on, that it was not something without basis. There is some evidence that muscle mass is higher in African Americans and that muscle has effect on creatinine. However, several attendees agreed that it should be removed, because it would be detrimental for African Americans with lower muscle mass and they would not want them to be penalized for that. Another attendee commented that, there was a study in the 1960s that was based on muscle mass in African Americans that contributed to higher creatinine. Adding that a lot of things have changed over the decades with multiracial candidates and that there has to be a more scientific way of looking at this or getting rid of it all together. Many attendees agreed to get rid of the separation.

Region 9 | 09/14/2021

Region 9 was strongly supportive of removing the inclusion of race in the eGFR equation. Several commented that this was a long overdue change. A member noted that some labs still use a race-based equation, which will need to be addressed when making this change. There was also a comment that non-race-based GFR equations could be used at any time while changes were being made.

Christie Thomas | 09/14/2021

This proposal to remove the race coefficient in creatinine based eGFR is a laudable in that it demonstrates an intent to reduce disparities and inequities that currently exist. However, I ask, is this a solution for the problem? I think not. Do we know whether race corrected eGFR reduces referral or is the real problem delayed referral overall for the socioeconomically disadvantaged and marginalized populations; where Blacks form the largest numeric group. If the reason for the disparity is because referrals are delayed until dialysis starts, then changing the calculation that gets your eGFR to 20 will not meaningfully change referrals. If the goal is to level the playing field here are two easy options: Adjust the creatinine based eGFR threshold for Blacks to 23 (20 x the race coefficient); or encourage or mandate a cystatin C eGFR for all transplant listings since the cystatin C based eGFR is accurate and race neutral. Parenthetically, I should note that the idea that an eGFR of 20 should get you waiting time is completely arbitrary and not supported by science. Here is a simple yet radical idea. Change the threshold to begin accumulating wait time to the start of dialysis. Patients can still be waitlisted at an eGFR of 20; but they will not gain wait time. Referral at an eGFR of 20 gives the transplant center time to process, evaluate and waitlist a candidate, hopefully, before they need to start dialysis. And allowing waitlisting at an eGFR of 20 or less without accumulating waiting time will still allow children, former living donors and the highly sensitized to be transplanted preemptively because their priority does not require waiting time (although it helps). It is worth noting that there is no evidence that preemptive deceased donor transplants are beneficial. (https://pubmed.ncbi.nlm.nih.gov/21272074/;https://pubmed.ncbi.nlm.nih.gov/21155898/; https://pubmed.ncbi.nlm.nih.gov/23371953/; https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.15472). Changing threshold for waiting time to dialysis start time is much more transparent and effective than transplant centers removing race coefficients in their own eGFR calculation. After all, for a patient to get to a transplant center from a referring physician, he/she must be cognizant of the race neutral eGFR that the transplant center is using, to refer that patient to the transplant center at an earlier point. There is little incentive for physicians to refer a patient early and the only mandate for referral comes from CMS after a patient starts chronic dialysis. UNOS/OPTN should not omit the race correction for eGFR for transplant candidates because it will have unintended consequences. If race correction is wrong, then it is wrong for all Blacks that have reason to be registered with UNOS/OPTN. It is not only transplant candidates that have to be considered but living donors also. Removing the race correction will mean that more Black living donors will likely be turned down as donors because their renal function will be thought to be too low. Bottom line: This is a well intentioned but misguided proposal. I have given suggestions for correcting inequities that exist for Blacks. This does not require dismantling what might be the most accurate (albeit flawed) way to estimate GFR using serum creatinine. Let’s be bold. Change the threshold to begin accumulating wait time to the start of dialysis. Removing race correction to creatinine based eGFR is just tinkering at the edges and is a feel-good idea which is not likely to remove disparities.

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Region 3 | 09/10/2021

Region 3 was supportive of removing the race coefficient in the eGFR equation. An attendee commented the ASN/NKF taskforce will presumably be coming out with a race neutral eGFR equation, and added they have announced they have submitted the final recommendations for publication. They went on to note transplant hospitals will be able to use this formula when available. The commenter also stated their institution no longer includes race in the eGFR calculation. Another attendee question how OPTN policy can impact labs that continue to use the separate values that are sent to primary care physicians who wait to refer patients. Another attendee strongly supported race elimination and encouraged replacing race in KDPI as well. A third attendee expressed strong support for the work of the ASN/NKF Taskforce and the Minority Affairs and Kidney Committees. This commenter added that their healthcare system no longer reports African American eGFR within it electronic medical record, and they look forward to the publication of the Taskforce’s recommendation for a new formula.

Region 2 | 09/10/2021

• Comments: Several members of the region voiced their support to stop the use of eGFR formulas that include the black race coefficient. One member noted that there is an urgent need to remove such formulas and the formulas should be more inclusive of non-white patients. Another member voiced support of using a marker like cystatin C, which has less racial bias. They also stated that Sarcopenia needs to be considered as a disparity in end-organ disease. Another member noted that the committee should consider APOL1 determination in risk stratification of donors. Lastly, it was stated that race has an effect on KDPI calculation and it is time for the community to move to a race neutral calculation.

Marcus Simon | 09/09/2021

The current eGFR formula has been severely flawed and discriminatory against African-Americans, or those who self identify as Black, since it has been used. Using this formula has delayed the timing of interventions that could have slowed CKD progression, leading to worse outcomes. It has delayed the time of when African American patients will be referred for transplant and delayed when qualified waiting time will begin for non-dialysis patients. Furthermore, the African American factor of the formula is also built on the belief that African Americans have more muscle mass than Caucasians, which is just simply untrue. While there may be some differences among races that will affect health conditions and how treatment is administered, these differences must be based in fact, not silly beliefs. Lastly, this change has been long overdue. There has been many conversations and studies pointing out the disparities that are present in healthcare, and it is time to actually take some actions instead of just continuing to talk. Removing race from the formula will be a great step in the types of actions needed to make the changes that are needed. Far too many have suffered, and the time has come to do something about it.

Catherine Ryan | 08/30/2021

The original race-based eGFr calculations were based on a small sample size and the unvalidated belief that Black people have higher muscle mass as a whole, and that therefore their creatinine level would be expected to be higher on this basis. Elevated creatinine is present in a higher proportion of African-Americans compared to white Americans, but this is likely a multifactorial association. Factors such as chronic hypertension and "weathering" are likely to play a role. Consider the parallel of racial populations with a high incidence of diabetes mellitus such as Native Americans. We do not change the definition leading to diagnosis of diabetes in these populations. The definition of chronic kidney disease should not change based on the underlying population by race, given the underlying pathophysiology, particularly as race-based eGFR has the unintended consequence of delaying transplant evaluation for Black men and women as their absolute creatinine level must be higher to meet criteria for transplant. I feel that the Organ Procurement and Transplantation Network should not consider race when determining wait times for organs.

Region 5 | 08/30/2021

Region 5 supported the proposal to Reassess Inclusion of Race in eGFR Equation. A member suggested that the committee research if there is a preferred or recommended formula to use in policy. Many members stated that they strongly support the removal of race in the eGFR equation, and that race should not be included in eGFR. A member supported the proposal and brought up whether a substitution of other facts should be considered to ensure equity on the renal transplant waitlist. The member explained this could prevent introducing other potential disparities in vulnerable groups. Further, the member suggested that the OPTN provide education to centers about current options for calculating eGFR. A member supported the proposal and also suggested to use a fractional decrease in the estimated glomerular filtration rate that utilizes the patient as their own baseline, as opposed to a set cut-off of 20, in order to show a decline in renal function.

Region 4 | 08/27/2021

Region 4 was generally supportive of removing the race coefficient in the eGFR equation. Several commenters agreed that the eGFR equation should be the same for all potential candidates. One attendee commented that the eGFR equation should be eliminated altogether and not considered when determining which patients should be listed. They went on to comment that race/ethnicity should not determine an individual’s ability to be listed for a kidney transplant. Another attendee commented that a better job should be done to educate the African American population on how to be proactive about their care. They went on to comment that everyone should be held to the same standard and eGFR or GFR should be the same for each person at all facilities. An attendee commented that they support efforts to improve access to transplant for groups that may have more difficulty getting an organ. They went on to comment that they also support efforts to increase utilization of every available organ. Finally, one attendee commented that patient feedback on these tools would be important to collect and assess.

Robert Brown | 08/21/2021

Certainly, given the inaccuracy of any eGFR formula, we ought to specify the use of one that puts all individuals on an equal footing when it comes to transplant eligibility. I would strongly endorse the use of a non-race based eGFR calculation for transplant purposes.

Eve Kahn | 08/20/2021

Adopting a race neutral formula will be an incredibly important and timely leap forward for the medical profession, extending lifespans for countless people by innumerable years. Kudos to everyone involved in, and everyone supporting, this groundbreaking work.

Anonymous | 08/19/2021

Someones race should never negatively be used in medical consideriation.

Anonymous | 08/17/2021

Artificially inflating EGFR which has been debunked in the scientific community and is negativity impacting the wait time for black people with CKD in need of a transplant.

Anonymous | 08/13/2021

After listing to the presentation at the UNOS Region 4 meeting, I'm not quite sure why UNOS does not mandate a race neutral test. This seems to be the most simple solution that would ensure the most rapid solution to level the playing field.

Tonya Bradford | 08/09/2021

I very strongly encourage the removal of race as a factor for calculating eGFR. The inclusion of that factor significantly disadvantages African Americans who would otherwise receive a similar eGFR reading without race being included. Those individuals wait longer to be referred for transplant as a result, which may negatively impact their quality of life given that a transplanted kidney provides for better quality of life than dialysis. African Americans should not be disadvantaged in terms of access to transplantation referral due to receiving an eGFR calculation that does not provide a comparable score to others in similar health circumstances.

Sara Hicklin | 08/06/2021

I strongly encourage removing race from the eGFR calculation. I do not believe that African American body composition (muscle mass) is different from other races. African Americans should not be singled out with an eGFR hat is artificially inflated.