The Board of Directors of the Organ Procurement and Transplantation Network (OPTN) voted to adopt the proposal Establish OPTN Requirement for Race-Neutral eGFR Calculations on June 27, 2022.
This policy took effect on July 27, 2022.
All transplant hospitals in the U.S. are required to use race-neutral calculations to estimate their kidney patients’ GFR values. An FAQ is available about race and eGFR.
This page contains information for the general public about the transition plan, including waiting time modification for registered candidates. Additional information has been prepared for transplant professionals.
What is GFR, and how does it relate to equity?
The glomerular filtration rate (GFR) is a measure of how quickly a person’s kidneys remove a waste product called creatinine from the blood. GFR can be measured directly or estimated using various calculations. These calculations help doctors understand how sick a kidney patient is.
Inclusion of a race variable in some estimated glomerular filtration rate (eGFR) calculations has resulted in disparities in medical practice and treatment, and is understood to have been a contributing factor in systematic underestimation of kidney disease in Black patients.
The removal of race variables from eGFR calculations is supported by recommendations from the American Society of Nephrology (ASN) and National Kidney Foundation (NKF), who formed a joint taskforce that released a report in 2021 and participated in a listening session with the OPTN in 2022. Improving equity in access to transplant opportunities for patients is an OPTN strategic goal.
What's on this page?
This page has information to help you understand:
- What changes were approved by the board
- Why these changes were proposed
- When this policy will be implemented
- How this change could impact future candidates for kidney transplant
- What is the OPTN’s transition plan for this policy
- Who may qualify for a recalculation and waiting time modification under the transition plan
- How the OPTN is planning a follow-on proposal to address additional waiting time modifications
- How to find out if a doctor used a race-based formula
- How to participate in public comment for the follow-on proposal
How is race used to assess patients for transplant?
The Minority Affairs and Kidney Transplantation Committees proposed updating OPTN policy to require eGFR calculations be race-neutral. The Board of Directors approved this policy change on June 27, 2022. This means that any eGFR calculation used for the purposes of the OPTN must not contain a race-based variable.
The proposed change went out for public comment in January 2022. An earlier request for feedback on reassessing the inclusion of race in eGFR had a public comment period in the summer of 2021.
Why were these changes adopted?
Recent research suggests that using a Black race variable in eGFR could actually disadvantage Black patients with chronic kidney disease (CKD). For example, studies suggest that using the variable in the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula has the potential to overestimate Black patients’ kidney function by as much as 16 percent. It’s a problem to overestimate a patient’s kidney function because it means they could appear to be less sick on paper than they actually are. This especially matters in relation to when candidates start to get waiting time. For adult candidates who are not on dialysis, eGFR values must be less than or equal to 20 mL/min to start waiting time.
Patients with overestimated eGFRs may take longer to access waiting time on the transplant waiting list. The overestimation of Black patients’ eGFRs could also lead to poor management of CKD, as well as overall worse outcomes for those patients. Learn more about eGFR and the impact of race-based adjustments.
This seems like it will lead to increased equity in transplant. When was this change be implemented?
The Board of Directors approved this policy change on June 27, 2022, and the policy implemented July 27, 2022. All transplant hospitals are currently required to use race-neutral eGFR calculations.
How could this policy impact future transplant candidates?
This policy intends to ensure that Black kidney candidates' GFR values are more accurately estimated. Upon implementation, calculations used to estimate any future candidates’ GFRs must not include a race variable. This prevents Black candidates’ eGFR values from being artificially increased due to their race. Learn more about eGFR and the impact of race-based adjustments.
But many candidates are already registered to the waiting list, and have already had their GFR calculated. What happens with these candidates when the policy is implemented on July 27, 2022?
A transition plan allows transplant programs to modify some candidates’ qualifying eGFR dates. Transplant programs are allowed to update the date for which a candidate qualified for transplant waiting time, if the program is able to determine the candidate’s current waiting time credit was based on a race-based eGFR. As currently approved, such an adjustment could occur as far back as the date the candidate was initially registered for a transplant. This transition plan is part of the policy approved by the board.
Who qualifies for race-neutral eGFR recalculation and modification to their waiting time under the transition plan?
Black candidates who were registered to the waiting list without a qualifying eGFR value, but who, at a later date, have a qualifying eGFR calculated with a race-inclusive calculation submitted to the OPTN may qualify for race-neutral eGFR recalculation and modification to their waiting time.
How will patients know if they qualify?
Transplant hospitals are responsible for identifying candidates who qualify for this transition plan. Patients should contact their transplant hospital directly about whether they qualify.
How will waiting time for candidates affected by eGFR calculations be addressed?
Not all candidates impacted by race- inclusive eGFR calculations will qualify for the proposal’s transition plan, so the sponsoring committees are developing a pathway for Black candidates whose eGFRs were affected to regain lost waiting time.
Specifically, a follow-on proposal will provide transplant hospitals the opportunity to modify the waiting time of impacted candidates who were already registered at the time of implementation. This proposal aims to allow these candidates to gain the waiting time they could have received if a race- neutral eGFR had been used when they were registered.
The sponsoring committees plans to propose these changes during the summer 2022 public comment period. Talk to your transplant hospital if you think your eGFR has been affected by a race- inclusive calculation.
Did my doctor use a formula with a Black race variable to calculate my eGFR?
The OPTN does not collect this information. Different transplant programs and their affiliated labs use different calculations. Patients should contact their doctor and their transplant program to learn how their eGFR was calculated.
Upon implementation, what will patients be required to do?
Patients are not required to take any action.
Can I get involved in OPTN committees?
Yes. OPTN committees are made up of both patients and professionals. The OPTN needs input from the broader transplant community, including patients and those who care for them, so that policies always incorporate feedback from all stakeholders. Committee members represent all backgrounds, viewpoints and roles within the transplant space. People who volunteer with the OPTN make a difference with organ donation and transplant. Learn how to get involved.
What if I have other questions?
The OPTN patient services line is available to help you with general information and data about donation and transplantation. Call 888-894-6361, Monday through Friday, 8:30 - 5 ET, or email Patient.Services@unos.org.
1 Eneanya ND, Yang W, Reese PP. Reconsidering the Consequences of Using Race to Estimate Kidney Function. American Medical Association. 2019. 322(2):113-114
2 Ahmed S, Nutt CT, Eneanya ND, Reese PR, Sivashanker K, Morse M, Sequist T, Mendu ML. Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes. Journal of General Internal Medicine. 2020. 36(2):464–71DOI: 10.1007/s11606-020-06280-5