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FOR PROFESSIONALS

Frequently asked questions about implementation of the requirement for race-neutral eGFR calculations

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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 are required to use race-neutral calculations to estimate their kidney patients’ GFR values.

This page contains information for transplant professionals about the transition plan, including how the OPTN plans to address waiting time modification for registered candidates. Additional information has been prepared for the general public.

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 changes have been adopted by the OPTN?

This policy prohibits the use of eGFR calculations that include a race-based variable in OPTN policy. The OPTN Board of Directors approved this policy on June 27, 2022, and it took effect on July 27, 2022.

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 proposed?

This requirement for race-neutral calculations intends to increase equity in access to transplantation for Black kidney candidates by more accurately estimating their GFR values. If the Black race coefficient is prohibited from use in eGFR calculations within OPTN policy, Black kidney candidates’ eGFR values will be more reflective of their actual kidney function. Read the Establish OPTN Requirement for Race-Neutral eGFR Calculations briefing to the OPTN Board of Directors.

When will this policy take effect?

This policy took effect July 27, 2022. All transplant hospitals are required to use race-neutral eGFR calculations when assessing patients for transplant.

I’m a transplant professional. What will I be required to do?

Transplant hospitals are required to stop any use of race-inclusive eGFR calculations, and transition to the use of only race-neutral calculations.

Do transplant hospitals need to use any specific formulas to calculate eGFR?

No. Transplant hospitals may use any eGFR calculation that does not include a race-based variable. As research on the topic continues to advance, members will be able to use the most current race-neutral eGFR calculations.

How should my transplant hospital prepare for this change?

Transplant hospitals should take steps to understand what calculations they use to estimate GFR, and understand what actions they would need to take to comply with these changes.

This could involve:

  • Program-wide notification of the policy change
  • Training and education for transplant hospital staff
  • Collaboration with laboratory partners to ensure use of race-neutral eGFR calculations
  • Updates to Electronic Medical Records (EMR) systems
  • Informing referring nephrologists and physicians of the changes

This list does not include everything your transplant program might need to do in order to comply with the requirement to use race-neutral eGFR calculations.

The OPTN will monitor GFR values entered into the OPTN computer system, and provide individual member instruction and validation of transition to race-neutral eGFR calculation.

What purview does this policy allow transplant hospitals to modify candidate eGFR waiting time?

The policy change outlines a transition plan that allows transplant programs to modify some candidates’ qualifying eGFR values. Transplant hospitals will be able to take action to immediately address these candidates. Transplant hospital participation in these procedures are optional.

If your transplant hospital:

  • Registered a candidate to the waiting list without a qualifying eGFR value and at a later date used a race-inclusive eGFR calculation to qualify the candidate to begin accruing waiting time

Then your transplant hospital may:

  • Recalculate the candidate’s eGFR using a race-neutral calculation and update the candidate’s qualifying eGFR date in the OPTN computer system

Participating transplant hospitals will be responsible for the identification of candidates who qualify for immediate eGFR waiting time modification on their transplant waiting lists.

Who qualifies for race-neutral eGFR recalculation and modification to their waiting time under the transition plan?

Black candidates who registered to the waiting list without a qualifying eGFR value, but who, at a later date, have a qualifying eGFR value calculated with a race-inclusive equation submitted to the OPTN may qualify for race-neutral eGFR recalculation and modification to their waiting time.

How should transplant hospitals identify candidates who qualify for the transition plan?:

Transplant hospitals should consider:

  • Using OPTN data to identify potentially affected candidates
  • Reviewing potentially affected candidates’ registration dates and calculations used to estimate GFR

When a candidate’s qualifying eGFR is updated in the computer system, they will be able to gain back any waiting time that would have been accrued after the candidate was originally registered.

Why can’t candidates gain waiting time back before their registration date?

OPTN Policy 8.4.A: Waiting Time for Candidates Registered at Age 18 Years or Older states that in order to accrue qualified waiting time, a candidate’s eGFR qualifying date can be the same as their registration date or be submitted after their registration date, but not before.

Does the OPTN plan to address waiting time modification for all registered candidates affected by race-inclusive eGFR calculations?

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.

  1. The committees are developing a follow-on proposal which would give transplant hospitals the opportunity to identify potentially affected Black candidates on their kidney waiting lists.
  2. Submit requests for modification of these candidates’ waiting time.

If the follow-on proposal is approved by the board, it could provide these candidates an earlier start date for accruing qualified waiting time which would allow them to regain any waiting time lost due to use of race-inclusive eGFR calculations. The sponsoring committees plan to propose these changes during the summer 2022 public comment period.

How did this policy change develop?

Prohibiting the use of the Black race variable in eGFR calculations within OPTN policy means that Black kidney candidates’ eGFR values will be more reflective of their actual kidney function. Learn more about eGFR and the impact of race-based adjustments.

The community made this change in order to increase equity in access to transplantation for Black kidney candidates by more accurately estimating their GFR values. Learn more about the proposal’s development.

Questions?

Email kelley.poff@unos.org with questions about this policy.