Equity Over Accuracy in Kidney Care
A new formula moves blacks to the front of the line for treatment, regardless of need.
“Health equity” could be claiming new victims. More than 10 million nonblack Americans with chronic kidney disease may have seen their treatments or transplants delayed because of policy changes enacted after 2020’s “racial reckoning.” Some of those patients now face greater risk of death because national transplant organizations have embraced racial activism.
The United Network for Organ Sharing (UNOS), a quasi-governmental nonprofit that runs American transplant centers, enacted a significant policy change. The network compiles the national waitlist for kidney transplants and consults a formula that helps determine which candidates it will prioritize. Before 2020, the network used a formula that measured serum creatinine concentrations to assess a patient’s estimated glomerular filtration rate—the best-known measure of whether a patient has chronic kidney disease. Since black patients typically have higher serum creatinine concentrations than nonblacks with the same kidney function, the formula had applied an adjustment for black patients to ensure a more precise GFR estimate.
Activists in the wake of George Floyd’s death claimed that the formula’s adjustment was racist. This prompted the National Kidney Foundation and the American Society of Nephrology to create a task force to “reassess inclusion of race in the estimation of glomerular filtration rate.” The task force decided to nix the racial adjustment and set to work choosing a new formula that would not take race into account, which it released in 2021.
In December 2022, the board of UNOS’s transplant system issued a directive requiring all transplant centers to apply retroactively the new formula to determine black patients’ spots on the national waitlist. Last December, the network announced the results of its application of the new formula. Removing the racial adjustments had moved the waitlist’s more than 6,100 black patients up by an average of 1.7 years, with just over 500 receiving a transplant. Of course, this meant that some nonblack patients were correspondingly pushed back in line.
While the board heralded this move as “underscor[ing] our commitment to equity” and ending a system that “unfairly delayed care for many black patients,” its decision resulted in unfairly delaying needed transplants for nonblack patients. The old race-conscious formula, far from being a remnant of the Jim Crow era, was published in 1999 and updated in 2009, and was based on studies and tests involving over 10,000 patients across racial, ethnic, and gender lines. The formula’s authors, renowned nephrologists, concluded that without the racial adjustment, the formula would have introduced significant error into screening for chronic kidney disease. It would have resulted in some black patients with less advanced disease or even no disease receiving treatment and transplants more quickly than nonblack patients with more advanced disease.
From City Journal, here.