Paul T. Williams 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.
The new formula, by contrast, is scientifically difficult to defend. Instead of adjusting for one race in the name of cross-racial accuracy, as the old formula did, the new formula removes the adjustment so that black patients can get faster treatment. Ironically, the formula without a racial adjustment is more racially biased.
The new formula sacrifices accuracy in the name of equity. A team of researchers, publishing in the Journal of the American Society of Nephrology, estimated that the new formula will deem more than 10 million nonblack patients to have either less severe chronic kidney disease or no disease at all—while deeming more than 1 million black patients to have more severe disease or to have disease for the first time. Because the new formula doesn’t include the necessary racial adjustments, however, these reclassifications misrepresent reality.
The human costs of this change will be severe. For every black patient who gains quicker access to treatment, ten nonblack patients risk losing such access. As those patients spend more time waiting for care or a new kidney, their conditions may worsen and bring some to the point of kidney failure, which, untreated, inevitably leads to death.
Patients of all races deserve a formula that accurately estimates their individual kidney function, not one that favors one racial group at the expense of others. The powers that be, however, seem more committed to ideology than fairness. Those patients who miss out on needed transplants because of this formula may be among the first victims of “health equity.” They will not be the last.
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