Association of the Estimated Glomerular Filtration Rate With vs Without a Coefficient for Race With Time to Eligibility for Kidney Transplant
Authors: Leila R. Zelnick, Nicolae Leca, Bessie Young, Nisha Bansal
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Kidney transplant is associated with improved survival and quality of life among patients with kidney failure; however, significant racial disparities have been noted in transplant access. Common equations that estimate glomerular filtration rate (eGFR) include adjustment for Black race; however, how inclusion of the race coefficient in common eGFR equations corresponds with measured GFR and whether it is associated with delayed eligibility for kidney transplant listing are unknown. <h3>Objective</h3> To compare eGFR with measured GFR and evaluate the association between eGFR calculated with vs without a coefficient for race and time to eligibility for kidney transplant. <h3>Design, Setting, and Participants</h3> This prospective cohort study used data from the Chronic Renal Insufficiency Cohort, a multicenter cohort study of participants with chronic kidney disease (CKD). Self-identified Black participants from that study were enrolled between April 2003 and September 2008, with follow-up through December 2018. Statistical analyses were completed on November 11, 2020. <h3>Exposure</h3> Estimated GFR, measured annually and estimated using the creatinine-based Chronic Kidney Disease-Epidemiology (CKD-EPI) equation with and without a race coefficient. <h3>Main Outcomes and Measures</h3> Iothalamate GFR (iGFR) measured in a subset of participants (n = 311) and time to achievement of an eGFR less than 20 mL/min/1.73 m<sup>2</sup>, an established threshold for kidney transplant referral and listing. <h3>Results</h3> Among 1658 self-identified Black participants, mean (SD) age was 58 (11) years, 848 (51%) were female, and mean (SD) eGFR was 44 (15) mL/min/1.73 m<sup>2</sup>. The CKD-EPI eGFR with the race coefficient overestimated iGFR by a mean of 3.1 mL/min/1.73 m<sup>2</sup>(95% CI, 2.2-3.9 mL/min/1.73 m<sup>2</sup>;<i>P</i> &lt; .001). The mean difference between CKD-EPI eGFR without the race coefficient and iGFR was of smaller magnitude (−1.7 mL/min/1.73 m<sup>2</sup>; 95% CI, −2.5 to −0.9 mL/min/1.73 m<sup>2</sup>). For participants with an iGFR of 20 to 25 mL/min/1.73 m<sup>2</sup>, the mean difference in eGFR with vs without the race coefficient and iGFR was 5.1 mL/min/1.73 m<sup>2</sup>(95% CI, 3.3-6.9 mL/min/1.73 m<sup>2</sup>) vs 1.3 mL/min/1.73 m<sup>2</sup>(95% CI, −0.3 to 2.9 mL/min/1.73 m<sup>2</sup>). Over a median follow-up time of 4 years (interquartile range, 1-10 years), use of eGFR calculated without vs with the race coefficient was associated with a 35% (95% CI, 29%-41%) higher risk of achieving an eGFR less than 20 mL/min/1.73 m<sup>2</sup>and a shorter median time to this end point of 1.9 years. <h3>Conclusions and Relevance</h3> In this cohort study, inclusion of the race coefficient in the estimation of GFR was associated with greater bias in GFR estimation and with delayed achievement of a clinical threshold for kidney transplant referral and eligibility. These findings suggest that nephrologists and transplant programs should be cautious when using current estimating equations to determine kidney transplant eligibility.