CKD Progression From the Time of Estimated GFR-Based Waitlist Eligibility and Racial Disparities in Transplant Access,American Journal of Kidney Diseases

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CKD Progression From the Time of Estimated GFR-Based Waitlist Eligibility and Racial Disparities in Transplant Access
American Journal of Kidney Diseases ( IF 9.4 ) Pub Date : 2021-09-17 , DOI: 10.1053/j.ajkd.2021.08.010
Chi D Chu ₁ , Neil R Powe ₂ , Deidra C Crews ₃ , Delphine S Tuot ₂

Affiliation

Rationale & Objective

Equations for estimated glomerular filtration rate (eGFR) that incorporate a term for race assign a higher value to Black individuals compared to non-Black individuals for the same sex, age, and serum creatinine concentration. This difference may contribute to racial disparities in kidney transplant access. We sought to (1) compare time from meeting a transplant eligibility threshold of eGFR ≤20 mL/min/1.73 m² to kidney failure with replacement therapy (KFRT) among Black, Hispanic, and White patients, and (2) assess the impact of incorporation of race into eGFR expressions on establishment of waitlist eligibility and time from eligibility to KFRT.

Study Design

Retrospective cohort.

Setting & Participants

Using the OptumLabs Data Warehouse, we assembled a cohort of 40,042 White, 8,519 Black, and 3,569 Hispanic patients having at least one eGFR value between 20 and 60 mL/min/1.73 m² within the preceding 2 years and an incident outpatient eGFR of ≤20 mL/min/1.73 m² between 2008-2018, using the CKD-EPI creatinine equation that includes a term for race coded as Black or non-Black. We then reassembled a Black patient cohort based on incident eGFR ≤20 mL/min/1.73 m² (n = 11,269) estimated using the same CKD-EPI equation but coding Black patients as non-Black.

Exposure

Race/ethnicity.

Outcome

Time to KFRT.

Analytical Approach

Unadjusted and adjusted Fine-Gray models; linear regression to compute eGFR slopes.

Results

By 3 years, the cumulative incidence of KFRT was 20.5% among White patients, 40.9% among Hispanic patients, 36% among Black patients whose GFR was estimated using a race term coded as Black, and 28.7% among Black patients whose GFR was estimated using a race term coded as non-Black. In fully adjusted analyses including 11,269 Black patients with an eGFR ≤20 mL/min/1.73 m² based on coding them as non-Black, KFRT risk remained greater among Black (HR, 1.28 [95% CI, 1.15-1.43]) and Hispanic (HR, 1.66 [95% CI, 1.18-2.31]) patients than among White patients. Based on slopes of eGFR decline, coding Black patients as non-Black would allow earlier waitlist activation by an estimated median of 0.5 [interquartile range, 0.27-1.23] years.

Limitations

Inability to exclude individuals who would not be kidney transplant candidates if comprehensively evaluated.

Conclusions

A uniform eGFR threshold provides less opportunity for being placed on the transplant waitlist among Black and Hispanic patients. For many Black patients, estimation of GFR as if their race category were non-Black would allow substantially earlier waitlisting but would not eliminate their shorter time to KFRT and reduced opportunity for preemptive transplantation compared with White patients.

中文翻译：

从基于 GFR 的估计等候名单资格开始的 CKD 进展以及移植机会的种族差异

理由和目标

包含种族术语的估计肾小球滤过率 (eGFR) 方程在相同性别、年龄和血清肌酐浓度下，与非黑人个体相比，黑人个体具有更高的值。这种差异可能会导致肾移植获得方面的种族差异。我们试图 (1) 比较黑人、西班牙裔和白人患者从满足 eGFR ≤20 mL/min/1.73 m ²的移植资格阈值到采用替代疗法 (KFRT) 发生肾衰竭的时间，以及 (2) 评估其影响将种族纳入 eGFR 表达式以确定候补名单资格以及从资格到 KFRT 的时间。

学习规划

回顾性队列。

背景及参与者

使用 OptumLabs 数据仓库，我们收集了一组由 40,042 名白人、8,519 名黑人和 3,569 名西班牙裔患者组成的队列，这些患者在过去 2 年内至少有一个 eGFR 值在 20 至 60 mL/min/1.73 m 2 之间，且门诊患者^eGFR ≤ 2008-2018 年间为20 mL/min/1.73 m ²，使用 CKD-EPI 肌酐方程，其中包括编码为黑人或非黑人的种族术语。然后，我们根据使用相同的 CKD-EPI 方程估计的事件 eGFR ≤20 mL/min/1.73 m ² (n = 11,269) 重新组装了黑人患者队列，但将黑人患者编码为非黑人。

接触

种族/民族。

结果

到 KFRT 的时间到了。

分析法

未调整和调整的 Fine-Gray 模型；线性回归计算 eGFR 斜率。

结果

到 3 年，白人患者中 KFRT 的累积发生率为 20.5%，西班牙裔患者中为 40.9%，使用编码为黑人的种族术语估计 GFR 的黑人患者中为 36%，使用编码为黑人的种族术语估计 GFR 的黑人患者中为 28.7%编码为非黑人的种族术语。在包括 11,269 名 eGFR ≤ 20 mL/min/1.73 m ²的黑人患者（基于将其编码为非黑人）的全面调整分析中，黑人中的 KFRT 风险仍然较高（HR，1.28 [95% CI，1.15-1.43]）和西班牙裔患者（HR，1.66 [95% CI，1.18-2.31]）患者高于白人患者。根据 eGFR 下降的斜率，将黑人患者编码为非黑人将允许较早激活候补名单，估计中位数为 0.5 [四分位距，0.27-1.23] 年。