Kidney Transplantation and Health Equity in ESKD Survival

Background: Recently, the OPTN mandated race-neutral equations to estimate kidney function, and to retroactively apply the results to credit Blacks for the wait time that would have been accrued. This will likely decrease the proportion of White ESRD patients receiving deceased donor kidneys. Because the risks for mortality and ineligibility due to deteriorating health are greater in Whites than non-Whites, the OPTN policy changes could increase racial health disparities in ESRD survival. Methods: Age- and sex-adjusted 2-year, 5-year, and 10-year survival rates from the 2021 United States Renal Data System ESRD cohort were used to estimate the effects of deceased donor kidney re-assignment on racial health equity in ESRD patients. Overall survival calculated as the weighted average of 2-year survival for dialysis, deceased donor, and live-donor transplant patients. Results: Two-year survival was substantially lower in White than Black ESRD patients as originally allocated (70.6% vs. 77.1%). Each 10% in deceased donor kidneys diverted from non-Black to Black recipients increased Black survival by 0.518% whilst decreasing White survival by 0.194%, further increasing Black-White health inequity. Conversely, re-allocating most of the 8853 deceased donor transplants originally allocated to non-White to White dialysis patients would theoretically eliminate White-Black inequity in 2-year survival (73.4% vs. 74.8%). Although this would decrease 2-year survival in non-Whites, all would continue to survive better than Whites. Conclusion: Increasing deceased donor kidney transplants to Blacks from non-Blacks is projected to increase Black-White survival disparities, contrary to the pursuit of health equity. Alternatively, deceased donor kidneys could be assigned by treating patients equally regardless of race, as has been the American ideal.