True: Including Race in GFR Calculation Delays Diagnosis and Transplant Eligibility for Black Individuals
The statement is TRUE—including race in GFR calculation results in systematically higher eGFR values for Black individuals, which delays diagnosis of kidney disease and delays eligibility for kidney transplant. 1, 2, 3
Evidence of Delayed Diagnosis
When race is included in eGFR equations (like the original CKD-EPI), Black individuals receive eGFR values that are approximately 10-16% higher than non-Black individuals with identical age, sex, and serum creatinine levels. 1, 4 This mathematical adjustment means:
- Black adults are less likely to meet diagnostic thresholds for CKD (eGFR <60 mL/min/1.73 m²) 1
- Approximately 2 million Black adults in the US would be reclassified to having CKD if race were removed from the calculation 1
- The race coefficient causes eGFR to overestimate measured GFR (iothalamate GFR) by a mean of 3.1 mL/min/1.73 m² in Black patients 3
Evidence of Delayed Transplant Eligibility
The NKF-ASN Task Force quantified that removing the race coefficient would increase the number of Black adults meeting transplant referral threshold (eGFR <20 mL/min/1.73 m²) by approximately 290,000 individuals (29% increase). 1 Specific impacts include:
- Delayed waitlist activation: Black patients experience an estimated median delay of 0.5 years (range 0.27-1.23 years) in achieving transplant eligibility when race is included 2
- Shorter time to kidney failure: Black patients have 35% higher risk of reaching eGFR <20 when race is excluded, meaning they actually reach this threshold 1.9 years earlier in real time 3
- Reduced preemptive transplant opportunity: At one center, only 26% of Black patients were listed preemptively before removing the race coefficient, compared to 70% of White patients 5
Clinical Consequences Beyond Transplant
The Task Force documented multiple areas where race-based eGFR creates systematic disadvantages for Black individuals 1:
- Nephrology referral delays: 260,000 fewer Black adults meet referral thresholds (eGFR <30) with race included 1
- Medication access: Fewer Black patients qualify for kidney-protective medications (ACE inhibitors, SGLT2 inhibitors) that require CKD diagnosis 1
- Vascular access placement: Delayed recognition of advanced CKD means fewer Black patients receive timely arteriovenous fistula placement before dialysis 1
The 2021 Solution
The NKF-ASN Task Force recommended in 2022 that all laboratories adopt the CKD-EPI 2021 equation without race (CKD-EPIcr_NB or CKD-EPIcr-cys_NB), which eliminates the race coefficient while maintaining accuracy. 1, 6, 7 This change:
- Reduces differential bias between Black and non-Black individuals 1
- Provides earlier identification of kidney disease in Black patients 1
- Improves equity in transplant access without disadvantaging other groups 1
Important Caveat
While removing race improves equity, the Task Force acknowledged that pre-existing disparities in blood pressure control, nephrology referral, and transplant access existed before race was included in equations and persist after its removal. 1 The race coefficient masked these disparities by systematically underestimating disease severity in Black patients, but removing it does not automatically eliminate all barriers to care 1.