Key Points

In 2023, national policy mandated that kidney transplant centers identify Black candidates for potential waitlist priority modification.Overall, 32% of Black candidates received modification with significant variation by candidate characteristics and transplant center.Candidates who received modification had close to three-fold higher rates of deceased donor transplantation.

Background

In 2023, kidney transplant programs in the United States were mandated by the Organ Procurement and Transplantation Network (OPTN) to identify all Black candidates on their kidney waiting lists and evaluate potential modifications of waiting time. This mandate was the result of established differences in eligibility for candidates to receive priority for donor offers based on race-neutral and race-inclusive eGFR. The policy went into effect on January 5, 2023, and required submission of appropriate modifications with a deadline of January 3, 2024.

Methods

We included OPTN data for adult Black candidates on the kidney and kidney/pancreas transplant waiting lists in the United States between January 6, 2023, and December 31, 2023. We evaluated incidence of wait time modifications based on eGFR, characterized candidates with and without modifications, heterogeneity in center-level implementation of eGFR modifications, and the association of modification with time to deceased donor transplantation using multivariable generalized estimating equations and Cox models.

Results

Overall, 32% (14,419/44,912) of Black candidate listings received an eGFR modification of waiting time priority. In multivariable analysis, candidates with modifications were older (compared with candidates aged 18–49, ages 65–69 and 70+ had adjusted odds ratio [aOR]=1.60 [95% confidence interval (CI), 1.49 to 1.72] and 1.52 [95% CI, 1.40 to 1.66] respectively), female (aOR=1.09, 95% CI, 1.04 to 1.14), and preemptively placed on the waiting list (aOR=2.58, 95% CI, 2.46 to 2.72). Kidney-alone candidates (versus kidney-pancreas candidates), candidates with higher body mass index, and prior transplant recipients also had higher adjusted likelihood of waiting time modification. The median increase in qualifying priority days for candidates was 610 (interquartile range=330–1049). Waitlist modification was associated with a significantly higher rate of deceased donor transplantation (adjusted hazard ratio=2.85 [95% CI, 2.70 to 3.02]). There was significant variation by transplant center in the proportion of prevalent patients with modifications (median=31%, interquartile range=11%–45%).

Conclusions

There was significant patient- and center-level variation in the implementation of eGFR modifications and a higher rate of transplantation for candidates who received modifications.