Racial disparities in preemptive waitlisting and deceased donor kidney transplantation: Ethics and solutions
2020; Elsevier BV; Volume: 21; Issue: 3 Linguagem: Inglês
10.1111/ajt.16392
ISSN1600-6143
AutoresPeter P. Reese, Sumit Mohan, Kristen L. King, Winfred W. Williams, Vishnu S. Potluri, Meera N. Harhay, Nwamaka D. Eneanya,
Tópico(s)Organ Transplantation Techniques and Outcomes
ResumoKidney transplantation prior to dialysis, known as "preemptive transplant," enables patients to live longer and avoid the substantial quality of life burdens due to chronic dialysis. Deceased donor kidneys are a public resource that ought to provide health benefits equitably. Unfortunately, White, better educated, and privately insured patients enjoy disproportionate access to preemptive transplantation using deceased donor kidneys. This problem has persisted for decades and is exacerbated by the first-come, first-served approach to kidney allocation for predialysis patients. In this Personal Viewpoint, we describe the diverse barriers to preemptive waitlisting and kidney transplant. The analysis focuses on healthcare system features that particularly disadvantage Black patients, such as the waitlisting eligibility criterion of a single glomerular filtration rate or creatinine clearance ≤20 ml/min, and neglect of wide variation in the rate of progression to end-stage kidney disease (ESKD) in allocating preemptive transplants. We propose initiatives to improve equity including: (1) standardization of waitlisting eligibility criteria related to kidney function; (2) aggressive education for clinicians about early transplant referral; (3) innovations in electronic medical record capabilities; and (4) rapid status 7 listing by centers. If those initiatives fail, the transplant field should consider eliminating preemptive waitlisting and transplantation with deceased donor kidneys. Kidney transplantation prior to dialysis, known as "preemptive transplant," enables patients to live longer and avoid the substantial quality of life burdens due to chronic dialysis. Deceased donor kidneys are a public resource that ought to provide health benefits equitably. Unfortunately, White, better educated, and privately insured patients enjoy disproportionate access to preemptive transplantation using deceased donor kidneys. This problem has persisted for decades and is exacerbated by the first-come, first-served approach to kidney allocation for predialysis patients. In this Personal Viewpoint, we describe the diverse barriers to preemptive waitlisting and kidney transplant. The analysis focuses on healthcare system features that particularly disadvantage Black patients, such as the waitlisting eligibility criterion of a single glomerular filtration rate or creatinine clearance ≤20 ml/min, and neglect of wide variation in the rate of progression to end-stage kidney disease (ESKD) in allocating preemptive transplants. We propose initiatives to improve equity including: (1) standardization of waitlisting eligibility criteria related to kidney function; (2) aggressive education for clinicians about early transplant referral; (3) innovations in electronic medical record capabilities; and (4) rapid status 7 listing by centers. If those initiatives fail, the transplant field should consider eliminating preemptive waitlisting and transplantation with deceased donor kidneys. Twenty years ago, Kasiske et al. reported that Black patients were much less likely to receive a preemptive kidney transplantation than White patients and recognized that "substantial efforts on the part of all who care for patients with kidney disease" would be required to correct this inequity.1Kasiske BL Snyder JJ Matas AJ Ellison MD Gill JS Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged.J Am Soc Nephrol: JASN. 2002; 13: 1358-1364Crossref PubMed Scopus (0) Google Scholar,2Jay CL Dean PG Helmick RA Stegall MD. Reassessing Preemptive Kidney Transplantation in the United States: Are We Making Progress?.Transplantation. 2016; 100: 1120-1127Crossref PubMed Scopus (51) Google Scholar Yet, subsequent policy changes to the US kidney allocation system (KAS) that were implemented to mitigate transplant disparities have neglected preemptive kidney transplantation. In 2019, 11% of all adult deceased donor kidney transplants (1,859) were preemptive. White patients received 65% and Black patients received only 17% of those preemptive kidneys, during a year when the waiting list comprised 38% White and 31% Black patients. Figure 1 shows persistent racial disparities in preemptive kidney transplantation over time (Figure S1 shows geographic variation). Recently, King et al. analyzed national registry data and reported that, compared to White patients, Black patients had an adjusted Odds Ratio of 0.41 (95% CI 0.37, 0.45; p < .001) for receiving a preemptive deceased donor kidney transplant since implementation of the KAS in 2015—representing a widening disparity from the adjusted Odds Ratio of 0.48 prior to KAS.3King KL Husain SA Jin Z Brennan C Mohan S. Trends in Disparities in Preemptive Kidney Transplantation in the United States.Clin J Am Soc Nephrol. 2019; 14: 1500-1511Crossref PubMed Scopus (39) Google Scholar Although isolating the disadvantages associated with race can be complicated, the authors adjusted for characteristics relevant to time-to-transplantation including blood group and sensitization to human leukocyte antigen.3King KL Husain SA Jin Z Brennan C Mohan S. Trends in Disparities in Preemptive Kidney Transplantation in the United States.Clin J Am Soc Nephrol. 2019; 14: 1500-1511Crossref PubMed Scopus (39) Google Scholar It is important to recognize that preemptively waitlisted patients carry forward their allocation priority even after starting dialysis, so the major advantage of timely transplant referral is a key mechanism that facilitates inequities in access to the entire pool of deceased donor kidneys.4Organ Procurement and Transplantation Network. Policies. https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Accessed November 20, 2020.Google Scholar Figure 2 reveals major disparities in preemptive waitlisting over time. In 2019, 48% of waitlisted White patients, but only 22% of waitlisted Black patients, began to accrue waiting time priority before dialysis.FIGURE 2Racial disparities in preemptive waitlisting for kidney transplantation in the United States, over time. The proportion of all adult (age ≥18 years) candidates added to the kidney transplant waiting list in the United States between 1/1/2005 and 12/31/2019 who were listed preemptively (no dialysis start date reported) was calculated using the National UNOS STAR file based on OPTN data as of March 20, 2020 (see Methods Supplement)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Notably, King et al. also revealed substantially lower access to preemptive kidney transplantation among demographic groups expected to face challenges in navigating complex healthcare systems (e.g., patients with less than high school education) and more limited choice of physicians (e.g., Medicaid beneficiaries). In this Personal Viewpoint, however, we deliberately focus on Black patients because inequities in access to kidney transplantation are substantial and likely require multiple remedies. The goals of rationing organs are to maximize benefit and share that benefit equitably.5Veatch RM Ross LF. Transplantation Ethics. Georgetown University Press, Washington, D.C.2015Google Scholar The first-come, first-served approach that allows transplant priority to accrue for patients prior to starting dialysis is not well supported by the main concepts of equity.6Persad G Wertheimer A Emanuel EJ. Principles for allocation of scarce medical interventions.Lancet. 2009; 373: 423-431Abstract Full Text Full Text PDF PubMed Scopus (551) Google Scholar Aside from racial disparities, preemptive deceased donor kidney transplantation requires accepting that the clinical benefits for the fortunate individuals who avoid dialysis completely are sufficiently large to "offset" the equity problem that other patients endure many years of dialysis or die before transplantation. In some prominent ethical theories related to the fair distribution of scarce resources, preferences are given to the most disadvantaged individuals.6Persad G Wertheimer A Emanuel EJ. Principles for allocation of scarce medical interventions.Lancet. 2009; 373: 423-431Abstract Full Text Full Text PDF PubMed Scopus (551) Google Scholar,7Rawls J. A Theory of Justice. Harvard University Press, Cambridge, Massachusetts1971Crossref Google Scholar As a concrete manifestation of this approach to equity in kidney allocation, preference is given to children—who are highly disadvantaged because severe childhood illness exerts negative consequences across a lifetime.8Amaral S Reese PP. Children first in kidney allocation: the right thing to do.Transpl Int. 2014; 27: 530-532Crossref PubMed Scopus (7) Google Scholar With preemptive kidney transplantation, we see the opposite: already-advantaged patients with both residual kidney function and greater ability to navigate the health system—who are most likely to be White, better educated, and privately insured—get greater access. Viewed from this angle, the persistent status quo of racial and socioeconomic disparities in preemptive transplantation looks indefensible. Preemptive kidney transplantation improves health by avoiding dialysis and reducing the rate of early transplant complications. The transition to dialysis is associated with elevated death rates driven by fluctuations in blood pressure and volume status, inflammation, medication changes, and infections due to dialysis catheters. Preemptively waitlisted patients also enjoy the luxury of time before their kidney function deteriorates and may be able to pass up lower-quality organ offers. The median kidney donor profile index (KDPI) in 2019 was 39% for preemptive adult transplant recipients versus the KDPI of 45% for kidneys accepted by patients who received dialysis prior to transplant. While this difference in kidney quality is small, this finding is consistent with the idea that preemptively listed patients can afford to be selective in kidney acceptance. Preemptively listed patients may also get enhanced access to the best kidneys that are offered first to patients with the longest projected survival, because the survival projection algorithm (i.e., Estimated Posttransplant Survival [EPTS] score) favors patients with less dialysis time. As expected, only 9% of preemptive transplant recipients in 2019 had delayed graft function versus 31% of recipients transplanted after starting dialysis. Preemptive kidney transplantation recipients also enjoy reduced rates of allograft rejection and longer graft survival compared to those who receive deceased donor kidneys after starting dialysis.1Kasiske BL Snyder JJ Matas AJ Ellison MD Gill JS Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged.J Am Soc Nephrol: JASN. 2002; 13: 1358-1364Crossref PubMed Scopus (0) Google Scholar,9Mange KC Joffe MM Feldman HI. Dialysis prior to living donor kidney transplantation and rates of acute rejection.Nephrology, dialysis, transplantation: official publication of the European Dialysis and Transplant Association - European Renal Association. 2003; 18: 172-177Crossref PubMed Scopus (0) Google Scholar For all these reasons, the National Kidney Foundation identifies preemptive transplant as the ideal approach to treating ESKD.10Myers J. National Kidney Foundation Newsletter. Preemptive Kidney Transplants: Why Aren't They More Popular? https://www.kidney.org/newsletter/preemptive-kidney-transplants. Accessed October 6, 2020.Google Scholar Figure 3 displays how disparities in access to health insurance, the conduct of referring physicians, waitlisting procedures, the flawed design of kidney allocation policy, and differences in kidney disease progression across racial groups create barriers to preemptive kideny transplantation, particularly for Black individuals. In some cases, late referral to nephrology likely prevents patient referral to transplant centers prior to dialysis and this problem is more severe for Black patients.11Yan G Cheung AK Ma JZ et al.The associations between race and geographic area and quality-of-care indicators in patients approaching ESRD.Clin J Am Soc Nephrol. 2013; 8: 610-618Crossref PubMed Scopus (41) Google Scholar,12Gander JC Zhang X Plantinga L et al.Racial disparities in preemptive referral for kidney transplantation in Georgia.Clin Transplant. 2018; 32 (e13380.)Crossref PubMed Scopus (41) Google Scholar Black patients with chronic kidney disease (CKD) are far less likely than White patients to have private insurance and more likely to be uninsured, and accordingly, may be less likely to get timely specialty referral.13Harhay MN McKenna RM. The Affordable Care Act and Trends in Insurance Coverage and Disease Awareness Among Non-elderly Individuals with Kidney Disease.J Gen Intern Med. 2019; 34: 351-353Crossref PubMed Scopus (2) Google Scholar It is also possible that structural racism at the level of the nephrology practice leads to reduced rates of transplant referral for Black patients or that Black patients have fewer resources than White patients to efficiently navigate the transplant evaluation.14Kim JJ Basu M Plantinga L et al.Awareness of Racial Disparities in Kidney Transplantation among Health Care Providers in Dialysis Facilities.Clin J Am Soc Nephrol. 2018; 13: 772-781Crossref PubMed Scopus (25) Google Scholar, 15Fishbane S Nair V. Opportunities for Increasing the Rate of Preemptive Kidney Transplantation.Clin J Am Soc Nephrol. 2018; 13: 1280-1282Crossref PubMed Scopus (14) Google Scholar, 16Lurie N O'Neill P. Disparities in transplantation: what should we do?.Am J Kidney Dis. 2004; 43: 386-387Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar The decision that any given patient is suitable for a kidney transplant requires multiple steps including medical record review, cardiovascular risk assessment, cancer screening, counseling, and confirmation of sufficient financial resources and social support to manage posttransplant recovery. Unfortunately, for patients with limited health literacy, difficulties with transportation or other social burdens, this process can be extra challenging.17Berry KN Daniels N Ladin K. Should lack of social support prevent access to organ transplantation?.Am J Bioeth. 2019; 19: 13-24Crossref PubMed Scopus (0) Google Scholar Clinician bias could also explain the disconcerting racial disparity in preemptive re-transplantation—that is, a patient with a failing kidney transplant getting a repeat transplant without requiring dialysis. This disparity is surprising because prior kidney transplant recipients by definition have relationships with transplant centers and previously navigated the evaluation process successfully.18Schold JD Augustine JJ Huml AM O'Toole J Sedor JR Poggio ED. Modest rates and wide variation in timely access to repeat kidney transplantation in the United States.Am J Transplant. 2020; 20: 769-778Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Longer time on the waiting list is a major driver of priority for kidney transplantation in the United States. The waiting time criterion follows the first-come, first-served model when patients have not started dialysis. According to Organ Procurement and Transplantation Network (OPTN) policy, "priority time" begins to accumulate on the date when a patient is registered on the waitlist and has a single "measured or calculated creatinine clearance or glomerular filtration rate (GFR) less than or equal to 20 ml/min."4Organ Procurement and Transplantation Network. Policies. https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Accessed November 20, 2020.Google Scholar The clinician can choose from multiple formulae—including CKD-EPI, MDRD, Cockcroft-Gault—to calculate kidney function. There is no requirement for sustained reduction in kidney function below 20 ml/min, such that a patient who qualifies for listing due to a temporary reduction in GFR—for example, from a pre-renal state due to diuretic use—can continue accumulating waiting time even after the kidney function rises above 20 ml/min. Therefore, transient kidney injury could allow a patient to accumulate years of waitlist priority before needing renal replacement therapy. Our group and others have also drawn attention to the problematic intersection of GFR estimation and race as it relates to transplant waitlisting.19Eneanya ND Yang W Reese PP. Reconsidering the consequences of using race to estimate kidney function.JAMA. 2019; 322: 113-114Crossref PubMed Scopus (159) Google Scholar GFR equations use Black race to achieve slightly better statistical precision in estimating kidney function on the population level.20Levey AS, Tighiouart H, Titan SM, Inker LA. Estimation of Glomerular Filtration Rate With vs Without Including Patient Race. JAMA Intern Med. 2020.Google Scholar The net effect is that compared to White patients with the same age, sex, and serum creatinine, Black patients are estimated to have a higher eGFR using the CKD-Epi and MDRD equations. Any biological basis for the race coefficient is unclear. Therefore, a 6-foot tall, 185-pound, 50-year-old Black man with a creatinine of 3.7 mg/dL and eGFR >20 ml/min/1.73 m2 could not start the kidney transplantation waiting time clock, while a 6-foot tall, 185-pound, 50-year-old White man with the same creatinine of 3.7 mg/dL and eGFR ≤20 ml/min/1.73 m2 could accumulate priority time.19Eneanya ND Yang W Reese PP. Reconsidering the consequences of using race to estimate kidney function.JAMA. 2019; 322: 113-114Crossref PubMed Scopus (159) Google Scholar Yet, Black individuals with CKD reach ESKD faster than their White counterparts.21van den Beukel TO de Goeij MC Dekker FW Siegert CE Halbesma N Group, PSDifferences in progression to ESRD between black and white patients receiving predialysis care in a universal health care system.Clin J Am Soc Nephrol. 2013; 8: 1540-1547Crossref PubMed Scopus (46) Google Scholar, 22Crews DC Banerjee T Wesson DE et al.Centers for Disease, C, Prevention Chronic Kidney Disease Surveillance, T: Race/Ethnicity, Dietary Acid Load, and Risk of End-Stage Renal Disease among US Adults with Chronic Kidney Disease.Am J Nephrol. 2018; 47: 174-181Crossref PubMed Scopus (0) Google Scholar, 23Grams ME Rebholz CM Chen Y et al.Race, APOL1 Risk, and eGFR Decline in the General Population.J Am Soc Nephrol: JASN. 2016; 27: 2842-2850Crossref PubMed Scopus (0) Google Scholar, 24Derose SF Rutkowski MP Crooks PW et al.Racial differences in estimated GFR decline, ESRD, and mortality in an integrated health system.Am J Kidney Dis. 2013; 62: 236-244Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 25Parsa A Kao WH Xie D et al.APOL1 risk variants, race, and progression of chronic kidney disease.N Engl J Med. 2013; 369: 2183-2196Crossref PubMed Scopus (526) Google Scholar For example, our group assembled a cohort of 56,767 veterans with stage 4 CKD from 2003 to 2015. Non-Hispanic Black veterans with Stage 4 CKD had a 74% higher risk (aHR 1.74; CI 1.69 – 1.78) of the composite outcome of dialysis, kidney transplantation, or doubling of creatinine compared to White veterans; for Hispanic Blacks, the risk of renal deterioration was more than twice as high as for White veterans.26Suarez J Cohen JB Potluri V et al.Racial Disparities in Nephrology Consultation and Disease Progression among Veterans with CKD: An Observational Cohort Study.Journal of the American Society of Nephrology: JASN. 2018; 29: 2563-2573Crossref PubMed Scopus (0) Google Scholar These data illustrate how Black patients with elevated creatinine will have a higher eGFR but nonetheless may need kidney transplantation sooner than similar White patients due to rapid disease progression. In Table 1, we propose policies and practices intended to improve fairness in access to kidney transplantation generally, while focusing attention on solutions that could alleviate racial disparities. These diverse remedies aim at education, transplant center referrals, patient eligibility, organ allocation, and transplant center listing practices.TABLE 1Potential remedies to improve equity in preemptive waitlisting and kidney transplantationRemedyPurposeChallenges and potential disadvantagesAddresses racial disparitiesAvailable remedies aimed at nephrologists, primary care doctors, and other referring cliniciansMore intense education among primary care physicians and nephrologists about the importance of referring CKD patients for transplant evaluation before eGFR ≤20Address the problem that some clinicians may not be mindful of transplant eligibility criteriaNo clear path to targeting those clinicians with knowledge deficitIndirect benefit likely if efforts are aimed at clinicians or health systems that serve communities with a higher proportion of racial minoritiesRequire that graduate medical education, CME, and other curricular materials for nephrologists include data on racial disparities in renal outcomes, including preemptive transplantClinician bias may play an important role in fostering disparities in access to transplantationFew data showing that CME and related curricular education leads to meaningful improvement in clinician behaviorYesEMRs supporting integrated health care networks should generate system-wide reports related to transplant education and referral. Transparent data about referral by race should be easily accessibleEnable equity in transplant referral rates to be treated as a quality measure by health systemsRacial disparities must be linked to effective actions and institutional commitment to equity for improvement to take placeYesEMR-based referrals of advanced CKD patients directly to transplant centers with simple executionReduce time and effort required to connect patients to transplant centers•Transplant centers would be burdened by addressing referrals of patients who might never follow-up consistently for medical and psychosocial evaluation•Referral would ideally take into account insurance coverage, given that some payors may require evaluation at specific centersIndirect benefit possible, if a simpler referral process overcomes bias by providersEMR reminders for nephrologists and other clinicians to refer for transplantation at eGFR thresholdsEncourage early referral for transplant evaluation for all patients•EMRs already include many reminders, causing "alert fatigue" to clinicians•EMRs might generate reminders for patients with non-transplant goals, such as hospiceIndirect benefit possible, if reminders succeed in redefining the default practice and overcoming bias by providerAvailable transplant center remediesIncentivize transplant centers to waitlist potential candidates rapidly after first contact with patient, by reducing fees and administrative burdensEnable preemptive waitlisting to take place rapidly instead of requiring burdensome—but necessary—evaluation process to be completed before waiting time can accruePatients with medical contraindications for transplant may be disappointed or lose faith in the medical system when later taken off the waiting listUncertainAvailable allocation system remediesStandardize GFR estimation such that renal function criteria are applied using a single equation or approachImprove fairness by applying the same standard to all patientsNephrologists and transplant professionals would need to decide on best eGFR equationIndirect benefit possibleEstimate GFR without a race coefficient for waitlisting purposes 19Eneanya ND Yang W Reese PP. Reconsidering the consequences of using race to estimate kidney function.JAMA. 2019; 322: 113-114Crossref PubMed Scopus (159) Google Scholar•For example, if CKD-EPI equation were used, all patients regardless of race would be assigned the non-Black race coefficient•Use CKD-EPI with cystatin as opposed to creatinine•Address the problem that on average, Black patients are assigned higher eGFR at the same creatinine but progress to renal disease more quickly•Enable more Black patients to be added to the kidney transplant waiting list•Implementation delays across clinical practices and institutions given no current guidelines•Cystatin C is not yet widely available in many laboratories and could add to costYesRequire sustained loss of kidney function for preemptive waitlistingaAs shown in Table 2, these approaches have been implemented in non-US allocation systems.Diminish the potential for patients with transient eGFR reduction to get waitlisted earlyAdditional burden of documentation on providers and patientsIndirect benefit possibleAllow patients to "back-date" their waitlist priority time to when they develop ESRD (e.g., eGFR <15), if sufficient medical documentation was availableImprove fairness by applying the same standard to all patientsThe patients with sufficient documentation may be those with more personal resources, private insurance and close attention to their lab testing when they have CKD; disparities might therefore worsenPersistent or worsening of racial disparities indirectly is possibleChange allocation system such that very low eGFR, and/or high risk of rapid progression to end-stage renal disease using a validated equation, is required for preemptive transplantationaAs shown in Table 2, these approaches have been implemented in non-US allocation systems.Limit preemptive transplantation to those patients for whom renal replacement therapy in the near future is neededCould reduce overall number of preemptive transplantsIndirect benefit possible, because Black patients with CKD commonly have more rapid loss of eGFRIf a preemptively waitlisted patient starts dialysis, their waiting time resets to the dialysis dateRemove transplant priority once the potential clinical benefits of preemptive transplantation are no longer availablePreemptively waitlisted patients who start dialysis may feel frustrated because they feel they have "lost" waiting time priorityIndirect benefit likelyLimit preemptive waiting time, such as 6-month maximum timeaAs shown in Table 2, these approaches have been implemented in non-US allocation systems.Limit the benefit that preemptive waitlisting can conferCould reduce overall number of preemptive transplantsA net result of more transplants for patients on dialysis would likely improve equitable access for Black and White patientsPatient-focused remediesDevelop educational materials or patient navigator programs aimed at promoting preemptive transplant evaluation for patients with CKD 30Sullivan CM Barnswell KV Greenway K et al.Impact of Navigators on First Visit to a Transplant Center, Waitlisting, and Kidney Transplantation: A Randomized, Controlled Trial.Clin J Am Soc Nephrol. 2018; 13: 1550-1555Crossref PubMed Scopus (0) Google Scholar•Promote patient autonomy related to transplant•Materials or programs may be customized to meet the needs of patients with low health literacy (e.g., by devising simple messages) or other barriers to waitlisting (e.g., by informing patients about how best to prepare for a transplant visit)Developing and disseminating these materials to patients will take investment and effortYesPolicy changes if initial remedies (listed above) do not reduce disparitiesEnd deceased donor preemptive transplantationaAs shown in Table 2, these approaches have been implemented in non-US allocation systems.•Improve equity in access to transplantation•Applying the date of chronic dialysis initiation as date of accruing transplant priority to all patients would ensure a fair standardBecause preemptive transplantation is viewed as the ideal treatment for end-stage kidney disease, and involves fewer complications after transplant, a proposal to abandon this practice may be resisted by transplant leadersIndirect benefit likelya As shown in Table 2, these approaches have been implemented in non-US allocation systems. Open table in a new tab Nephrologists and primary care doctors must take seriously the pernicious problem of racial disparities in kidney transplantation.14Kim JJ Basu M Plantinga L et al.Awareness of Racial Disparities in Kidney Transplantation among Health Care Providers in Dialysis Facilities.Clin J Am Soc Nephrol. 2018; 13: 772-781Crossref PubMed Scopus (25) Google Scholar,27Purnell TS Crews DC. Persistent disparities in preemptive kidney transplantation.Clin J Am Soc Nephrol. 2019; 14: 1430-1431Crossref PubMed Scopus (0) Google Scholar Timely referral to nephrology and then to transplant centers for Black patients and other disadvantaged groups is a necessary step to making preemptive transplantation equitable. We strongly advocate for better education aimed at nephrologists, other clinicians and CKD patients about racial disparities in CKD outcomes and the need to discuss transplantation well before patients reach an eGFR ≤20 ml/min.28Organ Procurement and Transplantation Network. Minority Affairs Committee. Educational Guidance on Patient Referral to Kidney Transplantation. Vol 2018: U.S. Department of Health & Human Services; 2015.Google Scholar Thorough education about transplant disparities should be integrated into nephrology and internal medicine training curricula as well as Continuing Medical Education. Given the widespread use of electronic medical records (EMRs), preliminary referrals to transplant centers ought to involve the simplicity that we associate with electronic consults and prescriptions. This process would require refinement to meet the needs of patients, referring providers and transplant centers while also including patient-facing materials.29Tuot DS Leeds K Murphy EJ et al.Facilitators and barriers to implementing electronic referral and/or consultation systems: a qualitative study of 16 health organizations.BMC Health Serv Res. 2015; 15: 568Crossref PubMed
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