In a groundbreaking move, hospitals across the United States are addressing the racial bias that has long hindered Black people from receiving kidney transplants. Jazmin Evans, a 29-year-old student from Philadelphia, found herself at the center of this transformative change. After waiting for a new kidney for four years, she received a shocking revelation from her hospital – she should have been put on the transplant list in 2015 instead of 2019, and a racially biased organ test was to blame. Evans is among over 14,000 Black kidney transplant candidates who have been given credit for their lost waiting time, moving them up the priority list for transplantation.
The issue lies with a test that was once widely used to assess kidney function. This test overestimated how well Black people’s kidneys were functioning, making them appear healthier than they actually were. The automated formula that calculated results for Black and non-Black patients differently caused a delay in the diagnosis of organ failure and evaluation for transplantation. This only exacerbated the existing disparities that already made Black patients more susceptible to needing a new kidney but less likely to receive one.
Recognizing the need for change, the National Kidney Foundation and American Society of Nephrology urged laboratories to switch to race-free equations in calculating kidney function. In response, the U.S. organ transplant network ordered hospitals to use only race-neutral test results when adding new patients to the kidney waiting list. However, there remained the question of what to do about the individuals already on the list who had been impacted by the race-based test. To address this, the transplant network gave hospitals a year to identify Black kidney candidates who could have qualified for a transplant sooner if not for the biased test. Their waiting times were then adjusted accordingly to make up for this discrepancy.
Between January 2023 and mid-March, more than 14,300 Black kidney transplant candidates have had their wait times modified, with an average adjustment of two years. Over 2,800 of them, including Jazmin Evans, have already received a transplant. This effort to rectify past wrongs is being hailed as an attempt at restorative justice.
The kidney saga serves as an example of a larger problem within healthcare. Many algorithms used in medical decisions, such as treatment guidelines, diagnostic tests, and risk calculators, adjust results based on race or ethnicity, putting people of color at a disadvantage. These equations are deeply embedded in medical software and electronic records, often without doctors even realizing their impact on care decisions.
Thankfully, change is slowly beginning to happen. Obstetricians are no longer supposed to include race in determining the risk of a pregnant woman attempting vaginal birth after a prior C-section. The American Heart Association recently removed race from a commonly used calculator for assessing heart disease risk. The American Thoracic Society has also urged the replacement of race-based lung function evaluation. Each of these steps represents progress toward eliminating racial bias in medical algorithms.
It is important to recognize that race is not a biological factor like age, sex, or weight – it is a social construct. However, it has found its way into calculations of kidney function through the estimated glomerular filtration rate (eGFR) test. In 1999, an equation used to calculate eGFR was modified to adjust results for Black patients based on flawed studies and an outdated theory about differences in creatinine levels. This meant that lab reports often listed two results – one for non-Black patients and another for Black patients – with the latter potentially overestimating kidney function by up to 16%.
Not every Black kidney candidate was affected by this biased test. Some may have had kidney failure diagnosed without relying on it. But for those who could benefit from the mandated lookback, transplant center staff had to play the role of detectives, scouring years-old records to find the test and recalculate it without the race adjustment. This meticulous work allowed them to identify candidates who should have qualified for a transplant sooner.
Jazmin Evans, for example, had her kidney disease discovered during a high school sports physical at the age of 17. She began dialysis while pursuing her master’s degree and Ph.D. at Temple University, eventually being placed on the transplant list in April 2019. However, when the Jefferson transplant center in Philadelphia unearthed her old lab tests, they realized she should have been listed in September 2015. The discovery was both infuriating and hopeful for Evans. It provided a glimmer of hope that she would be offered a matching kidney soon, but also highlighted the years of waiting she had lost due to the biased test.
On July 4, Evans finally received a new kidney and is now healthy again. She is grateful that the policy change came just in time for her. However, she emphasizes the importance of making amends for those who were impacted by the biased test. This extra step toward equity and equality in the medical field is crucial, as it not only restores faith in the healthcare system but also addresses the unfair and avoidable outcomes that Black people and other people of color face.
The kidney transplant saga is a microcosm of the larger issue of racial bias in healthcare. While progress is being made to eliminate biased algorithms and equations, there is still much work to be done. Health equity scholars have been raising concerns about the misuse of race in clinical algorithms for years, and it is encouraging to see these concerns finally being addressed.
Black Americans are over three times more likely than white people to experience kidney failure, highlighting the urgent need for a fair and equitable system. With approximately 30% of the 89,000 people currently on the waiting list for a new kidney being Black, it is clear that change is necessary.
Addressing racial bias in healthcare is a complex task that requires systemic changes. However, the transformative change happening in the kidney transplant field offers hope that progress is possible. By recognizing the impact of biased testing and implementing measures to rectify past wrongs, hospitals are taking a step toward a more equitable healthcare system.
While the kidney transplant saga is just one example of the larger problem, it serves as a beacon of hope for the future. It shows that change is possible when there is a commitment to addressing racial disparities in healthcare. As more healthcare organizations work to eliminate biased algorithms and embrace race-neutral approaches, we can move closer to a system that provides equal care for all, regardless of race or ethnicity.
