Thread by @PeterPReese1

The United Network for Organ Sharing passed a policy requiring centers to estimate kidney function without race. I support that. However, by applying the rule retroactively to all waitlisted Black patients, UNOS ignited equity concerns. And now, a lawsuit: tinyurl.com/4uhxnb5e

My central contention: this policy is undermining trust in the allocation system. For some, the policy is not aggressive enough in repairing injustice. The lawsuit claims that race-based eGFR was inaccurate, invalid + that Black patients are due faster + bigger remedies

To others, the policy is unfair in giving a big waitlist benefit to dialysis patients, but only those who are Black. Their view: race-based eGFR is only one barrier among many to being waitlisted for transplant pre-dialysis. Many non-Black patients also face barriers

Background: Patients start the wait-time clock for kidney transplant in 1 of 2 ways: 1) if they register with the center pre-dialysis, the clock starts the earliest day their eGFR was < 20; or 2) if they register after starting dialysis, clock starts on the day of 1st dialysis

My colleagues + I critiqued this waitlist policy. Who doesn’t get the early waitlist advantage? On average: Black + Hispanic patients, patients whose doctors don’t advocate well for them, patients with low health literacy, patients in remote areas, etc. tinyurl.com/ms77v6nf

Now: the new UNOS policy commands centers to review records of every waitlisted Black patient, find the earliest date their race-free eGFR was < 20 … award those Black patients more waiting time … even if they originally arrived at the center years after starting dialysis.

UNOS vetted this policy publicly. The AST among others supported the policy. Yet, it’s since become clear that many transplant center directors did not understand implications for dialysis patients, are worried about implementation and fairness.

I predict more similar lawsuits...and maybe some arguing from the opposite perspective about why this policy is unfair. We live in a moment of very low trust in institutions and UNOS may need more public discussion, transparency + consensus to succeed with a policy like this one

I'd like to hear views from other people - email or DM me. My sense is that a full discussion of the merits of this policy has not happened yet.

Last: My take on some of the objections is an implicit recognition that our current approach to pre-dialysis waiting time is flawed. Internationally, we're an outlier. Race based eGFR aside, it needs to change. My 1st recommendation: Cap pre-emptive waiting time benefit at 1 year