Racial disparities in preemptive waitlisting and deceased donor kidney transplantation: Ethics and solutions

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 pre-dialysis patients. In this Personal Viewpoint, we describe the diverse barriers to preemptive wait-listing and kidney transplant. The analysis focuses on healthcare system features that particularly disadvantage Black patients, such as the wait-listing 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 wait-listing 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 wait-listing and transplantation with deceased donor kidneys.