Opinion

Time to Abolish Metrics That Sustain Systemic Racism

VIEWPOINT
in Kidney Allocation

John S. Gill, MD, MS Inequitiesinhealthcarearemagnifiedinkidneytransplan- (hazard ratio, 1.20; 95% CI, 1.13-1.27).1 However, the bio-
Kidney Transplant tation because of the gross imbalance between the need logical basis for this association remains ambiguous. Ge-
Program, Division of and supply of donated kidneys. Currently, nearly 90 000 netic differences between Black and non-Black donor
Nephrology, University
patientshavebeenwait-listedfortransplantintheUS.Black kidneys could provide a biological rationale for the as-
of British Columbia,
Vancouver, British patientsarelesslikelytobereferredfortransplant,tocom- sociation. The large burden of chronic kidney disease
Columbia, Canada. plete the candidate evaluation, to be wait-listed, and to re- among Black US residents is partly attributable to 2 kid-
ceive a transplant compared with White patients. Efforts ney risk variants in the gene encoding apolipoprotein L1
Burnett Kelly, MD, to eliminate structural determinants of racism in the trans- (APOL1). The APOL1 kidney risk alleles are prevalent in
MBA
plantsystemareessentialtominimizethesedisparities.The populations of African ancestry and likely evolved be-
DCI Donor Services,
Nashville, Tennessee. Kidney Donor Profile Index (KDPI) is a metric used to allo- cause the variants protect carriers in western Africa from
catedeceaseddonorkidneys,whichbydesigndowngrades African sleeping sickness. Deceased donor kidneys with
Marcello Tonelli, MD, the perceived quality of kidneys donated by Black donors. 2 APOL1 kidney risk alleles that compose approxi-
SM This Viewpoint asserts that the KDPI in its current form is mately 15% of all kidneys donated by Black donors are
Department of
Medicine, University of
not fit to guide kidney allocation because it devalues organ at increased risk of transplant failure. Previous authors
Calgary, Calgary, donation by Black donors based on a weak association be- have advocated for incorporating APOL1 kidney risk
Alberta, Canada. tween donor race and kidney transplant failure. This asso- alleles in place of donor race in the KDPI.3 However, the
ciation is confounded by unmeasured differences in social relationship between APOL1 and transplant outcomes
determinantsofhealthbetweenthemainlyBlackrecipients is not uniform and many transplants from donors with
of Black donor kidneys and the mainly White recipients of 2 risk alleles demonstrate excellent survival. Further-
Viewpoint
non-Black donor kidneys. more, the role of recipient APOL1 genotype remains un-
TheKDPIwasdevelopedtopredictthetransplantsur- certain. Previous work deemphasized the importance of
Related article vivalofdeceaseddonorkidneys.1 Thecontinuousscorewas recipient genotype, but recently an association be-
basedon10variables,includingdonorrace.Despitelimited tween recipient APOL1 genotype and rejection was
predictive performance, the score was incorporated into reported.4 An ongoing National Institutes of Health–
funded study aims to clarify the role of
APOL1 in deceased donor kidney trans-
plant outcomes.5
Implementation of a race-free Kidney Alternatively, the association of do-
nor race with transplant failure may be
Donor Profile Index may increase confounded by differences in recipient
deceased donation in the Black social determinants of health. Black re-
community in the US and improve equity cipients are known to be at increased risk
for transplant failure compared with
in kidney allocation. White recipients in large part owing to
differences in social determinants of
the rules for kidney allocation. Kidneys with a KDPI score health. Although differences in recipient factors known
in the top 20% of donated kidneys are allocated to wait- to be associated with transplant failure were consid-
listed candidates with the top 20% expected posttrans- ered by the architects of the KPDI, characteristics re-
plant survival. Candidates must also consent to receive a lated to the social determinants of health are not re-
kidney in the 85th percentile or greater risk of transplant corded in national transplant registry data sets and so
failure predicted by the KDPI. The KDPI is used to accept could not be included in the KDPI. This confounding by
kidneys for transplant, with an abbreviated version of the recipient socioeconomic characteristics represents a
indexprovidedtoclinicianswhenadeceaseddonorkidney huge blind spot that has unfairly characterized Black do-
isofferedfortransplant.Approximately60% ofrecovered nor race as a key driver of transplant failure and has de-
Corresponding kidneys with a KDPI score in the 85th percentile or greater layed a balanced discussion of this issue.
Author: John S. Gill, are discarded despite evidence that when transplanted in Removing race from the KDPI would decrease the
MD, MS, St Paul’s appropriatecandidates,thesediscardedkidneyswouldim- KDPI score of Black donor kidneys and thereby
Hospital, UBC Division
of Nephrology, 1081 provepatientsurvivalcomparedwithcontinuedwaitingfor increase their use for transplant. However, removing
Burrard St, Providence akidneywithalowerKDPIscorewhileundergoingdialysis.2 race from the KDPI would also shift non-Black donor
Bldg, Ward 6a, The selection of variables in the KDPI was based on kidneys to a higher KDPI score, potentially decreasing
Vancouver, BC V6Z 1Y6,
statistical association with transplant failure.1 In the origi- their use for transplant and countering the increase in
Canada (jgill@
providencehealth.bc. nal description of the KDPI, Black donor race was asso- Black donor transplants. Numerous initiatives have
ca). ciated with a 20% increased risk of transplant failure aimed to increase deceased organ donation among

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 Opinion Viewpoint

the Black population, which remains lower than in the White
population in the US. These initiatives have focused on education
and engagement of the Black community. However, the trans-
plant community has failed to address the misperception that
Black donor kidneys are inherently inferior. Dropping race from
the KDPI may help correct this insulting error while perhaps
increasing organ donation among the Black population in the US.
Removing race from the KDPI would also likely decrease clinician
bias regarding the value of Black donor kidneys and might lead to
systematic improvements in the identification, approach, and
consent of Black deceased donors. Removing race from the KDPI
may also significantly improve the equity of deceased donor kid-
ney allocation. Black donor kidneys are far more frequently allo-
cated to Black patients than White patients because of differ-
ences in ABO blood group and human leukocyte antigens (HLAs),
which are important determinants of kidney allocation.6 Between
2005 and 2018, 50% of Black deceased donor kidneys were
transplanted into Black recipients compared with only 30% of
non-Black donor kidneys.7 By removing race from the KDPI and
thereby increasing the number of available kidneys from Black
donors—which in turn are more likely to be ABO blood group and
HLA compatible with Black wait-listed candidates than kidneys
from non-Black donors—the transplant rate for Black patients
should increase.
The KDPI was developed as a predictive model of transplant
failure, which did not require understanding of the basis for the
association between donor race and transplant failure. However,
with the benefit of hindsight, we believe that implementing the
KDPI into organ allocation policy without understanding this con-
founded association or considering the possibility of unintended
consequences was a mistake. The continued inclusion of donor
race in the KDPI according to the weak association of Black donor
race with transplant failure that may or may not be based in biol-
ogy is antithetical to the principles of equity and transparency
that are fundamental to the maintenance of public trust in the
organ donation and transplant system. The inclusion of donor
race in the KDPI devalues Black deceased organ donors and per-
petuates racist stereotypes. Furthermore, implementation of a
race-free KDPI may increase deceased donation in the Black
community in the US and improve equity in kidney allocation. It is
time to abolish use of the KDPI in deceased donor kidney
allocation.

ARTICLE INFORMATION REFERENCES 5. Freedman BI, Moxey-Mims MM, Alexander AA,

Published Online: February 27, 2023.
doi:10.1001/jama.2023.1076
Conflict of Interest Disclosures: Dr Gill reported
receiving grants from Astellas, fees from Astellas for
work on a data and safety monitoring board, and
consulting for Takeda outside the submitted work;
serving as immediate past president of the
American Society of Transplantation; serving as a
contract management board member for the
United States Renal Data System; and being a
member of the APOL1 Long-term Kidney
Transplantation Outcomes Observational Study
(APOLLO) External Expert Panel. Dr Kelly serves as
a member of the American Society of
Transplantation board of directors. No other
disclosures were reported.
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10.1097/TP.0b013e3181ac620b
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Segev DL. Survival benefit of primary deceased donor
transplantation with high-KDPI kidneys. Am J
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10.1016/j.ekir.2019.11.022
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