CKD Progression From the Time of Estimated GFR-Based Waitlist Eligibility and Racial Disparities in Transplant Access.
CKD Progression From the Time of Estimated GFR-Based Waitlist Eligibility and Racial Disparities in Transplant Access.
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DOI：
10.1053/j.ajkd.2021.08.010
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发表时间：
2022-06
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与非黑人个体相比，包含种族术语的 eGFR 方程为黑人个体赋予了更高的值，这与性别、年龄或血清肌酐无关。这种差异可能会导致肾移植获得方面的种族差异。我们试图 1) 比较黑人、西班牙裔和白人患者从达到 eGFR ≤ 20 ml/min/1.73M2 的移植资格阈值到接受替代治疗 (KFRT) 肾衰竭的时间，以及 2) 评估将种族纳入 eGFR 表达对建立候补资格和从资格到 KFRT 的时间的影响。回顾性队列。使用 OptumLabs® 数据仓库，我们收集了一组由 40,042 名白人、8,519 名黑人和 3,569 名西班牙裔患者组成的队列，这些患者在过去两年内至少有一个 eGFR 值在 20 至 60 mL/min/1.73m2 之间，并且 2008 年至 2018 年期间门诊患者 eGFR ≤20 ml/min/1.73m2，使用CKD-EPI 方程包含编码为黑人或非黑人的种族术语。然后，我们根据使用与黑人患者相同的 CKD-EPI 方程估计的事件 eGFR ≤20 ml/min/1.73m2 (n=11,269) 重新组装黑人患者队列，但将患者编码为非黑人。种族/民族。到 KFRT 的时间到了。未调整和调整的 Fine-Gray 模型；线性回归计算 eGFR 斜率。到 3 年，白人患者中 KFRT 的累积发生率为 20.5%，西班牙裔患者为 40.9%，使用编码为黑人的种族术语估计 eGFR 的黑人患者为 36%，使用编码为非黑人的种族术语估计 eGFR 的黑人患者中 KFRT 的累积发生率为 28.7%。在包括 11,269 名 eGFR ≤ 20 ml/min/1.73m2 的黑人患者（基于将其编码为非黑人）的全面调整分析中，黑人（HR 1.28；95% CI，1.15–1.43）和西班牙裔（HR 1.66；95% CI 1.18–2.31）的 KFRT 风险仍然高于白人患者。根据 eGFR 下降的斜率，将黑人患者编码为非黑人将允许较早激活候补名单，预计中位数为 0.5 年 [IQR 0.27–1.23]。无法排除综合评估后不会成为肾移植候选者的个体。统一的 eGFR 阈值减少了黑人和西班牙裔患者被列入移植候补名单的机会。对于许多黑人患者来说，将 GFR 估计为他们的种族类别为非黑人，将允许更早地进入候补名单，但与白人患者相比，不会消除他们接受 KFRT 的时间更短，并减少先发性移植的机会。目前的美国肾移植政策要求 GFR ≤ 20 ml/min 才能在等待名单上激活，但当前的 GFR 估计方程为黑人患者分配的值高于相同年龄、性别和肌酐值的非黑人患者，并且可能在先发性移植的时间方面对黑人患者不利。我们根据包含种族信息的 eGFR 估计检查了 50,000 多名 GFR ≤20 ml/min/1.73m2 的患者的 CKD 进展情况，发现黑人和西班牙裔患者比白人患者更快进展为肾衰竭。我们观察到，出于 GFR 估计的目的将所有患者分类为非黑人将使黑人患者有资格提前进入候补名单；然而，由于与白人患者相比，肾衰竭进展更快，因此抢先移植的时间仍然存在很大差异。此外，西班牙裔患者病情进展较快并不能通过改变 eGFR 计算来弥补。
eGFR equations that incorporate a term for race assign a higher value to Black individuals compared to non-Black individuals not attributable to sex, age, or serum creatinine. This difference may contribute to racial disparities in kidney transplant access. We sought to 1) compare time from meeting a transplant eligibility threshold of eGFR ≤20 ml/min/1.73M2 to kidney failure with replacement therapy (KFRT) among Black, Hispanic, and White patients, and 2) assess the impact of incorporation of race into eGFR expressions on establishment of waitlist eligibility and time from eligibility to KFRT. Retrospective cohort. Using the OptumLabs® Data Warehouse, we assembled a cohort of 40,042 White, 8,519 Black, and 3,569 Hispanic patients having at least one eGFR value between 20 and 60 mL/min/1.73m2 within the preceding two years and an incident outpatient eGFR of ≤20 ml/min/1.73m2 between 2008–2018, using the CKD-EPI equation that includes a term for race coded as Black or non-Black. We then re-assembled a Black patient cohort based on incident eGFR ≤20 ml/min/1.73m2 (n=11,269) estimated using the same CKD-EPI equation for Black patients but coding patients as non-Black. Race/ethnicity. Time to KFRT. Unadjusted and adjusted Fine-Gray models; linear regression to compute eGFR slopes. By 3 years, the cumulative incidence of KFRT was 20.5% among White patients, 40.9% among Hispanic patients, and 36% among Black patients whose eGFR was estimated using a race term coded as Black and 28.7% among Black patients whose eGFR was estimated using a race term coded as non-Black. In fully adjusted analyses including 11,269 Black patients with an eGFR ≤20 ml/min/1.73m2 based on coding them as non-Black, KFRT risk remained greater among Black (HR 1.28; 95% CI, 1.15–1.43) and Hispanic (HR 1.66; 95% CI 1.18–2.31) than among White patients. Based on slopes of eGFR decline, coding Black patients as non-Black would allow earlier waitlist activation by an estimated median of 0.5 years [IQR 0.27–1.23]. Inability to exclude individuals who would not be kidney transplant candidates if comprehensively evaluated. A uniform eGFR threshold provides less opportunity for being placed on the transplant waitlist among Black and Hispanic patients. For many Black patients, estimation of GFR as if their race category were non-Black would allow substantially earlier waitlisting but would not eliminate their shorter time to KFRT and reduced opportunity for preemptive transplantation compared to White patients. Current US kidney transplant policy requires a GFR of ≤20 ml/min for activation on the waitlist, but current GFR estimating equations assign a higher value to Black patients compared to non-Black patients for the same age, sex, and creatinine values and may disadvantage Black patients regarding time for preemptive transplantation. We examined CKD progression in over 50,000 patients who developed a GFR ≤20 ml/min/1.73m2 based on eGFR estimation that incorporates information about race, finding that Black and Hispanic patients progressed to kidney failure more quickly compared to White patients. We observed that classifying all patients as non-Black for the purpose of GFR estimation would allow Black patients to be eligible for earlier waitlisting; however, a large disparity remains in the time available for pre-emptive transplantation due to faster progression to kidney failure compared to White patients. Additionally, faster progression among Hispanic patients would not be remedied by changes in eGFR calculation.
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影响因子：
13.2
作者：
Grams, Morgan E.;Li, Liang;Appel, Lawrence J.
通讯作者：
Appel, Lawrence J.
影响因子：
13.2
作者：
Derose, Stephen F.;Rutkowski, Mark P.;Jacobsen, Steven J.
通讯作者：
Jacobsen, Steven J.
DOI：
10.2215/cjn.03140319
发表时间：
2019-10-07
影响因子：
9.8
作者：
King, Kristen L.;Husain, Syed Ali;Mohan, Sumit
通讯作者：
Mohan, Sumit
慢性肾功能不全队列研究中估计和测量的肾小球滤过率以及 CKD-EPI 方程种族系数的分析。
影响因子：
13.8
作者：
Hsu CY;Yang W;Go AS;Parikh RV;Feldman HI
通讯作者：
Feldman HI
影响因子：
39.2
作者：
Levey AS;Stevens LA;Schmid CH;Zhang YL;Castro AF 3rd;Feldman HI;Kusek JW;Eggers P;Van Lente F;Greene T;Coresh J;CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)
通讯作者：
CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)