Expanding the waitlisting criteria for kidney transplantation could improve patient outcomes

The current kidney transplant waitlisting criterion is based on a single measurement of kidney function (estimated glomerular filtration rate [eGFR] ≤20 ml/min/1.73m2) and does not consider an individual’s risk of progressing to kidney failure.

A new study reveals that inclusion of a patient's two-year risk of progression to kidney failure (using the Kidney Failure Risk Equation [KFRE], which incorporates age, sex, urine albumin, and eGFR) as a decision-making tool toward pre-emptive listing for kidney transplantation, has the potential to improve patient outcomes and reduce racial disparities. The findings were presented at ASN Kidney Week 2025, held November 5–9.

When examining the use of the two-year risk of progression to kidney failure of ≥25% based on the KFRE as a listing criterion and comparing it with the current eGFR ≤20 criterion, investigators found that among 10,368 US veterans with chronic kidney disease in 2022 who would meet at least one of the criteria, 60% met both and 20% met only one or the other.

In 2022, veterans who only qualified by the eGFR ≤20 criterion were older (71 years) than those who only qualify by KFRE ≥25% (53 years).

Also, using the kidney disease progression criteria only, more males, minorities (Hispanic, Black, and Asian), and those with diabetes and/or albuminuria would be waitlisted. When examining longitudinal data (2006–2019) to assess outcomes, the group who met both criteria or the KFRE ≥25% only, had the highest rates of kidney failure and lower mortality compared with those who only met the eGFR ≤20 criterion.

Expanding the waitlisting criteria for kidney transplantation to include risk of kidney failure prioritizes individualized approaches to care and could improve outcomes in younger patients with chronic kidney disease, as well as improve racial parity in access to kidney transplantation. This approach will continue to be studied prospectively and in populations beyond veterans to verify its potential to improve patient outcomes."

Jennifer L. Bragg-Gresham, MS, Ph.D., corresponding author, University of Michigan Medical School