The Alliance

Insight Series

The Alliance insight series offers critical resources for stakeholders across the donation and transplantation continuum. For each topic, you can find related action items, tools, and references.

The Alliance Insight Series

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Executive Summary

On January 5, 2023, policy implementation went into effect for OPTN Modifying Waiting Time for Candidates Affected by Race-Inclusive eGFR Calculations. Transplant centers have a year to comply with these policy requirements. This document provides action items for transplant centers to meet policy requirements, education on policy background and requirements, and a centralized location for tools and resources.


What do transplant centers need to do?

Identify cohort of patients

  1. Finding the right data:


Waitlisted patient demographics
(i.e. name, SSN, Center ID)
GFR lab results Dialysis Unit
Candidate Race GFR AA lab results GFR AA lab results
Listing Date EMR race Referring Practice
Qualifying Date Demographic information


  1. Creating/ Utilizing reports:

    1. Utilize the OPTN custom reporting tool in the data services portal “Current waitlisted African American Candidates” provides a list of current kidney candidates reported with AA/Black as race with wait time qualifying information.

    2. Create and use reports built in EMR system.

    3. A combination of both and a master spreadsheet to track where patients are in the process.

  2. Identifying patient labs outside transplant center:

    1. Accessing outside labs through care everywhere if you have EPIC.

    2. Using record retrieval technology (e.g. E-health)

    3. Collaborating with dialysis centers and referring practices:

      1. Providing education on what exactly is needed for the patient vs. having all lab results sent to the transplant center to comb through.

      2. Utilizing referral packets as a first step in identification of previous lab results

    4. Patient Advocacy – Engage with patients to find past lab results that might be eligible for wait time modification.

Note: Even if your center has never used a race-inclusive GFR calculator, the candidate may have historic race-inclusive labs prior to referral to your center.

Send Notification Letters:

  1. Create a notification letter or use a variation of the OPTN letter. We have included some samples of letters developed in the resource section.

  2. Letter tips:

    1. No OPTN language on timeframe between notification #1 and #2

    2. Dialysis center notification not required but may need to collaborate for records.

    3. Notification #2: Sent after reviewing waitlist.  Consider creating 2 notification templates- ELIGIBLE and NON-ELIGIBLE. All patients who do not identify as Black or African American (AA) are non-eligible by default

  3. WARNING We have heard that patients have experienced confusion around some of the individualized letters especially those that are listed at multiple transplant centers. To help combat this:

    1. Think about creating a FAQ to include with your letter.

    2. Consider having patient education review your letter for readability.  Identify and include in the letter who patients can contact if they have questions.

    3. Due to the complexities around this policy, centers have identified specific people to answer patient questions or provided education/ resources to access centers.

  4. Continued Implementation- Adherence to this OPTN policy is still required for patients who are being listed between 1/5/2023-1/3/2024. After 1/3/2024, patients will still need to be educated on this policy. How will your center continue to provide this information over the year?

    1. Update listing process to include the additional letter at listing.

    2. Consider building this policy information into your evaluation education.

Submit Modifications: Challenges and Lessons Learned

  1. Many centers are utilizing a signed PDF for multiple candidates. Some centers have been asked to submit a digital/ electronic signature.

  2. To comment or not to comment? It appears centers have been doing both practices on the modification form, it doesn’t appear to impact the submission process one way or the other.

  3. You can always resubmit modification forms for consideration if you feel that the patient is qualified for the modification time.

Other Considerations:

  1. Some patients are getting A LOT of time back, bouncing them to the top of the list to start receiving offers. This has had a significant operational impact on many transplant centers, especially in ensuring that a patient has been reevaluated recently.

  2. Some centers are tracking all their patients and the time they should be getting back so they can identify patients who may be receiving significant time back. At some centers the coordinators and physicians review this list frequently to determine if inactivation or expediating of reevaluation is needed.



In January 2022, the OPTN Minority Affairs and Kidney Transplantation Committees proposed Establish OPTN Requirement for Race- Neutral eGFR Calculations to require eGFR calculations used for the purposes of the OPTN be race-neutral. Race-inclusive calculations can overestimate Black candidates’ eGFR values and result in a delayed start of waiting time accrual to receive a kidney transplant. In August of 2022 the OPTN Minority Affairs and Kidney Transplantation Committees proposed Modify Waiting Time for Candidates Affected by Race-Inclusive eGFR Calculations to provide a pathway for registered candidates who have been impacted by a race-inclusive eGFR calculation to regain waiting time they could have received if a race-neutral calculation was used to estimate their GFRs.


This policy took effect January 5, 2023. Transplant programs must comply with this policy by January 3, 2024.

  • Black/African American candidates registered from January 5, 2023, until Jan 3, 2024, are required to be assessed for eligibility for a potential waiting time modification.
  • Black/African American candidates registered after January 3, 2024, remain eligible.

Specifics of Qualifying Candidates

Qualifying candidates must meet all the following criteria to be eligible for a waiting time modification:

  • Currently registered as Black or African American in the OPTN Computer System
  • Previously had their eGFR value calculated with a race-inclusive formula.
  • Presently accruing waiting time with eGFR, Creatinine Clearance (CrCl), or dialysis criteria (See OPTN Policy 8.3.A) OR are registered without qualifying criteria.
  • Transplant program can provide documentation demonstrating that with a race-inclusive calculation, the candidate’s eGFR was over 20 mL/min, but with a race-neutral calculation the candidate’s eGFR would have been 20 mL/min or less.

Eligible candidates may also include:

  • Black/African American adult and pediatric candidates registered on the OPTN waiting list.
  • Black/African American candidates registered for a Kidney- Pancreas or multi-organ transplant: if they are registered for an isolated kidney.
  • Candidates registered on the OPTN waiting list, with multiple races: If one of those races is Black or African- American

Breakdown of Policy Requirements

By January 3, 2024, all kidney transplant programs will be required to:
Assess Assess waiting list for all registered adult/pediatric Black/African American kidney candidates that have been affected by the use of race-inclusive eGFR calculations. This includes both dialysis and preemptive candidates.
SUBMISSION Submit eGFR waiting time modifications for affected adult and pediatric candidates to the OPTN

Supporting Documentation: the candidate’s eGFR value was over 20 mL/min, but with a race-neutral calculation the candidate’s eGFR value would have been 20 mL/min or less

To qualify for a waiting time modification, transplant programs must provide documentation demonstrating one of the following options along with completed waitlist modification form:
1. Documentation of the candidate’s eGFR value for Black and non-Black candidates
2. Documentation showing both the estimation of GFR with a race- inclusive calculation and a re-estimation of GFR with race-neutral calculation
2a A lab report showing estimation of a candidate’s GFR with a race-inclusive calculation, including the date and time of estimation 2b Evidence of re-estimation of the candidate’s GFR with any race-neutral eGFR calculation demonstrating a qualifying value.
NOTIFICATION Notify all registered adult and pediatric kidney transplant candidates and kidney/pancreas candidates registered for an isolated kidney transplant.
All kidney candidates registered at the transplant program, regardless of race, including active and inactive adult and pediatric candidates must be notified. The OPTN also wants to ensure that every candidate is registered with their correct race in the OPTN Computer System. Sending notifications to all candidates will be informative in the event a kidney candidate’s race has been misreported in the OPTN Computer System.
FIRST NOTIFICATION Programs are required to inform all adult and pediatric kidney candidates of the requirements of the program according to the policy
SECOND NOTIFICATION After assessing their waiting lists, programs are required to inform all adult and pediatric kidney candidates of the completion of list assessment and of their eligibility status
ATTESTATION OPTN policy requires transplant programs to submit documentation attesting to both of the following: That the transplant program has provided notification to all candidates registered at the transplant program of their eligibility for a waiting time modification according to this policy and
That the transplant program has submitted eGFR waiting time modifications for all eligible candidates registered at the transplant program
The attestation can be submitted at any time after a program has gone through their initial identified patient list.

Tools & Resources


We would like to express our sincerest gratitude for our contributors’ tireless efforts on making Transplant Quality Corner a reality. Their dedication and expertise have been an invaluable contribution to the successful launch of this project. We are incredibly grateful for all their hard work and commitment.

KP Headshot
Kelley Poff
MSWPolicy AnalystUnited Network for Organ Sharing
Screenshot 20230510 183049 Chrome
Tonya Walder
MSN, RN, CCTCPre-Kidney and Pancreas CoordinatorUniversity of Michigan
Kristin Smith
Kristin Smith
MSN, RN, CNL, CCTCManager, Abdominal Transplant and Living Donor ProgramsVanderbilt University Medical Center


Deepa Kurup
Deepa Kurup
RN, MSN, MBA, CPHQ, LSSBBQuality Manager, Center for Transplantation UC San Diego Health System
Melissa Robinson
Quality & Safety Director, Transplant Institute Loma Linda University Medical Center
Jenna Lawson
Jenna Lawson
MSAbdominal Transplant Quality ConsultantVanderbilt University Medical Center
Hellen Oduor Headshot
Hellen Oduor
Quality ManagerMethodist Dallas Medical Center
Randall Sung
Randall Sung
MDAssociate Professor of SurgeryUniversity of Michigan
Lindsay Smith
RN, MSNTransplant Quality DirectorVanderbilt Transplant Center


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