Black patients are 59% less likely to get a preemptive transplant

Black kidney disease patients have an adjusted odds ratio of 0.41 for receiving a preemptive deceased-donor kidney transplant compared to white patients -- meaning they are 59% less likely to be transplanted before ever starting dialysis. While 39.4% of white candidates are listed preemptively on the transplant waitlist, only 17.5% of Black candidates are. This disparity has actually widened since the 2015 Kidney Allocation System reform (from OR 0.48 pre-KAS to 0.41 post-KAS). The human cost is enormous: patients who receive preemptive transplants avoid dialysis entirely, have better graft survival, lower mortality, and dramatically better quality of life. Every year spent on dialysis while waiting reduces transplant outcomes. The structural reasons this persists are compounding: (1) Black patients experience faster CKD progression but are referred to nephrologists later, (2) the race-based eGFR correction that was used until recently systematically overestimated Black patients' kidney function, delaying referral, (3) transplant centers require extensive workups that disadvantage patients without reliable transportation or insurance, and (4) implicit bias in referral patterns means Black patients are 37% less likely to even be referred for transplant evaluation by their nephrologist.