{"doi":"10.1111/ajt.16392","title":"Racial disparities in preemptive waitlisting and deceased donor kidney transplantation: Ethics and solutions","abstract":"Kidney transplantation prior to dialysis, known as “preemptive transplant,” enables patients to live longer and avoid the substantial quality of life burdens due to chronic dialysis. Deceased donor kidneys are a public resource that ought to provide health benefits equitably. Unfortunately, White, better educated, and privately insured patients enjoy disproportionate access to preemptive transplantation using deceased donor kidneys. This problem has persisted for decades and is exacerbated by the first-come, first-served approach to kidney allocation for predialysis patients. In this Personal Viewpoint, we describe the diverse barriers to preemptive waitlisting and kidney transplant. The analysis focuses on healthcare system features that particularly disadvantage Black patients, such as the waitlisting eligibility criterion of a single glomerular filtration rate or creatinine clearance ≤20 ml/min, and neglect of wide variation in the rate of progression to end-stage kidney disease (ESKD) in allocating preemptive transplants. We propose initiatives to improve equity including: (1) standardization of waitlisting eligibility criteria related to kidney function; (2) aggressive education for clinicians about early transplant referral; (3) innovations in electronic medical record capabilities; and (4) rapid status 7 listing by centers. If those initiatives fail, the transplant field should consider eliminating preemptive waitlisting and transplantation with deceased donor kidneys. Kidney transplantation prior to dialysis, known as “preemptive transplant,” enables patients to live longer and avoid the substantial quality of life burdens due to chronic dialysis. Deceased donor kidneys are a public resource that ought to provide health benefits equitably. Unfortunately, White, better educated, and privately insured patients enjoy disproportionate access to preemptive transplantation using deceased donor kidneys. This problem has persisted for decades and is exacerbated by the first-come, first-served approach to kidney allocation for predialysis patients. In this Personal Viewpoint, we describe the diverse barriers to preemptive waitlisting and kidney transplant. The analysis focuses on healthcare system features that particularly disadvantage Black patients, such as the waitlisting eligibility criterion of a single glomerular filtration rate or creatinine clearance ≤20 ml/min, and neglect of wide variation in the rate of progression to end-stage kidney disease (ESKD) in allocating preemptive transplants. We propose initiatives to improve equity including: (1) standardization of waitlisting eligibility criteria related to kidney function; (2) aggressive education for clinicians about early transplant referral; (3) innovations in electronic medical record capabilities; and (4) rapid status 7 listing by centers. If those initiatives fail, the transplant field should consider eliminating preemptive waitlisting and transplantation with deceased donor kidneys. Twenty years ago, Kasiske et al. reported that Black patients were much less likely to receive a preemptive kidney transplantation than White patients and recognized that “substantial efforts on the part of all who care for patients with kidney disease” would be required to correct this inequity.1Kasiske BL Snyder JJ Matas AJ Ellison MD Gill JS Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged.J Am Soc Nephrol: JASN. 2002; 13: 1358-1364Crossref PubMed Scopus (0) Google Scholar,2Jay CL Dean PG Helmick RA Stegall MD. Reassessing Preemptive Kidney Transplantation in the United States: Are We Making Progress?.Transplantation. 2016; 100: 1120-1127Crossref PubMed Scopus (51) Google Scholar Yet, subsequent policy changes to the US kidney allocation system (KAS) that were implemented to mitigate transplant disparities have neglected preemptive kidney transplantation. In 2019, 11% of all adult deceased donor kidney transplants (1,859) were preemptive. 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Williams","orcid":"0000-0001-9984-7102","position":3,"is_corresponding":false},{"id":313573,"name":"Vishnu S. Potluri","orcid":"0000-0002-3307-8926","position":4,"is_corresponding":false},{"id":270989,"name":"Meera N. Harhay","orcid":"0000-0001-6500-2814","position":5,"is_corresponding":false},{"id":315755,"name":"Nwamaka D. Eneanya","orcid":null,"position":6,"is_corresponding":false},{"id":33943,"name":"Peter P. Reese","orcid":"0000-0003-1440-069X","position":0,"is_corresponding":true}],"reference_count":42,"raw_metadata":null,"created_at":"2026-07-18T21:08:26.834549Z","pmid":"33151614","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}