Disparities in access

Despite higher rates of chronic renal failure (CRF) and ESRD, African Americans do not enjoy equivalent access to renal allograft transplantation when compared to Caucasians. Among patients with ESRD for whom kidney transplantation would be the standard of care, blacks are less likely to be referred for evaluation to be placed on a waiting list to receive a donor kidney, having longer waiting times on dialysis prior to referral or transplantation. 

 


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Even after securing placement on a transplant waiting list, African Americans will, depending on blood type and region, wait two to four times longer on those lists than Caucasians, due to differing degrees of sensitization and due to the HLA allocation system.8.  According to the United Network for Organ Sharing (UNOS),3 of the 75,711 patients awaiting kidney transplants in 2007, more than one third (26,036) awaiting kidney transplants are African Americans.3,8

 

African-American patients are at an inherent disadvantage within the current system of organ allocation, which is weighted according to human lymphocyte antigen (HLA) matches.  The system favors Caucasian patients who have more HLA antigen matches with prospective cadaveric organs, the majority of which are from Caucasians.  Moreover, there are fewer living donors in the African-American population. Plans to broaden the geographic allocation of kidneys, alter scoring of HLA points, and expand utilization of available acceptable donor organs may permit greater opportunity for renal transplantation in minority candidates.9

 

Disparities in outcomes

African Americans are at high risk for early graft rejection following renal allograft transplantation. Multiple studies have confirmed that African American race is a significant independent predictor of early renal graft loss even when other potential negative factors are statistically controlled.5

 

Factors that may contribute to this lower long-term renal allograft survival include histocompatibility and acute rejection, delayed graft function, co-morbid diseases (such as chronic hypertension), hyperimmune responsiveness, noncompliance (with medications or follow-up) and ineffective immunosuppressive therapy.9,10

 

Because of their greater risk of failure after transplantation (marked by higher rates of acute rejection and diminished graft survival), African-American patients require greater immunosuppression to maintain graft function.11

 

Studies have shown that African Americans renal transplant recipients have fewer rejection episodes when immunosuppressed with combinations of tacrolimus, mycophenolate mofetil, sirolimus, and similar medications.10, 11, 12 Unfortunately, these more extensive immunosuppressive regimens place African American kidney recipients at increased risk for drug-related toxicities and other complications such as steroid-induced diabetes.9,10,11

 

Racial disparities are observed in other post-transplant outcomes in addition to higher rejection rates and graft survival.  Using multivariate regression analysis, Shibagaki et al.12 noted that African-American race was an independent risk factor for developing post-transplant anemia. Significant anemia (defined as hemoglobin levels less than 11 g/dL in females and less than 12g/dL in males) was more common in African Americans than in non-African-American patients, both at 6 months and one year after transplantation.12  Furthermore, data have shown that the incidence of post-transplant diabetes is higher in African Americans, particularly in the pediatric population.13

 

Conclusion

African Americans and other racial/ethnic minority populations are disproportionately affected by chronic renal failure (CRF) and ESRD. Disparities with respect to access to kidney transplantation have been observed along racial lines. Research suggests that the allocation system whereby individuals are allotted kidneys is weighted against African Americans. Disparities also exist with respect to outcomes of kidney transplantation. African Americans need to be aggressively educated regarding options for transplantation and organ donation.

 

In addition, policy changes are needed to encourage the equitable distribution of organs for transplantation into African Americans.

 

Dr. Modlin is a urologist & renal transplant surgeon at the Cleveland Clinic Glickman Urological & Kidney Institute in Ohio, where he is associate professor of surgery.  He is director of the Minority Men’s HealthCenter & Clinical Community Outreach & director of the ClevelandClinicTransplantCenter Minority Organ Donation & Transplant Initiative.  Mr. Zaramo is a research associate at the Glickman Urologic & Kidney Institute. Dr. Nguyen is a urology resident at the institute.  Please direct all correspondence to Dr. Modlin at Desk A100, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH44195.

 

References

  1. Dressler WW, Oths, KS, Gravlee CC. Race and ethnicity in public health research: Models to explain health disparities. Ann Rev Anthropol. 2005; 34: 231-252.
  2. Institute of Medicine.  “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.”  Washington, D.C.: NationalAcademy Press, March 2002.
  3. United Network for Organ Sharing May 25, 2007 Database (UNOS) Organ Procurement and Transplantation Network (OPTN).http://www.unos.org/what WeDo/research.asp. UNOS Data Request
  4. Callender CO, Miles PV, HallMB, Gordon S. Blacks, whites, and kidney transplantation:  A disparity! But why and why won’t it go away? Transplant Rev. 2002;16:163-176.
  5. Epstein AM, Ayanian JZ, Keogh JH et al. Racial disparities in access to renal transplantation—clinically appropriate or due to underused or overuse?  N Engl J Med. 2000;343:1537-1544.
  6. Klassen AC, Hall AG, Saksvig B, et al. Relationship between patients’ perceptions of disadvantage and discrimination and listing for kidney transplantation.  Am J Public Health. 2002;92:811-817.
  7. Rozon-Solomon M, Burrows L. ‘Tis better to receive than to give: the relative failure of the African American community to provide organs for transplantation. Mt. Sinai J. Med. 1999;66:273-276.
  8. Zaramo, C, Novick A, Modlin CS. The Assessments of Racial Health in Renal Transplantation. Am J Kidney Dis. 2006;47:A-14:178. Abstract presented at the National Kidney Foundation 2006 Spring Clinical Meetings in Chicago.
  9. Modlin CS, Goldfarb DA, Novick AC. The use of expanded criteria cadaver and live donor kidneys for transplantation.  Urol Clin North Am. 2001;28:687-707.
  10. Modlin CS, Flechner SM, Goormastic M, et al. Should obese patients lose weight before receiving a kidney transplant? Transplantation. 1997; 64:599-604.
  11. Podder H, Podbielski J, Hussein I, et al. Sirolimus improves the two-year outcome of renal allografts in African-American patients. Transpl Int. 2001;14:135–142.
  12. Shibagaki Y, Shetty A.  Anemia is common after kidney transplantation, especially among African Americans.  Nephrol Dial Transplant. 2004;19:2368-2373 (Epub ahead of print).
  13. Furth SL, Garg PP, Neu AM, et al. Racial differences in access to the kidney transplant waiting list for children and adolescents with end-stage renal disease. Pediatrics. 2000;106:756-761.