Racial Disparities and Transplantation
Article Outline
IN THIS ISSUE of the American Journal of Kidney Diseases, Weng et al1 report on rates of completion of the evaluation process to be placed on the cadaveric kidney transplant waiting list. The authors included 175 patients who had advanced chronic renal failure (soon to require dialysis or transplantation) or who were stable on dialysis therapy. All patients wished to be evaluated for transplantation, and the time to completion of evaluation and placement on the waiting list was longer in black patients than in others. Questions of health care disparity based on race naturally arise from such a study.
The authors use rather sophisticated statistical analyses to arrive at their conclusion. They appear to have included a number of interesting sociodemographic variables, including the size of the referring nephrology group, as well as the specific physician and transplant coordinator involved with each evaluation. Clearly, their attempt to leave no stone unturned is a strength of this work. Their end point of listing all patients with the United Network for Organ Sharing (UNOS), even if a potential living donor is identified, is sound for the study, but a departure from what many transplant centers do because listing itself is an expense that can be spared should living kidney donation be planned.
Unlike at many centers, more than 45% of their patients coming to transplant evaluation were not yet on dialysis therapy. Furthermore, of patients on dialysis therapy, most were relatively new dialysis patients, having been treated a median of 162 days. Additionally, the 175 patients who completed this study came from a group of 356 who initially presented for evaluation. Thus, fewer than half the referred patients completed the study, and we know nothing regarding the racial composition of persons not studied. In any event, during the follow-up period, 100 of 175 patients (57%) completed tests and were placed on the UNOS deceased donor renal transplant waiting list. The strongest associations with completing transplant medical evaluation were, in order, no additional test or evaluation needed, patient never married, insurance coverage, and initial information about transplantation from outside the medical profession. The strongest associations with not completing the evaluation were Medicaid coverage, patients seeking donation from a living donor, and black race. Therefore, it would seem that, at least at the University of Pennsylvania School of Medicine, persons who have complete medical records, those who never married, and those who have non-Medicaid insurance complete evaluations more quickly than patients who rely on Medicaid, have asked for a living donor, and are black.
This report and many others point to racial differences in renal transplantation. No American renal transplant professional active in clinical care can be ignorant of the racial composition (disproportionally black) of patients reaching end-stage renal failure in our country. Racial disparities at virtually every step of the transplant process have been reported: some are medical-biological, some are sociodemographic, most are multifactorial, and all appear complex.2, 3, 4, 5 Thus, some circumstances of health care disparity in renal transplantation may be largely beyond control of a transplant team. However, as physicians, we must remain ethically committed to serve all patients equally, and we may be able to address a number of issues.
It is important to understand that the delivery of care to minority patients often is exemplary for renal transplantation. Clearly, some centers in America have transplant wait lists that exceed 50% black patients and perform transplantation on that proportion, as well.6 Thus, in many centers, there may be little or no disparity when one looks at the real end point of a renal transplant evaluation, which is, of course, transplanting the kidney. Interestingly, Weng and his coauthors also published (with other authors) an equally sophisticated analysis that adherence to transplant medication regimens was really transplant center dependent when race and adherence to treatment were fully considered.7 In other words, the association of a specific transplant center with its inherent characteristics in treating its black recipients appears to modify and ameliorate racial disparity. We really can do something.
There is no question that the larger transplant community has addressed the issue of disparity. For example, removing the HLA-B match as a priority for allocation of cadaveric kidneys8 likely favors black patients on the UNOS waiting list. Conversely, this policy would decrease the number of transplantations among whites and slightly increase the rate of graft loss.9 Nonetheless, the option to adopt such a priority has been acceptable nationwide despite a seemingly clear racial bias positively affecting black potential transplant recipients. In addition, the sensitivity of the transplant community in studying outcomes regarding race and transplantation has shown several interesting beneficial effects in both single and multicenter studies of renal transplantation and black race.9, 10, 11, 12, 13, 14 For example, black kidney allograft recipients who had renal failure secondary to focal segmental glomerular sclerosis, especially those with a living donor allograft, had improved graft survival with a decrease in graft loss resulting from recurrent focal segmental glomerular sclerosis compared with whites. Furthermore, donor and recipient race matching, possibly related to HLA factors, has shown some advantage in outcomes for black transplant recipients. Happily, then, priorities and outcomes have actually favored minorities, at least in some instances.
The results and conclusions noted by Weng et al1 have several weaknesses, many of which they cite. The study reflects a single referral population that is small in number. They admit to potential confounding, as well as limited ability to adjust for comorbidity and case-mix severity. Additionally, the complexity of end-stage renal disease, untoward events affecting patients after initial consultation, and the need for additional testing because a step in the evaluation process showed an unexpected finding (the real reason we evaluate patients, by the way) may all influence predictability. Thus, the value of this work may not be that the authors found a statistical difference in an increased time to evaluation for blacks (or decreased for never married persons), but rather that they point out a racial disparity phenomenon that, even when not perceived by individual practitioners, must not be allowed to affect us or those for whom we care. Weng et al1 offer no solution to this matter.
The American Medical Association currently is involved in a significant effort to end disparities in the delivery of all health care and to foster appropriate communication skills among professionals while improving health literacy among patients. All who care for patients should embrace such efforts, which would approach system-related problems that may inadvertently perpetuate certain aspects of disparity. Making the least capable patient a partner in care should be the goal of all treating professionals, especially those who care for patients with such high-intensity needs as dialysis and transplantation. Clearly, no individual seeks to render care in a biased or racially charged manner. Nonetheless, our own training and the time demands placed on us may be unintentional impediments to an optimal physician-patient partnership that would ultimately diminish racial and ethnic disparities.
No study, single or multicenter, can confirm all the disparities that may come into play regarding the clinical and sociodemographic matters potentially affecting individual patients who, after all, really do participate in the ultimate decisions about whether transplant referral, evaluation, and organ acceptance occur. There are many reports, a number of which are appropriately cited by Weng et al,1 regarding renal transplantation and black race in America. Most such studies that showed disparities offered no real plan or solution to what is probably, and sadly, a multifactorial sociodemographic problem that may have no single and broadly applicable solution. Many affirm that persons rendering care and those receiving care are, indeed, different. In such a context, one must wonder how certain centers really do overcome racial disparity, at least as it is confirmed by some studies. Clearly, concerned caregivers of all racial and ethnic backgrounds should strive to eliminate system-related disparity. However, in the end, there also is the issue of patient responsibility. Professionals caring for the ill must leave the door open for all. All who receive service must share the responsibility, to the full extent possible, of becoming part of a medical system that, while imperfect, is attempting to address the uncomfortable issues of disparate care among groups of Americans.
References
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- The Organ Procurement and Transplantation Network (Transplants in the U.S. by Recipient Ethnicity, FLJT, 2003-2005) . 2005; http://www.optn.org/latestdata/rptData.asp Accessed: July 10
- Race and electronically measured adherence to immunosuppressive medications after deceased donor renal transplantation . J Am Soc Nephrol . 2005;16:1839–1848
- United Network for Organ Sharing: Policy 3.5.11.2, November 19, 2004. Available at: http://www.unos.org. Accessed: July 10, 2005
- Effect of changing the priority for HLA matching on the rates and outcomes of kidney transplantation in minority groups . N Engl J Med . 2004;350:545–551
- Graft loss due to recurrent focal segmental glomerulosclerosis in renal transplant recipients in the United States . Am J Kidney Dis . 2001;37:366–373
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- A decade of experience with renal transplantation in African-Americans . Ann Surg . 2002;236:794–805
- . Cold ischemia and outcome in 17,937 cadaveric kidney transplants . Transplantation . 1995;59:191–196
- Effect of donor factors on early graft survival in adult cadaveric renal transplantation . Am J Transplant . 2002;2:68–75
PII: S0272-6386(05)01107-8
doi:10.1053/j.ajkd.2005.08.004
© 2005 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved.
Refers to article:
- Rates of Completion of the Medical Evaluation for Renal Transplantation , 22 August 2005
