Racial Disparities in Transplantation Persist

Pam Harrison

January 04, 2018

Racial and ethnic disparities in live-donor kidney transplantation (LDKT) for end-stage renal disease (ESRD) have actually risen over time despite the implementation of dozens of interventions addressing these disparities in many centers across the United States during the past 2 decades, a national cohort study found.

"In this national study of more than 450 000 adult kidney transplantation candidates in the United States who were added to the deceased donor kidney transplantation waiting list between 1995 and 2014, racial/ethnic disparities in the receipt of live donor kidney transplantation increased from 1995-1999 to 2010-2014," Tanjala Purnell, PhD, MPH, Johns Hopkins School of Medicine in Baltimore, Maryland, and colleagues report. "These findings suggest that national strategies for addressing disparities in receipt of live donor kidney transplantation should be revisited."

The study was published online January 2 in JAMA.

The researchers used data from the Scientific Registry of Transplant Recipients to assess whether racial and ethnic disparities in LDKT had improved during the last 2 decades in the United States. The analysis included 453,162 adults, mean age 50.9 years, who were on the deceased-donor kidney transplantation waiting list between January 1995 and December, 2014. The study population was categorized as being white, black/African American, Hispanic/Latino, or Asian.

Forty-eight percent of the cohort was white, 30% were black, 16% were Hispanic, and 6% were Asian. A total of 13.1% of transplant recipients had LDKT, but the likelihood that blacks, Hispanics, and Asians received a live-donor organ was noticeably lower than it was for white transplant recipients in both 1995 and 2014.

Table. Cumulative Incidence of LDKT 2 Years After Placement on Deceased-Donor Kidney Transplantation Waiting List

Patients Cumulative Incidence of LDKT in 1995 (%) Cumulative Incidence of LDKT in 2014 (%)
White 7 11.4
Black 3.4 2.9
Hispanic 6.8 5.9
Asian 5.1 5.6

 

Hazard Ratios for LDKT

The investigators also looked at the hazard ratios for blacks, Hispanics, and Asians to undergo LDKT compared with white patients in models that treated death and deceased-donor kidney transplantation as competing risks. In this model, the subhazard ratio for white patients to have LDKT from 2010 to 2014 was 1.86 (95% confidence interval [CI], 1.80 - 1.92).

This compared with a subhazard ratio of 1.13 (95% CI, 1.06 - 1.21) for black patients, 1.17 (95% CI, 1.09 - 1.26) for Hispanic patients, and 1.39 (95% CI, 1.23 - 1.58) for Asian patients. "[E]ven in fully adjusted models, live donor kidney transplantation disparities substantially increased over time for black and Hispanic patients," the researchers write. They suggest that the racial and ethnic disparities seen in the receipt of what is widely recognized to be a superior transplantation protocol may reflect differences in access to healthcare as well as socioeconomic factors disadvantaging these specific ethnic groups.

For example, blacks and Hispanics may live in communities where risk factors for ESRD prevail, any of which might make residents unfit to donate a live kidney. (In the current analysis, ESRD was attributed to hypertension or diabetes in almost three quarters of black recipients and over two thirds of Hispanic recipients compared with fewer than half of white patients).

"Familial clustering of end-stage kidney disease risk factors may also contribute to the difficulties reported by black and Hispanic patients in identifying suitable living donors within their families and close social networks," the investigators write.

Live Donor Transplants Out of Reach for Many

In an accompanying editorial, Colleen Jay, MD, and Francisco Cigarroa, MD, both from the University of Texas Health Science Center in San Antonio, argue that in absolute numbers, rates of LDKT have not declined for blacks or Hispanics in the later years of the study compared with 1995 to 1999. In fact, between 1995 and 2009, "the volume of live donor kidney transplantation more than doubled for every racial/ ethnic group. T]he largest increases in live donor kidney transplantation were among Hispanic and Asian recipients, which increased by more than 2.6 times during this period," they write.

Rather, more black and Hispanic patients gained access to the transplantation waiting list over the study interval so that rates of LDKT among these groups still were lower overall relative to the increased numbers waiting to receive a donor kidney.

On the other hand, the number of deceased-donor kidney transplants increased for both black and Hispanic patients between 1995 and 2005 to 2009, the editorialists explain. Since 2014, the number of deceased-donor kidney transplants rose by 5% among white patients, 23% among black patients, and 32% among Hispanics patients, the editorialists explain.

Apart from socioeconomic factors that limit the ability of those in certain racial and ethnic groups to receive a live donor organ, the financial disincentives to donate a live kidney may well be the greatest barrier against getting more live donor kidneys to needy recipients.

Evidence from a recent study suggests that it costs more than $5000 for some 20% of donors to donate an organ and over $1000 for over half of them when direct and indirect costs are taken into account. "This analysis demonstrates the substantial gap between current realities encountered by kidney donors and the goals related to financial neutrality," Dr Jay and Dr Cigarroa write.

"Efforts to improve financial neutrality for living donors may in fact also contribute greatly to mitigating disparities still existing according to race/ethnicity," they conclude.

The authors and editorialists have disclosed no relevant financial relationships.

JAMA. Published online January 2, 2018. Abstract, Editorial

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