Seven years ago, Robert Gaston, a professor of medicine at the University of Alabama, broke the news that black Americans wait longer to receive needed kidney transplants than whites. That paper, published in the Journal of the American Medical Association, brought about significant concern and changes in the formula hospitals use for allocating transplant organs. But a new paper from Gaston and his colleague, Carlton Young--which appears in tomorrow's issue of the New England Journal of Medicine--now reveals that those changes didnt go far enough. Today, for complex scientific and political reasons, white Americans still receive a disproportionately larger percentage of donated kidneys for transplant, Gaston says, and black Americans still wait longer for transplantation.

Gaston and Young had expected that racial differences might have waned, thanks in part to a Medicare mandate requiring all patients undergoing kidney dialysis be evaluated for transplantation. As is, black Americans--though only 13 percent of the population--make up almost a third of all patients with kidney failure. But the researchers found that not only are black patients less likely than whites to be identified as transplant candidates, they are also less likely to appear on transplant waiting lists during their first year of transplant eligibility. At UAB, only 13 percent of eligible black transplant candidates ultimately got new organs, compared to 33 percent of whites.

The NEJM article highlights several possible explanationsamong them the fact that blacks are often less able to find living related donors without underlying health problems. In addition, they face problems finding cadaveric transplants because these organs are typically given to patients with the closest genetic match. Perfect matches are associated with a better transplant outcome and we have no quarrel with giving preference for a perfect match, even though whites are much more likely to benefit from this approach, the scientists write. Due to scientific advances, however, less-than-perfect matches make little difference in outcomes and should not exert a strong influence on who receives kidneys. In conclusion, they call for greater efforts to ensure that race is no longer an obstacle.