Although racial disparities continue to plague the health care system there is one bright spot: the gap in kidney transplants appears to have closed. For the first time rates of such transplants among white and black patients are at equal levels, according to an analysis of almost 200,000 end-stage kidney disease patients.
The change comes mostly as a result of deliberate policy changes made to help eliminate the racial gap rather than any particular medical improvement in transplantations. The imbalance disappeared in 2010 after organ regulators removed certain requirements for matching a kidney donor’s biological traits to those of a potential recipient, according to the new analysis, which looked at 13 years of data. The findings were published online August 31 in JAMA Internal Medicine.
A disparity in transplants has prevailed for years for several reasons. For one thing, white adults are more likely than blacks to donate their organs because people in black communities often have greater fear or distrust of the medical establishment, according to various studies. But when it comes to finding a good kidney match, ethnicity often matters. Successful organ transplantation hinges on finding a strong tissue match between donor and recipient, with certain proteins in common, and closer matches most often come from individuals in the same ethnic groups. Because the donor pool among blacks is smaller, it has been difficult to find enough donors for black people in need.
Making matters worse, minority communities disproportionately suffer from diabetes and hypertension—conditions that are more likely to lead to end-stage renal failure and necessitate a kidney transplant. Blacks, Hispanics, Asians and Pacific Islanders are three times more likely to suffer from end-stage renal failure than their white counterparts.
Nevertheless, policy changes have closed the gap by altering what is considered an acceptable match between a donor and potential recipient. Someone who is a “perfect match” will have the same protein markers (specific traits) located on the surface of several chromosomes on certain tissues in the body. This commonality increases the chances that the body will accept the transplant organ. When an organ donation comes from a live donor it typically comes from a family member who is a close genetic match. But live donations are often not an option for people in African-American communities because their family members are less likely to be healthy, says Douglas Keith, fellowship director of the Kidney Transplant Program at the University of Virginia School of Medicine. “The diseases that afflict them, like diabetes or high blood pressure—that can then lead to kidney failures—often afflict their family, too, so they get ruled out as donors.”
That leaves only organ transplants from deceased donors as an option, and that is where the improvement has come from, according to the study. The uptick is not because many more blacks have signed organ donor cards, however—the pool of donors still remains relatively small, because of factors that include poor education about organ donation in these communities, fear or mistrust. Instead, policy changes made by the United Network for Organ Sharing (UNOS) kidney committee in 2003 effectively widened the pool for available organ donations across ethnic lines. That year, UNOS stopped prioritizing matching of certain proteins as a requirement for receiving a kidney transplant. “It was a conscious decision of a trade-off,” Keith says. Relaxing the need to have such close matching “makes some difference but it’s not a huge difference,” in terms of success for the recipient, he says. The resulting strides against racial disparity is the good news and the findings were “surprising” says Akshay Sood of Henry Ford Hospital in Detroit, the first author on the study.
Still there is some bad news. Donations from live donors lead to better health outcomes so, overall, white transplant patients will still be healthier. Moreover significant disparities remain along racial and socioeconomic lines about who gets on transplant lists in the first place and how delayed that placement may be. Minority communities are often not as well-represented on organ transplantation wait lists for myriad reasons including poor education about transplants and transplant guidelines. And some patients decline to be added to a list because of worry about the long-term cost of care; immunosuppressant drugs can cost thousands of dollars a year and may not be covered by insurance, Mark Aeder, chair of the UNOS Kidney Committee says.
To reduce delays UNOS instituted a new policy late last year that is already boosting the number of black organ transplant recipients, according to preliminary reports. Previously, patients from ethnic minorities alongside those with lower socioeconomic status and those living in areas where fewer organs may be available and wait lists are longer have historically faced delays being placed on transplant lists. Instead, they often just received dialysis. But under the new policy change, when someone who was already on dialysis is put on the kidney transplant wait list, their place in the transplant line will be backdated to when they started dialysis. Prior to the change blacks accounted for only 31.5 percent of transplants, but four months after the new policy was instituted they accounted for 37.8 percent.
With other organs there has also been a disparity in transplant rates, says Jerry McCauley, UNOS Minority Affairs Committee chair. A Scientific American analysis of UNOS figures finds that for lung transplants, for example, blacks represented 11.7 percent of the patients on the transplant waiting list, but since 2010 they were only about 8.3 percent of the recipients. For intestines, 20.3 percent of the people on the list are black yet in the past five years only about 15.8 percent have received the organ. The news for hearts is better, however: 25 percent of the patients on the list are black as were almost 21 percent of the recipients in the past five years. Unfortunately, because each organ has its own prioritization system for donations, McCauley and other experts say it is unlikely that there will be many applicable lessons from the new kidney model for other organs.