Racial Disparities in Kidney Transplantation

By Charles Modlin, MD, MBA

African-Americans suffer from a significantly disproportionate incidence of kidney disease and kidney failure than Caucasian-Americans. Despite composing a little over 13 percent of the U.S. population, blacks compose more than 30 percent of Americans treated for end-stage renal disease (ESRD), a condition predominantly caused by diabetes and hypertension.1

This disparity is linked to a number of factors:

• African-American adults are 70 percent more likely than Caucasian-American adults to have been diagnosed with diabetes, according to the U.S. Department of Health & Human Services Office of Minority Health.
• Hypertension is more prevalent in black adults (33 percent) than white adults (20 percent). Some data indicate that blacks, as well as other ethnic populations, have a genetic predisposition for hypertension.2 Environmental factors, such as high salt intake, urban living, poverty and stress, also may contribute.
• Because of inadequate access to healthcare, African-Americans and other minorities with hypertension are more likely to be untreated. As a result, they are six times more likely than Caucasians to develop kidney failure from hypertension.2-3

Longer wait, higher rate of rejection

Despite higher rates of kidney disease and ESRD, research shows that African-Americans do not enjoy the same access to renal allograft transplantation as Caucasians.

Blacks are less likely to:

• Be referred for pre-transplant evaluation
• Be placed on a waiting list
• Receive a donor kidney

In addition, African-Americans spend two to four times longer on transplant waiting lists than Caucasians.4 Part of that has been due to the U.S. kidney allocation system, which matches transplant organs and recipients according to degree of genetic matching. Since up to 90 percent of transplant kidneys are from Caucasian-American donors, Caucasian-American recipients are often better matches.1,4

But the disparity doesn’t stop there. Even when African-Americans do receive donor kidneys, they have a higher risk than other Americans for early graft rejection. Studies confirm that simply being African-American is a significant independent predictor of early renal graft loss when other potentially negative factors are statistically controlled.5

This may be due to:

• Delayed graft function
• Comorbid diseases (such as chronic hypertension)
• Noncompliance (with medications or follow-up)
• Ineffective immunosuppressive therapy4,6 or differential response to immunosuppressive medications

Physicians can help level the playing field

In 2014, the U.S. kidney allocation system changed to more heavily consider a patient’s time on dialysis. This may favorably affect African-Americans — particularly those who were delayed in joining the waiting list because they hadn’t been aware of transplant options, weren’t evaluated for transplant, or other reasons.

But more needs to be done to improve African-Americans’ access to renal health. Physicians can support the effort by:

• Aggressively educating African-Americans on how to prevent kidney disease
• Aggressively educating African-Americans on the importance of early screening for and early diagnosis and treatment of kidney disease
• Aggressively educating African-Americans on their options for kidney transplantation, including the benefits of receiving a kidney from a living (related or unrelated) donor
• Promoting the National Kidney Registry and other programs, which can help those waiting for a kidney find a suitable match more quickly
• Encouraging more African-Americans to join organ donor registries and dispelling myths and misconceptions about organ donation

As always, the first step to correcting disparities is recognizing that they exist. Bringing this issue to the forefront and inviting more discussion will help us find the best solutions.

References

1. United Network for Organ Sharing (UNOS), Nov. 17, 2014, Database, Organ Procurement and Transplantation Network (OPTN). UNOS Data Request.

2. 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.

1. 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.
2. Modlin CS, Alster JM, Saad IR, et al. Renal transplantations in African Americans: a single-center experience of outcomes and innovations to improve access and results. Urology. 2014;84:68-76.
3. Epstein AM, Ayanian JZ, Keogh JH, et al. Racial disparities in access to renal transplantation—clinically appropriate or due to underuse or overuse? N Engl J Med. 2000;343:1537-1544.
4. 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.

Dr. Modlin is a kidney transplant surgeon, urologist and Founder and Director of the Minority Men’s Health Center of Cleveland Clinic’s Glickman Urological & Kidney Institute.