Blacks Less Likely Than Whites to Receive Renal Transplants, NEJM Study States

Blacks appear to receive fewer renal transplants than whites, regardless of clinical appropriateness, while there is "relative overuse" of renal transplants in "inappropriate" white patients, according to an article in the Nov. 23rd issue of the New England Journal of Medicine. Although there exists "abundant evidence" of racial disparities in regard to surgery, researchers from Harvard School of Public Health and Harvard Medical School noted that "it is uncertain whether these disparities reflect racial differences in clinical appropriateness or overuse or underuse of care." To explore the issue, the researchers focused on renal transplantation, as the procedure is "associated with longer life expectancy, a better quality of life and lower costs than ... long term dialysis." Researchers developed criteria for determining renal transplantation appropriateness through a literature review and "an expert panel," and then examined a study sample of end-stage renal disease patients from HCFA-funded regional end-stage renal disease networks in Alabama, southern California, Michigan and the District of Columbia, Maryland and Virginia. About 10 months after patients had begun dialysis, the researchers contacted 1,169 patients, asking them about transplantation referral, socioeconomic characteristics, health status and preferences for transplantation. Researchers also reviewed the patients' medical charts and used data from the patient survey to determine patients' perceptions.

Results
From their findings, researchers determined that at the time of chart review -- approximately nine months after dialysis began -- blacks were less likely than whites to be considered appropriate transplantation candidates and were more likely to have had an incomplete examination. Of 792 blacks in the study, 48 underwent transplantation, compared to 183 of 726 whites. More whites (12.9%) than blacks (3.2%) received a transplant from a living donor. In addition, whites deemed appropriate for transplantation were more often referred for evaluation. Nearly 98% of white women and 99% of white men who rated "appropriate" were referred for evaluation, compared with 94.1% of black women and 86.5% of black men. As for patients considered "inappropriate" for transplantation, whites were more likely than blacks to have been referred for evaluation and placed on a waiting list for transplantation. Within this category, a "larger proportion" of white patients than blacks actually received the procedure. Based on the results, researchers determined that "even if blacks and whites had equal access to renal transplantation, their rates of referral, placement on a waiting list and transplantation might not be the same." The researchers noted that the racial differences in transplantation rates might be due to "immunologic matching criteria that result in more frequent donor matches for whites than for blacks." In conclusion, the researchers said that explaining racial disparities in relation to renal transplantation is "complex," and added that reducing such disparities will require "efforts to distinguish the different causes and to tailor interventions in order to address them" (Epstein et al., "Racial Disparities in Access to Renal Transplantation: Clinically Appropriate or Due to Underuse or Overuse?" New England Journal of Medicine, 11/23 issue). An abstract of this article is available at http://www.nejm.org/content/2000/0343/0021/1537.asp