Cadaver-Donor Renal Transplantation of Children in Israel (1990–2001): Racial Disparities in Health Care Delivery?
* Division of Pediatric Nephrology, Shaare Zedek Medical Center, Hebrew University-Hadassah Medical School, Jerusalem, Israel
Israel Society for Dialysis and Transplantation of the Ministry of Health, Jerusalem, Israel
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ABSTRACT |
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Objective. To evaluate the allocation and outcome of cadaver-donor renal transplantation (CDRTx) among Jewish and Arab children in Israel.
Methods. Data on CDRTxs in patients who had end-stage renal failure (ESRF), were younger than 18 years, and were on dialysis treatment were obtained for the 11-year period of January 1990 to December 2000 from the Israeli Dialysis and Transplant Registry, supplemented by 10 years of follow-up (January 1991–December 2000) from our own center.
Results. The Israeli Dialysis and Transplant Registry data show that 64 of 130 available cadaver-donor kidneys (CDKs) were allocated to Jewish patients (49.2%) and 66 of 130 were allocated to Arab children (50.8%): Moslem, Druze, or Christian. The Jew/Arab patient ratio for a waiting time of <1 year was 0.97 and for 1 to 2 years was 1.45, whereas that ratio was 0.6 for 2 to 4 years and 2.0 for >4 years. The mean renal transplant score (RTx score), reflecting the urgency of the need for RTx of an ESRF patient, was identical for Jew and Arab: 4.93 and 4.96. Our own center data refer to 69 dialysis (47 Arabs and 22 Jews) and 4 predialysis patients younger than 18 years who underwent 78 RTxs. Eighteen Arab and 14 Jewish children from our center received 20 and 15 CDRTxs in Israel, with a mean waiting time of 29.6 and 25.4 months for Jew and Arab, respectively (ratio: 1.16). In our center, the outcome (after 7 years) of graft survival and function was not different between Jewish and Arab RTx recipients.
Conclusions. Allocation of CDRTxs between young Jewish and Arab ESRF patients on dialysis did not differ and was associated with comparable waiting times, identical RTx scores, and similar long-term outcome. This is a remarkable finding, certainly in the face of the unequal race allocation of RTxs in the United States as well as the long unstable local (Middle East) political situation.
Key Words: pediatrics • cadaver-donor renal transplantation • children • Israel • equality of renal care
Abbreviations: CDRTx, cadaver-donor renal transplantation • RTx, renal transplant • CDK, cadaver-donor kidney • ESRF, end-stage renal failure • IDTR, Israeli Dialysis and Transplant Registry
A number of publications, particularly from North America and mostly dealing with adults, have over 2 decades shown racial and gender difference in health care delivery, primarily in the field of cardiology, nephrology, and a variety of lifesaving surgical procedures.1–5 In the United States, the data clearly favor the white versus the black population and male versus female gender. Relatively few data are available regarding disparities in the care for children.6
Israel is a multiethnic society with increasing tension/animosity between Jews and Arabs, mainly across the borders of Israel and the Palestinian Authority but also within Israel proper. This article evaluates the distribution of cadaver-donor renal transplantation (CDRTx) among Jewish and Arab children in Israel.
Since 1993–1994, the registration of patients awaiting a renal transplant (RTx) and the allocation of the available (cadaver-donor) kidneys (CDKs) in Israel are centralized by the National Kidney Center according to objective criteria, such as 1) the age of the patient, 2) waiting time for RTx, 3) HLA-DR match/mismatch, and 4) presence (%) or absence of panel reactive-preformed-antibodies. These 4 parameters compose the so-called renal transplantation score (RTx score), which is determined just before the kidney is allocated. The RTx score is a reflection of the actual time that elapsed since the patient started dialysis and the most recent panel reactive antibodies test before transplantation. Together with the age of the patient and his or her HLA status, the RTx score represents an objective indication of the overall urgency of a specific transplant procedure. As elsewhere in the world, the main problem facing the (renal) transplant activity in Israel is the lack of suitable cadaver and living related donors. Official Jewish religious ruling by the Chief Rabbinate of Israel not only permits cadaver donor (as well as some living related) RTxs but also encourages this practice according to well-established medical considerations. The ruling stresses that cadaver donor harvesting can be done only when brain death has been established by independent doctors (not involved in the treatment of the donor or members of the transplant team) and after legally binding written consent has been obtained from the family of the dying or dead patient. Unfortunately, in practice, the official rabbinical ruling has not changed the psychological negative attitude of individual religious Jews toward RTx. There are at present 7 Israeli hospitals that perform RTxs, although the great majority of patients with end-stage renal failure (ESRF) receive a transplant at the adult and pediatric surgical services of the Rabin Medical Center in Petach Tikvah. All children with ESRF in Israel and those referred from the area of the Palestinian Authority with financial coverage are eligible to receive chronic dialysis therapy. To the best of our knowledge, no child has been refused treatment for ESRF. The young dialysis patients in the 11 pediatric nephrology units in Israel are almost immediately placed on the waiting list for RTx, once dialysis therapy is instituted, irrespective of their origin or ethnic background. The delay from initiation of dialysis until registration for RTx depends on the time needed to complete the necessary pre-RTx workup that may differ from patient to patient, and no national data on this aspect are at present available. In our own service, the time necessary for this evaluation was in all patients far less than 1 month. For practical reasons, the waiting time (in months/years) therefore is defined as the time elapsing from initiation of dialysis treatment until transplant surgery. In Israel, there is no preemptive CDRTx because registration for a CDRTx is not possible before the patient is on dialysis therapy. That is, of course, different in the case of an available living (related) renal donor. The only contraindications for RTx registration are clearly medical, such as a low body weight (<9 kg).
Our own center, located in Jerusalem, is one of the largest pediatric chronic renal failure programs in Israel but has no facilities for RTx. The patients undergo RTx elsewhere in Israel or abroad and return to our center shortly after surgery for long-term follow-up. For many years, we had an abundance of young Arab patients from Israel as well as from the West Bank and Gaza; recently, fewer Arab patients are referred by the Health Department of the Palestinian Authority. We have previously described some of the special aspects of the cohabitation of Jewish and Arab (Moslem) children in the setting of an Israeli pediatric dialysis service,7 an atmosphere that surprisingly continues until this day, unchanged by political events such as on the one hand the Oslo accords or on the other the two major "Intifadas" (Palestinian uprisings). Recently, a group of 25 Jewish and Arab (Israeli and Palestinian) dialysis and Tx patients from our unit traveled together to Switzerland for a well-earned vacation, for many their first trip abroad.
All Israeli patients, Jews and Arabs of all denominations, have compulsory (national) health insurance that will completely cover the medical treatments, including dialysis and RTx. The Palestinian (West Bank; Gaza) Arab patients initially had medical coverage through the Israeli Military (Medical) Authorities but now, since the establishment of the independent Palestinian Authority, by their medical services.
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METHODS |
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Our study represents a retrospective cohort study using existing patient data. These data were obtained from the Israeli Dialysis and Transplant Registry (IDTR) of the Ministry of Health and complemented with the results of our own center. The 2 sources were used concomitantly 1) to better validate the registry data and 2) at the same time to include personal experience.
In the IDTR data, we looked at 130 CDRTxs performed between January 1, 1990, and December 31, 2000, in children younger than 18 years, 70 boys and 60 girls. The number of CDRTxs in children younger than 18 years during this period varied from 0 in 1989 to approximately 15 CDRTxs per year from 1994 onward with a peak of 24 (13 Jews, 11 Arabs) in 1998. This 1998 peak was the result of an aggressive new major administrative effort to increase kidney donation. Our own center data relate to all RTxs (n = 78) performed in 69 dialysis patients (42 boys, 27 girls) younger than 18 years, 47 Arabs (28 Palestinians, 19 Israeli) and 22 Jews during a 10-year period from January 1, 1991, to December 31, 2000. Four additional children underwent preemptive (living and cadaver donor) RTx. Long-term graft survival (Kaplan-Meier curves) and graft function (creatinine clearance according to the Schwartz formula) of 25 Jewish and 26 Arab patients followed in our own center were determined during a follow-up period of 7 years. These latter data include CDRTxs (n = 40) as well as living donor RTxs (n = 14). Twenty-one Arab children who underwent living unrelated (commercial) RTx in India (2), Turkey (1), or Iraq (18) were excluded from this analysis because they did not have a matching patient group of Jewish origin. The living to cadaver donor RTx ratio was 0.3 for Jewish and 0.4 for Arab children.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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The IDTR nationwide data show that during the 11-year study period, 64 CDKs of the 130 available CDKs were transplanted into Jewish (49.2%) and 66 of 130 (50.8%) into Arab children, all on dialysis therapy. The latter number includes Arab children of Moslem (54 of 130 [41.5%]), Druze (9 of 130 [6.9%]), and Christian faiths (3 of 130 [2.3%]). Of the 130 children, 68 before CDRTx were on hemodialysis, 37 were on continuous cycling peritoneal dialysis, and 25 were on continuous ambulatory peritoneal dialysis. The mean waiting time for a CDRTx was in 69 children <1 year (Jew: 33; Arab: 36), in 28 between 1 and 2 years (Jew: 16; Arab: 12), in 24 between 2 and 4 years (Jew: 9; Arab: 15), and in 9 >4 years (Jew: 6; Arab: 3). The Tx score of 30 Jewish and 30 Arab CDRTx patients in the nationwide survey of the IDTR was identical, 4.93 (range: 3–10) and 4.96 (range: 4–10), respectively. The gender differences of the nationwide data were minimal with a 1.16 male:female ratio.
Among the 71 dialysis patients in our own center (Table) 45 children were on hemodialysis and 26 were on continuous ambulatory peritoneal dialysis/continuous cycling peritoneal dialysis. Four patients underwent preemptive RTx with living-related or living-unrelated donor kidneys. Eight Arabs and 6 Jews received a living-related RTx in Israel, whereas 21 Arab children and one Jewish girl underwent commercial, living-nonrelated donor RTx abroad. Five Jewish children underwent 5 CDRTxs in Europe and the United States. Eighteen Arab and 14 Jewish patients from our service received 20 and 15 CDRTxs in Israel with a mean waiting time of 29.6 and 25.4 months on dialysis for Jew and Arab, respectively. Two young Jewish children who were treated in our center died while placed on the CDRTx waiting list before a CDRTx became available. None of the Arab children in our unit died during the waiting period. The 7-year (first) graft survival and graft function of Jewish and Arab patients followed in our own center were comparable (Figs 1 and 2) and relate to CDRTxs as well as living donor RTxs.
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All cadaver kidneys for the CDRTxs performed in Israel were harvested in Israeli hospitals, not necessarily meaning that the majority of the donors were Jewish. We could not obtain reliable information on the ethnic background and the attitude of the cadaver-renal donors and their families.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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It is a sad worldwide phenomenon that health care delivery is unequal and unjust, often detrimental to adults and children of minorities. A recent report from Yale-New Haven Medical Center (New Haven, CT) emphasized this point in adults regarding the use of cardiac catheterization after acute myocardial infarction,4 followed by a thoughtful editorial.8 More recent is the article and its related editorial describing unequal racial and ethnic group representation in clinical treatment trials for adult patients with human immunodeficiency virus.9,10 The present report does not discuss the multiple and complex causes of the observed disparity in medical care; the interested reader is referred to the articles by Navarro11 and Fiscella et al12 that span 10 years of research on the subject.
Our field of interest is (pediatric) nephrology, and in these subspecialties there is abundant evidence that availability of dialysis therapy and RTx is unequal.1–3,13,14 These data relate almost exclusively to adults, but Furth et al15 (Johns Hopkins, Baltimore, MD) recently showed that this holds true for children in as far as access to RTx waiting list is concerned. Similar data were reported by the North American Pediatric Renal Transplant Cooperative Study.16,17 There have been suggestions to reduce the disparity in kidney allocation, but the reality remains dismal and "the struggle toward equality continues."18,19
The present study primarily addresses the issue of the availability of CDRTx for Jewish and Arab children younger than 18 years in Israel during an 11-year period from January 1990 to December 2001. We concentrated on CDRTxs because live-donor RTxs (related and nonrelated) are greatly influenced by cultural and even more so by socioeconomic factors. This is particularly true with the emergence in recent years of commercial, nonrelated living-donor RTx, despite being illegal in all Western countries, including Israel. The Palestinian Arab population on dialysis treatment in Israel, however, often opted for commercial RTx outside Israel in India and since the Gulf war in the Arab world, in Iraq.20 The allocation of a CDRTx therefore represents the just (or unjust) racial allocation of the available organs and the necessary funds by the Israeli Government through the National Kidney Center.
The nationwide IDTR data on the allocation of CDKs to children younger than 18 years during the past 11 years were complemented by those of our own service (10 years), despite that our own experience is already included in the nationwide data. Registry data depend on the accuracy of the reporting centers as well as the handling of the data by a central agency and have often been shown to have flaws. Single-center data are generally more reliable. The comparison of the nationwide data with those of our pediatric chronic renal failure program, one of the largest in Israel, was therefore used as an internal quality assessment of the nationwide data at the same time providing all important personal experience. The comparison between the 2 groups of data proved to be very positive, as outlined above.
The reported nationwide experience shows that the total number of CDRTxs performed in the young is unfortunately low, approximately 12 per year. This low number of CDRTxs in children somewhat limits the evaluation of possible differences between the 2 main ethnic groups studied, the majority being Jews and the minority being the Arab population. The nationwide allocation of the cadaver kidneys was almost equal between the Israeli Jewish (n = 64 of 130) and the Arab (Moslem, Druze, Christian) children (n = 66 of 130) from Israel, the West Bank, and Gaza who had identical RTx scores and almost no gender differences. For these calculations, only the ethnic background was used without subdivision in Israeli and Palestinian Arabs. In our own unit, more Palestinian than Israeli Arab children were referred to RTx. The mean waiting time for a CDRTx in the IDTR data does not place the Arab patients at a disadvantage. The ratio of Jew/Arab patients with a waiting time <1 year was 0.97; for a waiting time between 1 and 2 years was 1.45, for a waiting time between 2 and 4 years was 0.6, and for a waiting time of >4 years was 2.0. These ratios reflect the number of patients of the 2 main ethnic groups in the 4 time frames chosen arbitrarily by the IDTR. Their accuracy is somewhat less than the means of the individual waiting-list time data in our own service that give an actual Jew/Arab waiting time ratio of 1.16 at approximately 2 years, ie, a somewhat longer mean waiting time for the Jewish patients.
To complete the allocation data, we included the actuarial graft survival as well as graft function of the patients treated in our own unit. As can be seen in Figs 1 and 2, these 2 parameters did not differ for Jew and Arab during the follow-up period.
The reported data on CDRTx in children younger than 18 years and their racial allocation are remarkable, particularly in as far as waiting times are concerned. The figures are even extraordinary when viewed within the framework of the discrepancy in racial care reported from the United States as well as taking into account the Jewish-Arab tension in the country and beyond.
To the best of our knowledge, data on renal care and, more specific, of renal replacement therapy with dialysis and RTx in different ethnic groups are now available only for the 300 million population of the United States and with this article also from our small country (total population, 6.5 million plus approximately 1.5 million in the West Bank and Gaza). This certainly holds true for pediatric renal replacement therapy. We therefore urge colleagues worldwide, particularly in the ever more heterogeneous populations of Europe, to study and describe their experiences in "racial health care delivery," renal or otherwise. We may be naïve, but we have not lost the hope that equal health care delivery often remains the norm.
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ACKNOWLEDGMENTS |
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We thank our colleagues at the National Laboratory for Tissue Typing and Renal Transplantation of the Sheba Medical Center at Tel Hashomer for providing the RTx scores. We are indebted to Dr David Raveh, Division of Infectious Diseases, Shaare Zedek Medical Center, for help with the Kaplan-Meier calculations/graphs.
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FOOTNOTES |
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Received for publication Aug 23, 2003; Accepted Dec 2, 2002.
Reprint requests to (A.D.) Box 8504, Jerusalem 91804, Israel. E-mail: alfred{at}cc.huji.ac.il
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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