COMMENTARY |
Racial Disparities in Renal Transplantation in Children
Department of Pediatrics
University of Tennessee Health Science Center
LeBonheur Children’s Medical Center
Memphis, TN 38103
In an article in this month’s issue, Drukker et al1 from Jerusalem, Israel, are to be congratulated for writing a clear, precise, and provocative article concerning ethnic disparities in the selection of children for renal transplantation. Their article documents the remarkable finding that religious and ethnic biases do not affect access to transplantation in the midst of political upheaval. Their noteworthy article demonstrates that in Israel children are chosen for cadaveric renal transplantation regardless of ethnicity—(Israeli or Arab or religious status [Jewish, Muslim, Druse, or Christian faith]). This finding is reassuring not only to pediatric nephrologists, but to all physicians who care for children. The Jerusalem group deserves our admiration.
In the discussion, the authors make a comparison between children in Israel, where there exists equal access to cadaveric kidneys for Jewish and Arab children despite a tense political situation, and children in the United States, where access for transplantation for members of minority groups has been and is problematic.2 While no direct comparison (numbers versus numbers) is made, Drukker et al cite several well-known studies of diminished access for minorities, especially blacks.2,3 Although these racial disparities are more demonstrable for adult conditions,4,5 they extend to children with renal disease.2,3 However, this type of comparison is not straightforward and the issue of access to renal allografts by children in the United States is not only complex, but requires careful examination. The article is somewhat one-dimensional when it compares the situation in Israel with the situation in the United States, where, as noted, racial disparities are documented and are a subject of intense scrutiny.2–5 This commentary is written to emphasize why such a comparison is not straightforward and to discuss the complexity of the situation.
The outcome for child health in general, and for renal transplantation in particular, relates to 5 factors: biology, medical progress, access to services, environmental factors, and health habits. An interplay of these factors is key to the outcome of a given health care situation. The article by Drukker et al1 suggests that the concept of prejudice on the part of the provider is another factor.
In the context of the child with end-stage renal disease who is offered renal transplantation, the term biology means the underlying genetic makeup, complex immunologic factors, type of disease causing progressive renal failure, and the pathophysiology of that disorder. The term medical progress captures the form of transplant, cadaveric or living-related, and immunologic determinants, as well as therapeutic approaches. Access indicates access to services, insurance status, and the availability of transplant centers for children. Environmental factors include the child in the context of his/her family, socioeconomic status, educational status, and belief system. Ethnic issues are typically contained in this area. Health habits refer to the role of the child and his/her family with adherence to a healthy lifestyle, adherence to medications, diet, and belief structure.
The situation in Israel with regard to biology is especially interesting. The elucidation of the human genome has shown that Arabs and Jews share a group of genes not always found in Northern Europe, Asia, or Africa.6 A wide variety of these genes are more common in Middle Eastern populations. Accordingly, one of the barriers to transplantation—immunologic response and poor histocompatibility—may be more straightforward within such a homogenous population. The situation in the United States typically involves white, black, Asian, Latino, and Native American populations, each with distinct predominant HLA types and gene polymorphisms.7 Finding a "match" can be more difficult. With more potent forms of antirejection therapy8 and new approaches to induce immune tolerance,9 HLA barriers are becoming less important, but organs are still shared by HLA matching.10
The black population also has a higher rate of glomerular disorders leading to end-stage renal disease.11,12 One particular glomerular disease, focal segmental glomerulosclerosis, is common in blacks and can result in recurrence of disease in renal allografts and loss of the transplanted organ.11
In fact, access to cadaveric transplantation in children appears to be equivalent in Israel and the United States. The article carefully describes the situation in Israel. However, using data from the most recent volume of the US Renal Data System,12 a publication of the Department of Health and Human Services, this equivalence is noted for 1998 data. Because renal transplantation is reimbursed by Medicare or Medicaid in the United States, a classical access issue—lack of health insurance—is not pertinent. Renal transplant centers serving children are readily available in most areas of the country. It is within the area of environmental factors where a huge issue arises—living-related donor transplants are much more common (rate, prevalence, incidence) in whites, and much less common in blacks and Asians. Data indicate that blacks and Asian males tend not to donate to family members. Moreover, hypertension is more common in potential black donors. If transplantation is examined in terms of race, living-related donor transplants are most common in whites (male and female) and female Native American children.12
The rates of cadaveric transplant are highest in children of Asian descent. Mortality rates are lower for pediatric dialysis patients, as compared with children who have received transplants. Both patient and graft survival curves for both living-related and cadaveric transplants indicate comparable rates in males and females. However, survival rates are lower for black children in relation to white children, as shown below.12
As stated above, the comparison that should be made between Israel and the United States is in cadaveric renal transplants. In the United States in 1998, the number of cadaveric transplants in children ages 0 to 19 years was 15 per 100 patient years on dialysis for white males; 15 for white females; 17.5 for black males; 11 for black females; 17.5 for Native American males; 16 for Native American females; 25 for Asian males, and 21 for Asian females.12 However, white males and females had a rate of 20.5 and 20 for living-related transplants, a rate 3 times that in black children.12 Not only has much been written on this phenomenon, but many prominent black athletes, including National Basketball Association star Oscar Robertson and track and field star Carl Lewis, have served as spokesmen to increase donation and living-related transplants. National Basketball Association stars Sean Elliott (a transplant recipient himself) and Alonzo Mourning have also been spokesmen; each is said to have focal segmental glomerulosclerosis.
Within 2 years on dialysis, fully 70% of white children have been transplanted versus only 44% of black children, but the difference can be accounted for in part by the high rate of living-related donor transplants in whites (20.5 per 100 patient dialysis years in whites vs 7.8 in black children).12 Histocompatibility mismatch is also more common in blacks.6 As noted, if one only examines cadaveric-renal transplants, racial disparities are minimal. However, disparities are real for total transplants.
Survival after transplant—of the organ and of the patient—is better in whites than in blacks. Kaplan-Meier 5-year patient survival rates in whites of all age groups are in excess of 90% (93% for those 0–4 years old, 100% for those 5–9 years old, 98% for those 10–14 years old, and 97% for those 15–19 years old) in contrast to 92% (0–4 years old), 73% (5–9 years old), 98% (10–14 years old), and 93% (15–19 years old) for blacks. Organ survival in blacks is also lower than in whites (40%–62% in blacks vs 58%–68% in whites) of the 4 age groups. Recurrence rates for focal segmental glomerulosclerosis and drug compliance issues may account for these differences. Another factor includes the increased degree of immunologic hypersensitization that makes matching for retransplants using cadaveric kidneys especially problematic.3,12
Prejudice should always be viewed as a real issue in society and in the history of mankind. It is also very real in Israel and in the United States. However, racial prejudice is unlikely to influence the offering of renal transplants in children in either country. The article by Drukker et al1 shows this in Israel and the US Renal Data System12 shows it in the United States. One interesting fact is that in Israel patients are divided by their religion and in the complex, diverse and polyglot United States, this designation does not occur.
The challenges for US pediatric nephrologists are to overcome genetic and histocompatibility factors, to engage the community to enhance living-related donor transplants, and to understand recurrent disease. Prejudice does not appear to be a barrier and should never play a role in selection for transplantation.
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FOOTNOTES |
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Received for publication Oct 14, 2002; Accepted Oct 14, 2002.
Address correspondence to Russell W. Chesney, MD, Department of Pediatrics, University of Tennessee Health Science Center, LeBonheur Children’s Medical Center, 50 N Dunlap, Room 306, Memphis, TN 38103. E-mail: rchesney{at}utmem.edu
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REFERENCES |
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 TOP REFERENCES |
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- Drukker A, Feinstein S, Rinat C, Rotem-Braun A, Frishberg Y. Cadaver-donor renal transplantation of children in Israel (1990–2001): racial disparities in health care delivery?
Pediatrics.2003; 112
:341
–344
[Abstract/Free Full Text] - Furth SL, Garg PO, Neu AM, Hwang W, Fivush BA, Powe NR. Racial differences in access to the kidney transplant waiting list for children and adolescents with end-stage renal disease.
Pediatrics.2000; 106
:756
–761
[Abstract/Free Full Text] - Warady BA, Hebert D, Sullivan KE, Alexander SR, Tejani A. Renal transplantations, chronic dialysis and chronic renal insufficiency in children and adolescents. The 1995 annual report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol.1999; 13 :404 –417[CrossRef][Web of Science][Medline]
- Epstein AM, Ayanian JZ. Racial disparities in medical care.
N Engl J Med.2001; 344
:1471
–1473
[Free Full Text] - King TE. Racial disparities in clinical trials.
N Engl J Med.2002; 346
:1400
–1402
[Free Full Text] - Zachary AA, Bias WB, Johnson A, Rose SM, Leffell MS. Antigen, allele, and haplotype frequencies report of the ASHI minority antigens workshops: part 1, African-Americans. Hum Immunol.2001; 62 :1127 –1136[CrossRef][Medline]
- Shahin H, Walsh T, Sobe T, Lynch E, King MC, Avraham KB, Kanaan M. Genetics of congenital deafness in the Palestinian population: multiple connexin 26 alleles with shared origins in the Middle East. Hum Immunol.2002; 110 :284 –289
- Swiatecka-Urban A, Garcia C, Feuerstein D, et al. Basilizimab induction improves the outcome of renal transplants in children and adolescents. Pediatr Nephrol.2001; 16 :693 –696[Medline]
- Krensky AM. Immunologic tolerance. Pediatr Nephrol.2001; 16 :675 –679[Medline]
- Hata Y, Cecka JM, Takemoto S, Ozawa M, Cho YW, Terasaki PI. Effects of changes in the criteria for nationally shared kidney transplants for HLA-matched patients. Transplantation.1998; 65 :208 –212[Medline]
- Greenstein SM, Delrio M, Ong E, et al. Plasmapheresis treatment for recurrent focal sclerosis in pediatric renal allografts. Pediatr Nephrol.2000; 14 :1061 –1065[Medline]
- USRDS. United States Renal Data System: 2000 Annual Data Report. Atlas of End-Stage Renal Disease in the United States. Minneapolis, MN: USRDS Coordinating Center; 2000
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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