Article Review: Addressing Racial and Ethnic Disparities in Live Donor Kidney Recipients

Live donor kidney transplantation (LDKT) more than doubled between 1988 and 2004 and (remaining relatively static since then) it currently represents one-third of all kidney transplantations. While the overall number of LDKTs increased for the two largest racial/ethnic groups in the United States (Caucasian and Black), a large disparity exists between the two groups in regard to the percentage of LDKT recipients. According to a Journal of the American Medical Association (JAMA) article written by Purnell et al, LDKT recipient rates for Caucasians rose from 7 percent to 11.4 percent between 1995 and 2014, whereas recipient rates for Blacks declined from 3.4 percent to 2.9 percent—despite Blacks being at higher risk for developing end stage renal disease (ESRD). Recipient rates for Hispanics dropped from 6.8 percent to 5.9 percent and for Asians, rates rose slightly from 5.1 percent to 5.6 percent. In the JAMA article, Purnell et al examined numerous variables to try to isolate the factors contributing to these disparities and their relative impact.

The article attributed the disparity between different racial/ethnic groups to a variety of factors, including the following.

• Genetic factors. The broad genetic base for Blacks may lead to greater variation in human leukocyte antigen polymorphisms, subsequently limiting Blacks’ kidney matching more than those experienced by Caucasians. Similarly, stronger immune response to the allograft and variation in immunosuppressive drugs absorption and metabolism may each increase the complexity of managing this patient population.
• Socioeconomic and overall health status. The authors found that Blacks on the transplant waiting list had, on average, lower socioeconomic status, higher BMI, less education, decreased access to private insurance and more family members with kidney disease or other donation-limiting comorbidities.
• Kidney disease etiology. Etiology of kidney disease is also a determinant in widening this disparity and disadvantage. The prevalence of kidney disease due to glomerular disease was highest in Caucasian patients, and ESRD due to hypertension or diabetes was highest among Blacks and Hispanics. Between 1995 and 2014 the incidence of hypertension and type II diabetes has increased at a greater rate for Blacks (more than 72 percent) and for Hispanics (68 percent) than for Caucasians (46 percent). This disparity is a double edge sword, both increasing the incidence of advanced CKD and ESRD in Black and Hispanic people, while simultaneously reducing the pool of individuals suitable to donate.

Efforts to educate potential donors across all socioeconomic groups have been in place for several years as the kidney transplant disparity garnered national attention. The authors suggest that more culturally competent strategies need to be employed to increase understanding of live donation within Hispanic communities. They urge the deployment of “evidence-based culturally and linguistically appropriate live donor kidney transplantation educational materials, online communities, patient navigation services and policies to standardize and increase the availability of kidney exchanges and chains to help overcome immunological barriers for recipient-donor pairs.”

This is a multifaceted challenge with both biologic barriers and psychosocial conditions affecting living donor availability. The solution isn’t simple, nor is it one-size-fits-all. If we are to prevail, the solution cannot solely rest with health care providers—communities and community leaders also play a leading role in driving positive change. As with other health disparities, it is our (health care providers and community leaders) joint responsibility to help identify opportunities, educate patients, improve access to care for potential donors, inform policy makers, overcome barriers and develop solutions so that all eligible ESRD patients may experience more support with and access to live donor kidney transplants.