SEARCH

SEARCH BY CITATION

Abstract

  1. Top of page
  2. Abstract
  3. Racial Bias…Fact or Fiction?
  4. Education at the Grassroots Level
  5. Should Transplant Organizations Be More Proactive?
  6. Genes May Hold the Answer
  7. GENETIC DIFFERENCES MAY ACCOUNT FOR VARIA-
  8. References

Are the muchdocumented disparities in transplantation rates between ethnic groups actually racism, or are they a result of other differences?

inline image

Racial Bias…Fact or Fiction?

  1. Top of page
  2. Abstract
  3. Racial Bias…Fact or Fiction?
  4. Education at the Grassroots Level
  5. Should Transplant Organizations Be More Proactive?
  6. Genes May Hold the Answer
  7. GENETIC DIFFERENCES MAY ACCOUNT FOR VARIA-
  8. References

In transplantation, as in other areas of healthcare, skin color matters. Whether it's unconscious racial bias, the consequences of socioeconomic status, patient beliefs and preferences, or biologic differences that predispose populations to disease and shortened survival, race is associated with outcome disparity.

Pang-Yen Fan, MD, chair of the United Network for Organ Sharing (UNOS) Minority Affairs Committee, says the problem is due to many factors, from financial constraints to poor social support and living situations, language barriers, limited education, inadequate healthcare coverage and patient mistrust. Medical factors include differences in blood type and HLA, and even geography plays a role, as minority patients are often concentrated in areas with long waiting times for transplants.

Studies and articles over many years have documented the problem. Recently:

  • • 
    A 2007 study found that doctors' unintentional racist feelings can affect how they diagnose and treat patients.1
  • • 
    Minorities, particularly blacks, are referred for transplantation later than whites.2
  • • 
    A 2007 study found that black patients living in poorer neighborhoods were 56% less likely than whites to be placed on the transplant waiting list.3
  • • 
    A 10-year-study published in 2008 determined that blacks with chronic obstructive pulmonary disease are less likely than whites to get a lung transplant.4

Are these much-documented disparities actually racism, or are they the result of differences in patient financial, educational and cultural status? We take a look at this topic in specific relation to blacks and find that the situation evokes passionate commentary from transplant professionals. “Of course there's racism,” says Clive O. Callendar, MD, head of the transplant program at Howard University in Washington, DC, and founder of the Minority Organ Tissue Transplant Education Program (MOTTEP). “It reeks in transplantation, along with the rest of healthcare. It affects all solid organs, but it exists even more so in end-stage renal disease.”

On the other hand, Robert Gaston, MD, a transplant nephrologist and professor of medicine at the University of Alabama at Birmingham, says, “It's not that the system is rigged or that there's necessarily racism in the sense most of us think the term. There's just a convergence of physiologic, socioeconomic, educational and environmental variables, with the net impact that African Americans are more likely to have problems getting transplants than others.”

Whether there's been any improvement in recent years is another issue. Akinlolu Ojo, MD, PhD, professor in the Department of Internal Medicine at the University of Michigan, Ann Arbor, says he continues to see presumption of behavioral risks by providers on the basis of race alone, a poor understanding of black culture and a lack of resources and sophistication on the part of candidates and recipients in navigating the pathway to transplantation and remaining engaged in the system. “Access to kidney transplantation for African Americans has not changed significantly between 1996 and 2005,” he says, specifically noting slow referrals. “Nothing has been done to meaningfully improve access other than marginally effective and counterproductive redistributive allocation practices.”

Education at the Grassroots Level

  1. Top of page
  2. Abstract
  3. Racial Bias…Fact or Fiction?
  4. Education at the Grassroots Level
  5. Should Transplant Organizations Be More Proactive?
  6. Genes May Hold the Answer
  7. GENETIC DIFFERENCES MAY ACCOUNT FOR VARIA-
  8. References

Dr. Callendar and MOTTEP are trying, however. With funding first from Dow Chemical Company and later from the National Institutes of Health (NIH; $16 million from 1993 to the present), MOTTEP set up offices in 15 communities, with a goal of educating minorities about prevention, donation, and transplantation, all at the grassroots level. A Dow-sponsored Gallup poll between 1985 and 1990 that compared MOTTEP sites with other communities demonstrated a 14% increase in signed donor cards for blacks and a 20% increase in the number of blacks who knew about the high success rate of transplantation. Citing recent data from the Scientific Registry of Transplant Recipients, Dr. Callendar notes that donation rates at MOTTEP sites were 43.4%, compared with 32.9% at non-MOTTEP sites.

Currently, the number of MOTTEP sites has fallen to 11 nationwide, and only four are currently funded through 2008. An additional $3 to $5 million dollars a year is needed to fund 15 to 25 MOTTEP sites for five years, Dr. Callendar says.

Funded by the NIH National Center on Minority Health and Health Disparities, a new MOTTEP initiative called A Research Center to Reduce Ethnic Disparities in ESRD is in the works. At a handful of sites (Washington, DC, Richmond, Va., Gary, Ind., and Detroit, Mich.), “we plan to put kiosks with hypertension information in central locations within the community,” Dr. Callendar says. People will manage their own hypertension and diabetes in an interactive way with the help of healthcare professionals and tele-health technology.”

Should Transplant Organizations Be More Proactive?

  1. Top of page
  2. Abstract
  3. Racial Bias…Fact or Fiction?
  4. Education at the Grassroots Level
  5. Should Transplant Organizations Be More Proactive?
  6. Genes May Hold the Answer
  7. GENETIC DIFFERENCES MAY ACCOUNT FOR VARIA-
  8. References

Regarding the potential role of UNOS, Dr. Fan says impaired access to transplantation will persist unless negative impact factors are corrected. “Although many of the socioeconomic issues are beyond the scope of UNOS, the organization could certainly increase educational efforts to stimulate physician referral of and increase awareness about transplantation in minority patients,” he says.

Dr. Fan also suggests that UNOS work with CMS to place more emphasis on transplant referral and wait listing as essential elements of quality care. “Establishing benchmarks and increasing oversight, perhaps even with monetary penalties for noncompliance, would be one possible approach,” he says.

Robert S.D. Higgins, MD, at Rush University Medical Center and J.A. Fishman, MD, at Massachusetts General Hospital in Boston, suggested in 2006 that the American Society of Transplantation (AST), the U.S. Department of Health and Human Services and other professional societies “must take leadership roles in the development of educational programs specially aimed at the training of minority transplant professionals and primary care providers” to help solve the problems related to racial disparity in healthcare.5

Meanwhile, several transplant professionals have suggested that wait-list time begin with the onset of dialysis rather than placement on an official wait list. The advantages of a revised wait-list proposal were discussed in the November 2002 issue of AJT, in which Gabriel Danovitch et al. suggested that although patient and professional education was well meaning, it was unlikely to be effective in the absence of a change in the definition of waiting time.6

J. Keith Melancon, MD, a transplant surgeon at Johns Hopkins Hospital in Baltimore, agrees with the revised wait-list proposal. “I believe giving waiting time from the start of dialysis will help, along with eliminating HLA matching for national sharing strategies,” he says. “This will help lessen disparities and also focus our efforts on facilitating transplantation in young diabetics.”

In kidney transplantation, if the new Life Years from Transplant/Donor Profile Index system is adapted, wait-list time will begin at the onset of dialysis.7

Genes May Hold the Answer

  1. Top of page
  2. Abstract
  3. Racial Bias…Fact or Fiction?
  4. Education at the Grassroots Level
  5. Should Transplant Organizations Be More Proactive?
  6. Genes May Hold the Answer
  7. GENETIC DIFFERENCES MAY ACCOUNT FOR VARIA-
  8. References

Ultimately, researchers may find that genetics play a major role in transplantation barriers faced by minorities. Dr. Higgins notes, for example, that once a black person receives a heart transplant (even if he or she is sicker than a white person), they do about as well at the one-year post-transplant mark. However, at three years there is a statistically significant difference: 72% for blacks versus 79% for Caucasians. “This suggests that there may be other factors influencing outcomes rather than wait-list access and socioeconomic factors,” Dr. Higgins says, such as biologic indicators that predetermine intolerance of immunosuppressant drugs. (See “Genetic Differences may Account for Variation,” left).

“I think we have this wonderful therapy that can save lives and ultimately enhance the quality of life,” he adds. “It makes sense that we should be able to offer that to all members of our communities across the country regardless of their ethnicity, their background, or their socioeconomic status.”

GENETIC DIFFERENCES MAY ACCOUNT FOR VARIA-

  1. Top of page
  2. Abstract
  3. Racial Bias…Fact or Fiction?
  4. Education at the Grassroots Level
  5. Should Transplant Organizations Be More Proactive?
  6. Genes May Hold the Answer
  7. GENETIC DIFFERENCES MAY ACCOUNT FOR VARIA-
  8. References

Gilbert Burckart, PharmD, a researcher now with the U.S. Food and Drug Administration, provides an example of genotypic variations that affect the absorption, elimination and effect of immunosuppressant drugs in racial groups.

Gene polymorphisms of cytochrome P450 3A5 (CYP3A5) and P-glycoprotein play an important role in decreased drug absorption and increased drug resistance. Cyclosporine, tacrolimus, sirolimus, and corticosteroids are all substrates for P-glycoprotein and CYP3A5. Additionally, T-cells, which play a major role in the rejection process, have a very active P-glycoprotein pumping mechanism.

“While most African Americans have the active form of CYP3A5, most Caucasians have an inactive form of the enzyme which does not metabolize the immunosuppressant drugs,” he says.

“Similarly, most African Americans have the more active form (high pumper) of the gene that encodes for P-glycoprotein, called ABCB1, while most Caucasians have a lower pumping form of the gene. Therefore African Americans get double trouble with their immunosuppressant drugs; poor drug absorption from a very active pump and very active metabolism,

References

  1. Top of page
  2. Abstract
  3. Racial Bias…Fact or Fiction?
  4. Education at the Grassroots Level
  5. Should Transplant Organizations Be More Proactive?
  6. Genes May Hold the Answer
  7. GENETIC DIFFERENCES MAY ACCOUNT FOR VARIA-
  8. References