Gap in living kidney transplants between white and minority recipients has widened instead of narrowed

Black and Hispanic kidney transplant patients are less likely than white patients to receive a kidney from a live donor despite concerted efforts over the past two decades to increase organ transplant donation.

The incidence rate among white patients who received a live-donor kidney after two years on the waiting list increased four percentage points, climbing to 11% in 2014 from 7% in 1995. At the same time, incidence rates among both black and Hispanic patients decreased, half a percentage point and close to a full percentage point, respectively, according to a study published Tuesday in the Journal of the American Medical Association.

"Unfortunately, these disparities have been apparent since 1988," said study author Tanjala Purnell, assistant professor of surgery in the Division of Transplantation at Johns Hopkins University School of Medicine. "We've known about this now for close to 30 years."

Kidneys from living donors are used in about one-third of all kidney transplants and are associated with better health outcomes and higher survival rates compared with transplants of kidneys from deceased donors. Living-donor kidney recipients have a survival rate of 92% the first five years after surgery, according to the Health Resources and Services Administration compared to an 83% survival rate among deceased-donor kidney recipients.

The study examined more than 450,000 adult kidney transplant candidates who were added to the waiting list between 1995 and 2014 and found the incidence rate at which a black patient received a living donor kidney fell to 2.9% from 3.4%. Living kidney donations among Hispanic patients had the steepest decline over the study period, falling to 5.9% in 2014 from 6.8% in 1995. Asian patients had an increase in living donor transplantation over that time, rising to 5.6% from 5.1%.

Purnell said a multitude of factors have contributed to the widening gap in living donations between white and minority patients. Some of the major contributors relate to the disproportionate impact that social determinants such as income, health insurance coverage, lack of stable housing and transportation have on people of color when it comes to poorer health outcomes. Also, the disparity that continues to exist between white and racial/ethnic minority patients when it comes to healthcare access and quality, Purnell said, has played a role in reducing educational opportunities for minority patients to learn more about the benefits of transplantation.

Purnell said she's concerned about the approach taken over the past two decades to encourage greater organ donation among the entire public rather than targeting more donation among specific racial/ethnic groups.

"Many of the programs and the policies that have been available on the national level have really, I believe, been motivated by the need to just improve overall rates of living kidney donation versus saying there are national policies currently in place that specifically target the need to reduce disparities in access," Purnell said.

Declines in living kidneys from black and Hispanic donors have reduced access to viable organs among minority patients. The majority of living organ donations have traditionally come from relatives, but Purnell wrote that an increased prevalence in health risk factors such as obesity, hypertension and diabetes has shrunk the pool of possible candidates.

Purnell said there were indications that racial disparities continued to exist even when factors such as income, healthcare coverage and educational level were adjusted, which suggested that another possible factor could be differences on the part of healthcare providers in the timing and quality of the patient conversations they have about kidney transplantation as a treatment option.

"This could have severe consequences if patients have concerns about whether transplantation is a safe versus dangerous procedure," Purnell said. "The quality of those conversations is really so important."

Moving forward, Purnell is looking at how to better get evidence-based information about transplantation to patients so they don't have to rely so heavily on getting such information from kidney dialysis centers. The CMS requires dialysis centers to inform new patients about kidney transplantation as an option, which Purnell said has made such sites the primary source about transplants for many minority patients.

She said the federal government could play a bigger role in encouraging more patients to opt for transplant over dialysis. In 2014, Medicare spent $32.8 billion to cover beneficiaries' costs of end-stage renal disease compared to $3.1 billion in spending for transplant patients.

"This is something that should be more widely available on a national level before patients even make it to the stage of dialysis," Purnell said.