Rates of Kidney Transplantation From Living and Deceased Donors for Blacks and Whites in the United States, 1998 to 2011

Kidney transplantation, the treatment standard for patients with end-stage renal disease (ESRD), is associated with prolonged survival, improved quality of life, reduced morbidity, and lower health care costs compared with dialysis.¹ Racial disparities in kidney transplantation are well documented; studies show that black patients are less likely than white patients to be referred for transplant evaluation, registered for transplantation, progress through the waiting list, and ultimately receive a transplant.² The effects of ongoing efforts to eliminate these disparities are uncertain.³ We used data from the United Network of Organ Sharing (UNOS) registry to examine current patterns of racial disparities in kidney transplantation. To focus on the decision to refer patients for transplantation, we used patients with ESRD as the denominator, not patients on the transplant waiting list.

To identify transplant recipients and living donors, we queried the UNOS data registry (1998 to 2011). We obtained data on the incidence of ESRD, stratified by race, from the United States Renal Data System and calculated temporal trends in kidney transplantation (per 1000 patients with ESRD) for all transplant recipients and separately for those with deceased and living donors. We adjusted the trends for age, sex, ESRD cause, and geographic region using the direct-iterative adjustment method⁴ and reported the adjusted trends using the estimated annual percent change methodology.

Between 1998 and 2011, 184 303 patients, 13.5% of the 1 355 671 patients with ESRD in the United States Renal Data System, underwent kidney transplantation. Of these patients, 37.1% (n = 68 381) underwent living donor transplantation. Figure 1 shows that the incidence of kidney transplantation in black patients increased at an annual rate of 2.84% from 93 per 1000 patients with ESRD in 1998 to 128 per 1000 in 2011 (95% CI, +2.32% to +3.41%; P < .001). Thus, by 2010, the incidence of kidney transplantation for black and white patients was equivalent.

In whites, the rate of transplantation from deceased donors declined between 1998 and 2011 (estimated annual percent change, −1.66%; 95% CI, −2.11% to −1.20%; P < .001), while the rate of transplantation from living donors was unchanged (estimated annual percent change −1.05%; 95% CI, −2.33% to +0.24%; P = .14) (Figure 2A). For black patients, the rate of kidney transplantation from deceased donors increased (estimated annual percent change, +3.49%; 95% CI, +2.81% to +4.29%; P < .001), while the rate of transplantation from living donors was unchanged (estimated annual percent change, +0.14%; 95% CI, −1.73% to +2.01%; P = .88) (Figure 2B). Over the study period, the percentages of kidney transplants from living donors were 43.2% for white patients and 22.2% for black patients. Of live kidney donations, 15.5% were from black donors; the rate remained stable (estimated annual percent change, −0.78%; 95% CI, −2.53% to +1.21%; P = .45).

In 2003, UNOS changed the allocation policy for kidneys from deceased donors by eliminating priority points for HLA-B matching.³ Because HLA shows clustering within race, and whites represent the majority demographic, most deceased donors are white; thus, kidneys from deceased donors are more likely to have favorable HLA matches with white patients. This policy change has been associated with an attenuation of the racial disparity in deceased donor kidney transplantation from 38% in the 2000-2003 period to 19% from 2006 to 2009.⁵ We found that by 2010, the overall rate of kidney transplantation was the same for blacks and whites; this change was driven wholly by increased rates of transplants from deceased donors.

Kidney transplants from living donors are associated with better outcomes than transplants from deceased donors.⁶ The persistence of lower rates of living donors among blacks limits access to the best possible transplant outcomes. Lower donation rates have been attributed to differences in socioeconomic status, personal attitudes toward transplantation, fear of surgery, and health literacy.^1,4 The higher prevalence of comorbid conditions among potential black donors, such as hypertension and diabetes, may also preclude organ donation.¹ Approaches to increasing living donor kidney transplantation rates include outreach and educational programs, better patient-physician communication, and counseling of black patients with ESRD and their families. Such measures, if effective, hold potential for expanding the overall donor pool, thus improving care for all patients with ESRD.

Corresponding Author: Jesse D. Sammon, DO, Center for Outcomes Research, Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, 2799 W Grand Blvd, K-9 Urology, Detroit, MI 48202 (jsammon79@gmail.com).

Published Online: August 31, 2015. doi:10.1001/jamainternmed.2015.4530.

Author Contributions: Drs Sood and Sammon had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sood, Abdollah, Abouljoud, Trinh, Menon, Sammon.

Acquisition, analysis, or interpretation of data: Sood, Abdullah, Abdollah, Menon, Sammon.

Drafting of the manuscript: Sood, Abdullah, Sammon.

Critical revision of the manuscript for important intellectual content: Sood, Abdullah, Abdollah, Abouljoud, Trinh, Menon, Sammon.

Statistical analysis: Sood, Abdullah, Abdollah, Sammon.

Administrative, technical, or material support: Sood, Sammon.

Study supervision: Sood, Abdollah, Abouljoud, Trinh, Menon, Sammon.

Conflict of Interest Disclosures: Dr Abdollah is a medical advisor of Genome Dx Biosciences. No other disclosures are reported.

Funding/Support: This work was supported in part by Health Resources and Services Administration contract 234-2005-370011C. Dr Sammon is supported in part by the Henry Ford Hospital Medical Education Department grant 1308. Dr Trinh is supported by an unrestricted educational grant from the Vattikuti Urology Institute and the Professor Walter Morris-Hale Distinguished Chair in Urologic Oncology at Brigham and Women’s Hospital.

Role of the Funder/Sponsor: The funding institutions had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.

Additional Information: This work is based on United Network for Organ Sharing, Organ Procurement and Transplantation Network data as of June 2013.