Research Updates in Kidney and Urologic Health
DHHS Launches Drive To Increase Organ Donation
Shortly after he took office, Tommy Thompson, secretary of the Department of Health and Human Services (DHHS), declared that increasing organ donation would be a priority during his tenure. Partnering with businesses to encourage employees to sign donor cards, DHHS launched a campaign in April 2001. The program creates a national medal for families of donors, a curriculum on organ donation for driver education courses, and a national donor card that gives health care providers greater authority to procure organs from people who have signed the card.
HHS Secretary Tommy Thompson announced his "Gift of Life Donation Initiative" in April 2001. |
Health officials are hoping that the campaign will begin to reverse some discouraging trends. Although the number of organs donated every year continues to climb, that rise is much slower than the rise in demand. As a consequence, the organ shortage continues to grow. In March 2001, the number of Americans waiting for donated organs topped 75,000—more than triple the 1990 level. The number waiting for a kidney approaches 50,000—up from 13,000 in 1988. The median wait for a cadaver kidney increased from 400 days in 1988 to 938 days in 1996.1,2 For minorities, the wait is even longer. For African Americans, the median wait was 1,313 days; for Hispanics, 1,215 days; and for Asian Americans, 1,312 days.2
People waiting for kidneys have an advantage over those waiting for a heart or liver in that they can be maintained on dialysis in the interim. But studies show that transplantation gives patients a better chance of survival and a better quality of life than dialysis.3,4
NIDDK-FUNDED RESEARCH
Researchers Study Transplantation Disparities Among Races and Genders
Researchers have proposed a range of medical and sociodemographic explanations for the disparities. NIDDK-supported researchers Alexander and Sehgal identified a series of steps in the transplant system that tend to be barriers for African Americans, women, and poor people, starting with the evaluation for transplantation and registration for the waiting list.5 With current strategies to increase minority transplantation focusing on patients already on the waiting list, the researchers noted the need to also ensure that minorities, women, and poor people are first equitably represented on the waiting list.
Another team of researchers looking at whether racial disparities in access to renal transplantation were the result of clinical differences between whites and African Americans found overuse of transplantation among whites and underuse among African Americans. Arnold Epstein, M.D., and colleagues at the Harvard School of Public Health used an expert panel to develop criteria to determine when transplantation is clinically appropriate. The researchers then reviewed the cases of patients who started dialysis in 1996 or 1997 in five states and the District of Columbia and used the criteria to review decisions to refer or not refer patients for transplantation.
The researchers found that the clinical criteria did indicate that transplantation was more likely to be appropriate for whites than for African Americans. But they also found that whites were more likely to be referred for transplantation when it was not appropriate (overuse) and that African Americans were more likely to be denied referral even when the criteria indicated that it would be appropriate (underuse). So, while following clinically appropriate criteria might result in a small racial disparity in access to transplantation, the actual disparity is far greater than the clinical criteria would dictate.6
From 1994 to 1996, 65 percent of white dialysis patients under age 70 were registered on the transplant waiting list, while only 29 percent of African American dialysis patients under 70 were registered.7 A recent study in the New England Journal of Medicine explored the possibility that the preferences of patients themselves might account for the differences. While the study found that African Americans were less likely to prefer transplantation, the difference was not large enough to account for the disparity. The reasons for the racial disparities are still not understood.8
Achieving Equal Access to Transplantation
The Healthy People program is a DHHS initiative that sets public health goals and tracks progress toward those goals. Members of NIDDK's Division of Kidney, Urologic, and Hematologic Diseases (DKUHD) worked with a team of kidney experts from a variety of Federal agencies to develop a chapter on chronic kidney disease for the Healthy People 2010 report, the first such chapter to be included in the Healthy People series.
One of the goals listed in chapter 4 of Healthy People 2010 is to bring the percentage of dialysis patients registered for a kidney transplant up to 66 percent for all racial groups and genders. While this figure describes the current status of white patients (65 percent of white dialysis patients under 70 are on waiting lists), the baseline for the total U.S. population is 20 percent.7 For African Americans, the baseline is 29 percent. However, only 2 percent of the American Indian and Alaska Native patients on dialysis have been placed on a waiting list for transplantation.
Reaching this goal will require examining the criteria used to refer patients for transplantation, as well as increasing organ donation and the most efficient use of available organs. Without expanded donation and better use of organs, adding to the number of registrants will only increase waiting times for those already on the list.
References
1. Cecka J. Outcome of renal transplantation. In: Massry S, Glasscock R, eds. Textbook of Nephrology. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2001:1711–1720.
2. 2000 Annual Report of the U.S. Scientific Registry for Transplant Recipients and the Organ Procurement and Transplantation Network: Transplant Data: 1990–1999. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Office of Special Programs, Division of Transplantation, and Richmond, VA: United Network for Organ Sharing; 2000.
3. Evans R, Mannien D, Garrison L, Hart L, Blagg C, Gutman R, Hull A, Lowrie E. The quality of life of patients with end-stage renal disease. New England Journal of Medicine. 1985;312(9):553–559.
4. Wolfe R, Ashby V, Milford E, Ojo A, Ettenger R, Agodoa L, Held P, Port F. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. New England Journal of Medicine. 1999;341(23):1725–1730.
5. Alexander G, Sehgal A. Barriers to cadaveric renal transplantation among blacks, women, and the poor. Journal of the American Medical Association. 1998; 280(13):1148–1152.
6. Epstein A, Ayanian J, Keogh J, Noonan S, Armistead N, Cleary P, Weissman J, David-Kasdan J, Carlson D, Fuller J, Marsh D, Conti R. Racial disparities in access to renal transplantation: clinically appropriate or due to underuse or overuse? New England Journal of Medicine. 2000;343(21):1537–1544.
7. U.S. Department of Health and Human Services. Tracking Healthy People 2010. Washington, DC: U.S. Government Printing Office; 2000.
8. Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients' preferences on racial differences in access to renal transplantation. New England Journal of Medicine. 1999;341(22):1661–1669.
[Top]
|
