Race/Ethnic Disparities in Cardiac Transplantation

Abstract

Heart transplant (HT) is the therapy of choice for patients with end-stage heart failure (HF), leading to substantial improvements in quality of life, functional status, and longevity compared to optimal medical therapy for end-stage HF. However, race/ethnic disparities in post-HT survival persist and remain a major concern. The purpose of this review is to describe differences in post-transplant outcomes based on race/ethnicity and to highlight evolving knowledge of the reasons for these persistent disparate outcomes. Black HT recipients have the highest risk for allograft failure and the worst survival post-HT compared to other race/ethnic groups. Although differences in socioeconomic status, access to medical care, and medical compliance have been cited in the past as reasons for these disparate outcomes, recent research highlights the importance of heightened immune reactivity in black HT recipients as a major cause of allograft loss and death. Novel techniques such as gene expression profiling, detection of donor specific antibodies, and detection of genotypes associated with increased metabolism of immunosuppressive medications highlight the role of immune and inflammatory dysregulation and reduced immunosuppressive drug efficacy as significant contributors to post-HT outcomes. Race/ethnic disparities in post-HT outcomes are due to a complex interplay of immunologic, clinical, and socioeconomic factors. However, multiple reports that demonstrate that black race confers a survival disadvantage post-HT that is independent of differences in access to care or socioeconomic status highlight the need for more research to understand racial differences in biological and genetic responses to immunosuppressive therapy.