African American Recipients Research Articles

Predictors of reduced tacrolimus dose and trough level through 36 months post‐transplant among 578 adult primary kidney transplant recipients

AbstractBackgroundA multivariable linear regression model including baseline and immunosuppression‐related predictors of the post‐kidney transplant tacrolimus dose/day required for achieving a target tacrolimus trough level of 4–8 ng/mL (currently accepted reduced tacrolimus dosing strategy) would provide a practical guide to clinicians.MethodsUsing our prospectively followed cohort of 578 adult primary kidney transplant recipients assigned to receive reduced tacrolimus dosing as part of maintenance therapy, we determined the significant predictors of absolute tacrolimus dose (mg), tacrolimus trough level (ng/mL), and dose‐adjusted tacrolimus trough level (%/L) during the first 36 months post‐transplant.ResultsTwo demographic variables were associated with a significantly higher tacrolimus dose at each post‐transplant time analyzed: African American recipient (p < 0.000001) and younger recipient age (p ≤ 0.00009). Use of maintenance corticosteroids was also associated with a significantly higher tacrolimus dose but only during the first 12 months post‐transplant (p ≤ 0.002). None of the other baseline variables (or use of sirolimus) were predictive of tacrolimus dose, and none of these factors were associated with the tacrolimus trough level (thus, effective therapeutic drug monitoring was achieved). Results for dose‐adjusted tacrolimus trough level were inversely related to the tacrolimus dose findings.ConclusionsSignificantly higher tacrolimus dosing to achieve the target tacrolimus trough level (lower bioavailability) was required, but only among African Americans, younger recipients, and those receiving maintenance corticosteroids.

Cardiac Transplantation in African Americans: A Single‐Center Experience

In view of limited data on the subject of graft and patient survival differences between African American (AA) and non-AA heart transplant recipients, we reviewed our experience. There is a higher mortality among AA recipients compared with non-AA recipients after cardiac transplantation. The study included all AA patients who have received a heart transplant in our center since 1983. Stepwise Cox regression was used for covariates affecting the survival. The χ(2) test was employed to identify the effects of a mechanical assist device and pretransplant creatinine (Cr) on the outcomes in AA and non-AA patients. Kaplan-Meier curves were used to examine survival. The average survival among AA recipients was 5.4 years, compared with 12 years for the non-AA recipients, with 1-, 5-, and 10-year survival rates of 80%, 55%, and 25%, respectively. This was found to be statistically inferior to the survival probabilities of 92%, 78%, and 58% for the non-AA group (P < 0.005). Based on stepwise Cox regression, the variables such as ethnicity (P < 0.05), pretransplant Cr (P < 0.05), presence of a mechanical assist device (P < 0.005), and United Network for Organ Sharing (UNOS) status at transplant (P < 0.05) independently predicted the outcomes. Kaplan-Meier analysis of pretransplant Cr level and survival showed that the AA group did significantly worse for all Cr classes. There is a statistically significant difference in outcomes between AA and non-AA patients after cardiac transplantation. African American patients have decreased survival over a period of time. Pretransplant Cr, ethnicity, presence of a mechanical assist device, and UNOS status at transplantation are independent predictors of outcomes.

(430) - Heart Transplant Recipient and Donor Age Mismatching: Should the Older Recipient Be Paired with the Older Donor?

As heart transplant (HTX) donor organs become scarcer, older donors are increasingly evaluated. It is unknown whether older donors or recipient-to-donor age discrepancies have prohibitive long-term risk. We sought to identify effects of recipient-to-donor age differences on long-term survival in HTX recipients. The United Network for Organ Sharing data registry was analyzed for all adult HTX recipients from 1987 to 2012 stratified by recipient age >= 55 years or < 55 and donor age >= 30 years or < 30. Recipients with right or bi-ventricular support or total artificial hearts were excluded. Standard statistical methods were used. 45,005 HTX recipients were included & 28.8% (n=12953) R<55 D<30, 22.9% (n=10292) R<55 D>=30, 24.1% (n=110856) R>=55 D<30, and 24.2% (n=10901) R>=55 D>=30. The mean age of the recipient and donors are: R<55 D<30 (42.4 & 20.7), R<55 D>=30 (43.9 & 40.8), R>=55 D<30 (60.6 & 20.8), R>=55 D>=30 (61.1 & 42.5). R<55 D<30 had the best long-term survival while R>=55 D>=30 the poorest (p<0.05 for log-rank & pair-wise comparisons). Causes of death varied. In multivariate analysis, LVAD at HTX did not impact survival while female donor to male recipients, African-American recipients, pulmonary hypertension, &increasing ischemic time decreased survival. In a population based analysis, the impact of donor & recipient age combinations impacts survival independently & was not impacted by the use of mechanical circulatory support. Allocation of organs should be directed so younger recipients receive younger donor hearts so as to benefit from the long-term survival advantage.

Pancreas transplantation: The Wake Forest experience in the new millennium.

To investigate the Wake Forest experience with pancreas transplantation in the new millennium with attention to surgical techniques and immunosuppression. A monocentric, retrospective review of outcomes in simultaneous kidney-pancreas transplant (SKPT) and solitary pancreas transplant (SPT) recipients was performed. All patients underwent pancreas transplantation as intent-to-treat with portal venous and enteric exocrine drainage and received depleting antibody induction; maintenance therapy included tapered steroids or early steroid elimination with mycophenolate and tacrolimus. Recipient selection was based on clinical judgment whether or not the patient exhibited measureable levels of C-peptide. Over an 11.25 year period, 202 pancreas transplants were performed in 192 patients including 162 SKPTs and 40 SPTs. A total of 186 (92%) were primary and 16 (8%) pancreas retransplants; portal-enteric drainage was performed in 179 cases. A total of 39 pancreas transplants were performed in African American (AA) patients; of the 162 SKPTs, 30 were performed in patients with pretransplant C-peptide levels > 2.0 ng/mL. In addition, from 2005-2008, 46 SKPT patients were enrolled in a prospective study of single dose alemtuzumab vs 3-5 doses of rabbit anti-thymocyte globulin induction therapy. With a mean follow-up of 5.7 in SKPT vs 7.7 years in SPT recipients, overall patient (86% SKPT vs 87% SPT) and kidney (74% SKPT vs 80% SPT) graft survival rates as well as insulin-free rates (both 65%) were similar (P = NS). Although mortality rates were nearly identical in SKPT compared to SPT recipients, patterns and timing of death were different as no early mortality occurred in SPT recipients whereas the rates of mortality following SKPT were 4%, 9% and 12%, at 1-, 3- and 5-years follow-up, respectively (P < 0.05). The primary cause of graft loss in SKPT recipients was death with a functioning graft whereas the major cause of graft loss following SPT was acute and chronic rejection. The overall incidence of acute rejection was 29% in SKPT and 27.5% in SPT recipients (P = NS). Lower rates of acute rejection and major infection were evidenced in SKPT patients receiving alemtuzumab induction therapy. Comparable kidney and pancreas graft survival rates were observed in AA and non-AA recipients despite a higher prevalence of a "type 2 diabetes" phenotype in AA. Results comparable to those achieved in insulinopenic diabetics were found in the transplantation of type 2 diabetics with detectable C-peptide levels. In the new millennium, acceptable medium-term outcomes can be achieved in SKPT and SPTs as nearly 2/3rds of patients are insulin independent following pancreas transplantation.

Kidney allograft survival of African American and Caucasian American recipients with lupus

African Americans with lupus who receive kidney transplants have high prevalence of predictors of allograft failure, which can explain their poor outcomes. Of 1223 African Americans and 1029 Caucasian Americans with lupus who received kidney transplants from deceased donors between 1987 and 2006 with complete records in the UNOS program, 741 pairs were matched in 16 predictors employing a predicted probability of group membership. The primary outcome was allograft failure. Main secondary outcomes were rejection, allograft failure due to rejection, and mortality. Matched pairs were predominantly women (82%) with a mean age of 39 years. Twenty-four percent of recipients received kidneys from expanded criteria donors. African Americans and Caucasian Americans matched well (p ≥ 0.05): donor age, gender and race; recipient age, gender, education and insurance; dialysis prior to transplant, kidneys from expanded criteria donors, cold ischemia time, history of prior kidney transplant, panel reactive antibodies, human leukocyte antigens mismatch, blood type compatibility, transplant Era, and follow-up time. Contrary to the unmatched cohort with significantly higher allograft failure rate (events per 100 patient-years) in African Americans compared to Caucasian Americans (10.49 vs 6.18, p<0.001), matched pairs had similar allograft failure rates (8.41 vs 7.81, p=0.418). Matched pairs also had similar rates of rejections (9.82 vs 9.39, p=0.602), allograft failure due to rejection (6.19 vs 5.71, p=0.453), and mortality (2.79 vs 3.52, p=0.097). In lupus recipients of kidney transplants from deceased donors, African American and Caucasian Americans have similar allograft failure rates when predictors are matched between groups.

ZFN-Driven Gene Editing Prevents HLA-A Expression On Hematopoietic Stem Cells -Improving The Chance Of Finding An HLA-Matched Donor

Hematopoietic stem cells (HSCs) are administered (i) to restore hematopoiesis and immunity in the course of hematopoietic stem-cell transplantation (HSCT), (ii) as a replacement for inherited blood disorders and bone marrow failure, (iii) to regenerate cells of alternative lineages for restorative medicine, and (iv) as a source for generating specific hematopoietic cells (e.g., T cells, NK cells, and dendritic cells). However, the widespread application of allogeneic HSCs for humans is hampered by their immune-mediated destruction by host T cells recognizing mismatched HLA or by HLA-specific antibodies. Despite pre-banking umbilical cord blood (UCB) units and access to adult donors through the National Marrow Donor Program (NMDP), finding a suitable HLA-matched product is challenging for many recipients, especially those from ethnic minorities who are under-represented in the donor pool. The available donor pool would be markedly increased if donor HSCs were edited to eliminate expression of the HLA-A locus. Indeed, modeling from NMDP shows that the chance of an African American recipient finding a HLA-matched donor increases from 18% to 73% when matched for HLA-B, C and DR, instead of HLA-A, B, C and DR. We have previously shown that engineered zinc finger nucleases (ZFNs) can disrupt HLA-A expression in genetically edited T cells (Blood 2013). To extend this proof-of-concept to HSCs, we sought to disrupt HLA-A expression by introducing ZFNs targeting this locus. CD34+lineageneg HSCs (99% purity) were isolated using paramagnetic beads from UCB. Electro-transfer of in vitro transcribed mRNA encoding the HLA-A-specific ZFN generated 30% HLA-Aneg HSCs after one week ex vivo culture with defined cytokines (FLT3-L, SCF, TPO, and IL-6) and an aryl hydrocarbon receptor antagonist (stem reginin-1, SR-1). As expected, SR1 treatment maintained greater numbers of CD34+ cells (also CD34posCD38neg) in culture compared to controls. DNA sequence analysis revealed that HLA-Aneg HSCs encode the expected nucleotide changes at the ZFN target site. An in vivo engraftment assay, using NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ (NSG) mice, demonstrated that HLA-Aneg HSCs maintain the capability of engraftment and differentiation into HLA-Aneg hematopoietic cells (Figure). Thus, disruption of HLA-A expression in HSCs provides an appealing approach to increasing the chances for of finding HLA-matched donors and may broaden the clinical application of allogeneic HSCT. Furthermore, the ability to genetically edit HSCs has implications for (i) preventing immune-mediated recognition of HLA-disparate HSC and (ii) preventing immune mediated recognition of self-antigens.Engraftment of HLA-A2neg HSCs was evaluated in vivo. Data shown are flow-cytometry analysis of bone marrow obtained from NSG mice 16 weeks after HSC injection. HSC engraftment and HLA-A2 expression in NSG mice injected with un-modified HSCs (left panel) and HSCs treated with the HLA-A specific ZFNs (right panel) are shown. Data are gated on human CD45 positive cells. [Display omitted] Disclosures:Reik:Sangamo BioSciences: Employment. Holmes:Sangamo BioSciences: Employment. Gregory:Sangamo BioSciences: Employment.

Scientific Hero: Dr. James E. K. Hildreth

Scientific Hero: Dr. James E. K. Hildreth

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Published studies have suggested that African Americans (AA) have reduced long term kidney transplant (KT) survival compared to non AA. OPTN/SRTR registry data (1998 – 2007) indicate that 10 year deceased donor (DD) KT survival is significantly less for AA, 34.6%, compared to Caucasians, 45.8%. In this 10 year single center study of DD KT we examined factors that might account for significant differences in transplant outcomes among racial groups. The study population consisted of 426 (307 AA, 119 non AA) consecutive recipients that received DD KT at our center from January 1, 1998 to December 31, 2007. All recipients had negative T cell CDCXMs (Amos). FCXMs with the pre transplant CDCXM negative sera were performed within 48 hrs of transplantation. Immunosuppression: Induction with Thymoglobulin, maintenance therapy, Tacrolimus, MMF, prednisone. End point: Graft failure with return to dialysis. DD KT survival in T- B- FCXM AA recipients was 84.4% (n = 237) which was similar to non AA, 86.2% (n = 87). The latter outcomes were significantly better (p = 0.001) then AA and non AA with T- B+ FCXMs, 44.4% (n = 27) and 50.0% (n = 12), respectively. However, there was a difference in graft survival for AA with T+ B+ FCXMs, 55.8% (n = 43) compared to non AA 80% (n = 20). Multivariate analyses (COX HR) of the study population (n = 426) indicated that DD age but not race was a risk factor for DD KT survival as there was a significant difference in the age (42.8) of DD to AA compared to the age (38.3) of DD to non AA. In contrast to registry data, our 10 year study indicated that DD KT survival in AA was slightly less but not significantly different then KT survival in non AA though a difference was detected, respectively, in T+ B+ FCXM groups. Differences in transplant outcomes among racial groups may be observed if the following factors are not considered: presence of low levels of donor specific antibody (by FCXM and/or SAB), donor age and use of induction therapy. Norin: Immucor - Lifecodes: Speakers Bureau.

Racial Differences and Income Disparities Are Associated With Poor Outcomes in Kidney Transplant Recipients With Lupus Nephritis

An analysis of income and racial/ethnic disparities on renal transplant outcomes in recipients with lupus nephritis (LN) has not been reported. We analyzed the United States Renal Data System database to assess the impact of these disparities on graft loss and death in the LN and non-LN cohorts. We identified 4214 patients with LN as the cause of end-stage renal disease in a retrospective cohort of 150,118 patients first transplanted from January 1, 1995 to July 1, 2006. We merged data on median household income from the United States Census based on the ZIP code. In multivariate Cox regression analyses, African-Americans (AF) recipients with LN (vs. non-AF) had an increased risk of graft loss (adjusted hazard ratio [AHR], 1.39; 95% confidence interval [CI], 1.21-1.60) and death (AHR, 1.33; 95% CI, 1.09-1.63). Furthermore, there were significant associations of lower-income quintiles with higher risk for graft loss and death among AF with LN. In comparison, among non-AF recipients with LN, income levels did not predict risk for transplant outcomes. The racial disparity for both graft loss and death outcomes among AF with LN was greater than among AF without LN (AHR, 1.32; 95% CI, 1.29-1.36 for graft loss and AHR, 1.02; 95% CI, 0.99-1.05 for death). AF kidney transplant recipients with LN were at increased risk for graft loss and death compared with non-AF. Income levels were associated with the risk of graft loss and death in AF but not in non-AF recipients with LN.

Ethnicity, medical insurance, and living kidney donation

Relationships between race/ethnicity, recipient medical insurance, and living donor kidney transplantation (LKT) are incompletely described. Associations between medical insurance and LKT were assessed in 447 recipients at a southeastern US transplant center. Primary and secondary payers were included in the analyses. A total of 387 deceased donor transplantations and 60 LKTs were performed in 246 (55%) European American (EA), 175 (39.2%) African American (AA), 15 (3.4%) Asian, and 11 (2.5%) Hispanic recipients. Among recipients, 182 (40.8%) were privately insured, 125 (28%) had Medicaid, and the remainder had Medicare, Medicare supplements, or Medicare replacement policies. A higher proportion of patients with private insurance, relative to those without private insurance, received LKT (22% vs. 7.6%, p < 0.0001). Among ethnic groups, LKT with, vs. without, private insurance was 27.5% vs. 12.4% in EAs (p = 0.0028) and 14.3% vs. 0.9% in AAs (p = 0.0005). Medicaid recipients (n = 125) were less likely to receive LKT than those without Medicaid (4.8% vs. 16.8%, p = 0.0003). Among the 69 AA recipients with Medicaid, none received LKT (0 Medicaid vs. 9.5% without Medicaid, p = 0.0065). Recipient insurance status is associated with LKT, positively with private insurance and negatively with Medicaid. AAs were impacted to a greater extent, potentially contributing to lower rates of LKT.

Body Mass Index Impacts Immediate and Long-Term Survival of Heart Transplant Recipients

Purpose Obesity in heart failure may be associated with improved outcomes. We sought to assess the impact of pre-transplant body mass index (BMI) on post-heart transplant survival. Methods and Materials We analyzed The United Network for Organ Sharing data registry for adult orthotopic heart transplant recipients from 1987 to 2012. Recipients with right or bi-ventricular support or total artificial hearts were excluded. Patients were stratified based on body mass index (BMI in kg/m²) at time of transplant based on conventional thresholds for transplantation into BMI 15-18.4 (UNDERWEIGHT), 18.5- 29.9 (NORMAL), 30-34.9 (OVERWEIGHT) and 35-40 (OBESE). Kaplan-Meier estimates were used to evaluate survival. Results 52,903 heart transplant recipients were identified and 45,261 were included. Of the overall cohort, 78.4% - NORMAL, 15.2% - OVERWEIGHT, 3.3% - UNDERWEIGHT and 3.1% - OBESE. Pre-transplant BMI affected survival significantly at 30 days, 1, 5, and 10 years post-transplant (p figure 1 ] In the proportional hazards model, OVERWEIGHT and UNDERWEIGHT patients had decreased survival. Factors negatively affecting survival include female donor to male recipients, African-American recipients, pulmonary hypertension, LVAD, increasing age and ischemic times. Conclusions In a population based analysis, BMI influences survival in the short and long term. Underweight recipients may not have physiologic reserves for optimum results. Hazard ratio 95% Hazard Ratio Confidence Limits OBESE 1.101 0.927–1.308 OVERWEIGHT 1.165 1.066–1.274 UNDERWEIGHT 1.367 1.117–1.672 Female donor to male recipient 1.176 1.060–1.305 African-American 1.419 1.296–1.554 PH 1.113 1.031–1.201 LVAD at transplant 1.022 0.930–1.123

Induction Therapy in African American Heart Transplant Recipients: Analysis of the UNOS Database

Purpose Induction therapy (IND) after heart transplant (HTx) remains controversial despite its use in over 50% of programs. No randomized trials exist to suggest benefit. African Americans (AA) are at high risk for allograft rejection. We sought to explore whether the use of Antithymocyte globulin (ATG) or Basiliximab improved survival in AA, using the UNOS database. Methods and Materials We reviewed 2,523 consecutive adult AA HTx patients from the UNOS database from 1/2000 to 3/2011. Data were analyzed using two age groups; younger ages 21-59 years (n=2,037) and older ≥60 years (n=486). Five-year (5-yr) survival was estimated by Kaplan-Meier method. Survival was compared across groups by Log-Rank test. Cox proportion hazards models were used to assess factors related to 5-yr survival and to obtain hazard ratios and their 95% confidence intervals. Results Univariable analysis found younger AA who received ATG had better 5-yr survival compared to Basiliximab (P=0.002) or no IND (P=0.016). Older AA with Basiliximab experienced better 5-year survival than ATG recipients (P=0.019). In multivariable models, adjusting for Creatinine>2mg/dL and PRA>10%, younger AA, had a trends for ATG to be protective vs Basilximab (HR=0.74, P=0.075) and no IND (HR=0.78, P=.076). In older AA, Basiliximab was protective vs ATG (HR=0.46, P=0.022) and there was a trend for no IND to be protective vs ATG(HR=0.72, P=0.16). [ figure 1 ] Conclusions ATG may confer protection in the young AA but worsen survival in AA age 60 and older. For AA of age ≥60 Basiliximab appears protective vs ATG. Age-related differences in immune activation may explain these findings. Randomized trials to assess efficacy of induction therapy are indicated.

Cytomegalovirus esophagitis presents as chest pain in a renal transplant recipient

Cytomegalovirus esophagitis presents as chest pain in a renal transplant recipient

Effect of Induction Agent on Posttransplant Outcomes in Deceased Donor Kidney Transplant Recipients: Influence of Race

BackgroundThe effect of induction agents on kidney transplant outcomes with respect to race is not well studied. We aimed to compare the outcomes of deceased donor kidney (DDK) transplants in African American (AA) and non-African American (non-AA) recipients who underwent induction therapy with rabbit-antithymoglobulin (rATG), alemtuzumab (ALE), or interleukin (IL)-2 receptor blocker (IL-2B) and were maintained on a calcineurin inhibitor, (CNI)/mycophenolate mofetil (MMF)–based regimen with/without steroid. MethodsUsing OPTN/UNOS database, we identified patients (≥18 years) who underwent DDK transplants from January 2000 to December 2008 and received rATG (n = 21,506), ALE (n = 3476), or IL- 2B (n = 17,869) and were maintained on a CNI/MMF–based regimen with/without steroids. Multivariate analysis was performed adjusting for steroid use and factors known to adversely impact graft outcome. ResultsThe median follow up was 29.6 months (range, 10.7–60.1). ALE induction as compared to rATG had inferior adjusted graft (P < .001) and patient (P = .003) survivals in non-AA recipients but similar in AA recipients. In non-AA recipients, IL-2 induction as compared with rATG had similar adjusted graft but inferior patient survival (P = .04), and in AA recipients had inferior graft (P = .002) but similar patient survival. ConclusionOur study shows racial differences in renal transplant outcomes with regard to induction modality.

Racial differences in fibrosis progression after HCV-related liver transplantation.

Black recipients undergoing liver transplantation (LT) for hepatitis C virus (HCV) have decreased patient and graft survival compared with white recipients, a finding that is primarily limited to black recipients of livers from white donors. The cause(s) for these discrepant outcomes are unclear but may be related to HCV disease recurrence. The rates of HCV-related disease recurrence and liver fibrosis progression among black and white liver transplant recipients have not been investigated. In this study, we compared liver fibrosis progression between 105 black and 364 white recipients after HCV-related LT in a multisite cohort study and assessed the impact of donor race. At 6, 12, and 24 months after LT, there was a significantly higher percentage in the black recipient/white donor (B/W) group with severe fibrosis, defined as stage 3 or 4 (F3/F4), compared with all other recipient/donor race combinations. The adjusted odds ratio of developing F3/F4 for the B/W group was 2.54 (1.49-4.69; reference group, white recipient/white donor). Black recipients with black donors demonstrated a similar rate of progression to F3/F4 as white recipients. Patient survival was also decreased in the B/W group compared with other recipient/donor race combinations. African American recipients with white donors have more severe fibrosis progression after HCV-related LT. The mechanisms responsible for accelerating fibrosis progression in this high-risk race-mismatched group need to be investigated.

Donor race and outcomes in kidney transplant recipients

African Americans are at greater risk to reach end-stage renal disease and this risk may carry over in a kidney transplant recipient after kidney transplantation. Linking the five-yr patient data of a large dialysis organization to the Scientific Registry of Transplant Recipients, we identified 13 692 hemodialysis patients who underwent first kidney transplantation. Mortality or graft failure and delayed graft function risks were estimated by Cox's regression (hazard ratio [HR] and 95% confidence interval) and logistic regression, respectively. Patients were 48 ± 14 yr old and included 39% women and 26% patients with diabetes. After adjusting for several relevant clinical and transplant-related variables, African American donor race was associated with higher all-cause mortality, with HR of 1.39 (1.09-1.78) for all-cause mortality, 1.80 (1.17-2.76) for cardiovascular mortality, 1.30 (1.03-1.64) for death-censored graft loss and 1.31 (1.10-1.57) for combined outcome over the six-yr observation period. In the non-African American recipient subcohort, but not in the African American recipient subcohort, African American donor race was associated with higher risk of death-censored graft loss (2.24 [1.44-3.49]) in our fully adjusted model. African American donor race was associated with increased all-cause and cardiovascular mortality and graft loss.

The Contribution of Donor Quality to Differential Graft Survival in African American and Caucasian Renal Transplant Recipients

Although a number of factors contributing to the disparity in graft survival between African American (AA) and Caucasian kidney transplant recipients have been described, the role of donor quality is less well understood. This study was undertaken to determine the impact of donor quality differences on this disparity, based on review of UNOS (United Network for Organ Sharing) data on deceased donor renal transplantation from 2000 to 2010. Donor quality was determined by the kidney donor risk index (DRI), and was compared between AA and Caucasian recipients. There were 33,405 Caucasians and 22,577 African Americans in the study, with mean DRI of 1.17 versus 1.27 (p < 0.001), respectively. In analysis 2,446 recipients of each race matched by propensity scoring (based on medical, socioeconomic and immunologic covariates), mean DRI was 1.25 for Caucasians and 1.28 (p = 0.02) for AA. The hazard ratio (HR) for graft failure associated with AA race was 1.8 (p < 0.001) on unadjusted analysis, and decreased to 1.6 (p < 0.001) after matching for DRI. These results indicate a significant disparity in quality of kidneys received by African Americans, which propensity analysis indicates is partially explained by differences in medical, immunologic and socioeconomic factors. Furthermore, this difference in donor quality partially accounts for poorer graft survival in African Americans.

The Impact of Medicare’s Lifetime Immunosuppression Coverage on Racial Disparities in Kidney Graft Survival

Beginning January 1, 2000, Medicare effectively extended its coverage of immunosuppression medications from 3 years to lifetime for patients eligible for Medicare on the basis of age or disability status. We examined the impact of this policy on racial disparities in kidney transplant outcomes at 5 years. Using data from the US Renal Data System, we identified cohorts of Medicare-insured kidney transplant recipients according to patient characteristics defining eligibility for lifetime immunosuppression coverage according to the year 2000 policy. We compared racial disparities in graft survival among those eligible for lifetime coverage with the Kaplan-Meier method. We modeled adjusted associations of patient race, patient income, benefits eligibility category and policy exposure with graft loss by multivariable Cox's regression. The racial disparity in graft survival between African American and non-African American among transplant recipients eligible for the lifetime benefit persisted. The graft survival disparity between high- and low-income African American recipients was insignificantly reduced among those eligible for the lifetime benefit. The results of the study suggest that insurance coverage of medication did not eliminate or reduce the racial disparity in graft survival.

Recipient-Donor race mismatch for African American liver transplant patients with chronic hepatitis C

African American (AA) recipient-donor race mismatch has been associated with graft loss and mortality, but studies of an association between race mismatch and hepatitis C virus (HCV) disease severity are lacking. HCV-infected adults from 4 US centers who underwent liver transplantation for the first time (n = 1093) were followed for a median of 3.05 years to determine the rates of advanced HCV disease (bridging fibrosis or cirrhosis) and graft failure; 11% of the patients were AA. The unadjusted cumulative rate of advanced fibrosis was higher in AAs than non-AAs (56% and 40% at 4 years, respectively, (P < 0.01), and 59% and 56% for AA recipient-donor-matched patients and AA recipient-donor-mismatched patients, respectively (P = 0.89). In adjusted models, both AA recipient race [hazard ratio (HR) = 1.47, 95% CI = 1.06-2.03, P = 0.02] and AA recipient-donor mismatch (versus match; HR = 1.48, 95% CI = 1.03-2.12, P = 0.03) were significant predictors of advanced fibrosis; other independent predictors were donor age (HR = 1.21, P < 0.01) and cytomegalovirus infection (HR = 1.55, P < 0.01). The 4-year unadjusted cumulative rates for HCV-associated graft loss were 10% and 17% for non-AAs and AAs, respectively (P < 0.01), and 0% and 21% for AA recipient-donor-matched patients and AA recipient-donor-mismatched patients, respectively (P < 0.01). In adjusted models, AA recipient-donor-mismatched patients had a 62% higher rate of graft loss than non-AA recipients (HR = 1.62, 95% CI = 1.14-2.29, P < 0.01), and AA recipient-donor-matched patients had a 76% lower rate of graft loss/mortality (HR = 0.24, 95% CI = 0.06-0.97, P = 0.05). In conclusion, AA recipient-donor-mismatched patients who are infected with HCV are at high risk for advanced HCV disease and HCV-related graft loss and constitute a patient group that will benefit from new therapeutic strategies for preventing graft loss.

Risk Factors for Hyperuricemia and Gout in African American Renal Transplant Recipients

Risk Factors for Hyperuricemia and Gout in African American Renal Transplant Recipients