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Published on: September 6, 2017
Effect of eliminating priority points for HLA-B matching on racial disparities in kidney transplant rates
Erin C Hall1, Allan B Massie, Nathan T James
1Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA.
Insights
The 2003 kidney allocation policy change reduced, but did not eliminate, the disparity in deceased donor kidney transplants (DDKT) for African Americans compared to whites. Further changes are needed to achieve transplant equity.
Area of Science:
- Nephrology
- Transplantation Immunology
- Health Services Research
Background:
- African Americans experience lower rates of deceased donor kidney transplants (DDKT) compared to white individuals.
- Differential HLA (Human Leukocyte Antigen) distributions are a proposed factor contributing to this disparity.
- A 2003 policy change removed HLA-B matching priority to address racial disparities in kidney allocation.
Purpose of the Study:
- To quantify the impact of the 2003 kidney allocation policy change on HLA-B matching priority.
- To assess the effect of this policy change on the disparity in DDKT rates between African Americans and whites.
Main Methods:
- An observational cohort study analyzed 178,902 patients awaiting DDKT from January 2000 to August 2009.
- Cox models were used to compare DDKT rates between African Americans and whites before and after the policy change, adjusting for key demographic and clinical factors.
- Transplant rates were measured as time from waitlisting to DDKT, censored for living donor transplant or death.
Main Results:
- Before the policy change, African Americans had 37% lower DDKT rates (aRR, 0.63) compared to whites.
- After the policy change, African Americans had 23% lower DDKT rates (aRR, 0.77) compared to whites.
- The policy change resulted in a 23% reduction in the racial disparity, but did not achieve parity.
Conclusions:
- The HLA-B policy change decreased the racial disparity in DDKT rates but did not eliminate it.
- Unaddressed factors in kidney allocation continue to contribute to disparities for African Americans on the transplant waiting list.
- Further research and policy interventions are necessary to achieve equitable kidney transplant access.
Background:
African Americans have lower rates of obtaining a deceased donor kidney transplant (DDKT) compared with their white counterparts. One proposed mechanism is differential HLA distributions between African Americans and whites. In May 2003, the United Network for Organ Sharing/Organ Procurement and Transplantation Network changed kidney allocation policy to eliminate priority based on HLA-B matching in an effort to address this disparity. The objective of this study was to quantify the effect of the change in policy regarding priority points for HLA-B matching.
Study Design:
Observational cohort study.
Setting & Participants:
A cohort of 178,902 patients registered for a DDKT between January 2000 and August 2009.
Factors:
African Americans versus whites before and after the policy change. Cox models were adjusted for age, sex, diabetes, dialysis type, insurance status, education, panel-reactive antibody level, and blood type.
Outcomes:
Adjusted relative rates (aRRs) of deceased donor kidney transplant for African Americans compared with whites.
Measurements:
Time from initial active wait listing to DDKT, censored for living donor kidney transplant and death.
Results:
Before the policy change, African Americans had 37% lower rates of DDKT (aRR, 0.63; 95% CI, 0.60-0.65; P < 0.001). After the policy change, African Americans had 23% lower rates of DDKT (aRR, 0.77; 95% CI, 0.76-0.79; P < 0.001). There was a 23% reduction in the disparity between African Americans and whites after the policy change (interaction aRR, 1.23; 95% CI, 1.18-1.29; P < 0.001).
Limitations:
As an observational study, findings could have been affected by residual confounding or other changes in practice patterns.
Conclusions:
Racial disparity in rates of DDKT was decreased by the HLA-B policy change, but parity was not achieved. There are unaddressed factors in kidney allocation that lead to continued disparity on the kidney transplant waiting list.
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