Racial Equity in Renal Transplantation: The Disparate Impact of HLA-Based Allocation,
270 Journal of American Medical Association 1352 (1993) (with Robert Gaston, Laura
Dooley and Arnold Diethelm).
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Kidney transplantation from either a living related or cadaveric donor is optimal
treatment for most patients with end-stage renal disease (ESRD). However, due to a
critical shortage of organ donors, while more than 23,000 Americans await a suitable
cadaveric kidney, fewer than 8000 receive transplants each year. Approximately one
third of ESRD patients in this country are African American (black), a proportion threefold
greater than the representation of this racial group in the general population (12%).
Recently, the Inspector General reported that blacks are less likely than whites to
receive a transplant, with almost double the waiting time. Currently, cadaveric kidneys
are allocated according to a federally mandated system based on quality of HLA
matching. This policy is based on evidence that antigenic similarity between donor and
recipient may enhance cadaveric graft survival and should be the primary factor
influencing distribution. Gjertson and colleagues have proposed that there be even
greater emphasis on HLA matching in organ allocation, with all cadaveric kidneys to be
placed in a single national pool and distributed to the transplant candidate with the
"best" HLA match. In the face of a critical (and growing) shortage of transplantable
kidneys, current directives place potential black recipients at a significant disadvantage;
extension of HLA-based allocation will magnify racial disparity. We contend that all
suitable renal transplant candidates should have equitable access to cadaveric kidneys.
To the extent that HLA matching demonstrably improves survival of cadaveric renal
allografts, it is an efficient means to effect difficult allocative choices. But, given its
documented negative impact on black ESRD patients, the system must be reevaluated to
determine whether the cost in equity is truly justified. A recent editorial suggested that
"every kidney counts"; we submit, rather, that every patient counts.
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