Racial disparities in survival after lung transplantation.

CONTEXT: Racial disparities have not been comprehensively evaluated among recipients of lung transplantation. OBJECTIVES: To describe the association between race and lung transplant survival and to determine whether racial disparities have changed in the modern (2001-2009) compared with the historical (1987-2000) transplant eras. DESIGN, SETTING, AND PATIENTS: A retrospective cohort study of 16 875 adults who received primary lung transplants from October 16, 1987, to February 19, 2009, was conducted using data from the United Network of Organ Sharing. MAIN OUTCOME MEASURES: We measured the risk of death after lung transplant for nonwhites compared with whites using time-to-event analysis. RESULTS: During the study period, 14 858 white and 2017 nonwhite patients underwent a lung transplant; they differed significantly at baseline. The percentage of nonwhite transplant recipients increased from 8.8% (before 1996) to 15.0% (2005-2009). In the historical era, 5-year survival was lower for nonwhites than whites (40.9% vs 46.9%). Nonwhites were at an increased risk of death independent of age, health and socioeconomic status, diagnosis, geographic region, donor organ characteristics, and operative factors (hazard ratio, 1.15; 95% confidence interval, 1.01-1.30). In subgroup analysis of the historical era, blacks had worsened 5-year survival compared with whites (39.0% vs 46.9%) and black women had worsened survival compared with white women (36.9% vs 48.9%). In the modern transplant era, survival improved for all patients. However, a greater improvement among nonwhites has eliminated the disparities in survival between the races (5-year survival, 52.5% vs 51.6%). CONCLUSION: In contrast to the historical era, there was no significant difference in lung transplant survival in the modern era between whites and nonwhites.

The construct validity of the health utilities index mark 3 in assessing health status in lung transplantation.

PURPOSE: To assess the cross-sectional construct validity of the Health Utilities Index Mark 3 (HUI3) in lung transplantation. METHODS: Two hundred and thirteen patients (103 pre-transplant and 110 post-transplant) with mean age 53 years old (SD 13) were recruited during a randomized controlled clinical trial at the out-patient clinic in a tertiary institution. At baseline, patients self-completed measures that included the HUI3, EuroQol EQ-5D, Hospital Anxiety and Depression Scale (HADS) and socio-demographic questionnaire. Six-minute walk test scores and forced expiratory volume in 1 second data were collected from patient's medical records. A priori hypotheses were formulated by members of the transplant team about the expected degree of association between the measures. Correlation coefficients of < 0.1 were considered as negligible, 0.1 to < 0.3 as small, 0.3 to < 0.5 as medium, and ≥ 0.5 as large. RESULTS: Of the ninety predictions made, forty three were correct but in 31 the correlation was slightly lower than predicted and in 7 the correlations were much higher than predicted. In 48% of the cases, predicted and observed associations were in agreement. Predictions of associations were off by one category in 42% of the cases; in 10% of the cases the predictions were off by two categories. CONCLUSIONS: This is the first study providing evidence of cross-sectional construct validity of HUI3 in lung transplantation. Results indicate that the HUI3 was able to capture the burden of lung disease before transplantation and that post-transplant patients enjoyed higher health-related quality of life than pre-transplant patients.

Impact of donor-recipient race matching on survival after lung transplantation: analysis of over 11,000 patients.

BACKGROUND: Few studies have examined the effect of race in lung transplantation (LTx). The United Network for Organ Sharing (UNOS) database provides an opportunity to examine outcomes of race matching for a large cohort of patients. METHODS: We retrospectively reviewed UNOS data for 11,323 adults receiving primary LTx (1997 to 2007). Patients were stratified by donor-recipient race matching and divided into groups of specific race. All-cause mortality was examined with Cox proportional hazards regression incorporating 19 covariates. Short-term mortality (30 days, 90 days, 1 year and 2 years) and rejection in the first year were examined. RESULTS: Of 11,323 patients, 7,414 (65%) were race matched, including 7,104 (71%) Caucasians, 184 (22%) African Americans, 117 (28%) Hispanics and 9 (11%) Asians. During the study, 4,862 (43%) patients died. Race matching decreased the 30-day, 90-day, 1-year and 2-year unadjusted mortality. Race matching decreased risk-adjusted cumulative mortality (hazard ratio 0.88, 95% confidence interval 0.80 to 0.96, p = 0.006). Kaplan-Meier modeling showed that race matching significantly improved survival. Race matching did not impact rejection in the year after LTx. When deaths in the first year were censored, race matching no longer affected cumulative survival. Donor African American race conferred an increased risk of death, regardless of recipient race. CONCLUSIONS: Our study represents the largest cohort evaluating the effect of race matching in LTx. Race matching resulted in an improvement in long-term survival. This improvement appears to manifest in the 2 years after LTx.

Registry of the Japanese Society of Lung and Heart-Lung Transplantation: the official Japanese lung transplantation report 2008.

The year 2008 marked the 10th anniversary of the Japanese lung transplantation program started in accordance with the Japanese Organ Transplant Law, which took effect in 1997. A total of 105 lung transplantations, including 39 deceased-donor transplants and 66 living-related transplants, had been performed as of the end of 2007. This article is the 2008 official report of the Japanese Society of Lung and Heart-Lung Transplantation. It summarizes the data for clinical lung transplantation during the period 1998-2007 and discusses the current status of Japanese lung transplantation. The overall 5-year survival rate was 67.0%: including 53.4% and 74.6% for deceased-donor lung transplantation and living-donor lobar lung transplantation groups, respectively. The total operation-related and 1-month mortality rates after surgery were 3.8% and 10.4%, respectively. These data are better, or at least acceptable, in comparison with the international registry data.

Racial differences in waiting list outcomes in chronic obstructive pulmonary disease.

RATIONALE: Blacks with chronic illness have poorer outcomes than whites in the United States. The health outcomes of minorities with chronic obstructive pulmonary disease (COPD) on the lung transplant waiting list have not been studied. OBJECTIVES: To compare outcomes of black and white patients with COPD after listing for lung transplantation in the United States. METHODS: Retrospective cohort study of all 280 non-Hispanic black and 5,272 non-Hispanic white adults 40 years and older with COPD listed for lung transplantation in the United States between 1995 and 2004. MEASUREMENTS AND MAIN RESULTS: Blacks with COPD were more likely to have pulmonary hypertension, obesity, and diabetes; to lack private health insurance; and to live in poorer neighborhoods than whites. Blacks were less likely to undergo transplantation after listing compared with whites, despite adjustment for age, lung function, pulmonary hypertension, cardiovascular risk factors, insurance coverage, and poverty level (adjusted hazard ratio, 0.83; 95% confidence interval, 0.70-0.98; P = 0.03). This was accompanied by a greater risk of dying or being removed from the list among blacks (unadjusted hazard ratio, 1.31; 95% confidence interval, 1.05-1.63; P = 0.02). CONCLUSIONS: After listing for lung transplantation, black patients with COPD were less likely to undergo transplantation and more likely to die or be removed from the list compared with white patients. Unequal access to care may have contributed to these differences.

The path not taken: social and cultural barriers to thoracic transplantation.

Religious beliefs, misperceptions, and distrust of the health care system have been cited as barriers to organ donation or transplantation in minorities. Improved training of hospital staff on donation protocols has been demonstrated to increase consent rates for or-gan donation. Increased interaction of minorities with ethnically appropriate transplant candidates, recipients, and donation or procurement personnel has a positive effect on donor rates. Programs using such practices must be expanded to overcome significant barriers to the transplantation of solid organs. Research into additional ways to improve acceptance of organ transplantation by minorities is needed to increase participation rates.

Social adaptation after cardiothoracic transplantation: a review of the literature.

From the earliest days of transplantation, research has contributed to our knowledge of the psychosocial sequelae associated with the outcomes of the procedure. The purpose of this review is to describe the social adaptation literature for heart, lung, and heart-lung recipients. Social adaptation refers to employment and performance of social roles and responsibilities. Employment research focused on vocational rehabilitation, physical health restoration, and return to work. Social roles and responsibilities research focused on social roles, family relationships, social support, and psychosocial adjustment. Predictors, interventions, and their associations with outcomes are discussed.

Is there racial disparity in outcomes after solid organ transplantation?

BACKGROUND: We sought to determine if disparities in survival and health-related quality of life (HRQOL) occurred after solid organ transplantation at our institution. METHODS: Data were extracted from a database including information regarding transplants that took place from 1990 to 2002. The HRQOL was assessed in patients by using the Karnofsky functional performance (FP) index and the Medical Outcomes Study Short Form 36 (SF-36) questionnaire. RESULTS: Data were collected on recipients of liver (n = 413), heart (n = 299), kidney (n = 892), and lung (n = 156). Blacks represented a minority of recipients: liver 7%, heart 8%, kidney 23%, and lung 6%. There were no statistically significant differences in patient survival between blacks and whites. Graft survival differed in kidney only with a 5-year survival: 72% for blacks versus 79% for whites (P <0.001). The FP and HRQOL improved (P <0.05) after transplantation in both groups. There were no differences on measures of the FP or HRQOL. CONCLUSIONS: Blacks had comparable survival and improvement in FP and HRQOL in comparison with whites.

Sarcoidosis, race, and short-term outcomes following lung transplantation.

BACKGROUND: Patients with sarcoidosis, many of whom are African American, may require lung transplantation (LT). Little is known about survival following LT for sarcoidosis. OBJECTIVE: To determine short-term mortality following LT for sarcoidosis, to evaluate if survival after LT for sarcoidosis is similar to outcomes after LT for other diseases, and to investigate the impact of race on the results of LT. DESIGN: Retrospective review. PATIENTS: All patients who underwent LT, irrespective of diagnosis, in the United States between January 1995 and December 2000. MEASUREMENTS: Vital status at 30 days after LT and cause of death. RESULTS: During the study period, 4,721 LTs were performed; of these 133 LTs (2.8%) were for sarcoidosis. Approximately 83% of patients with sarcoidosis survived following LT compared to 91% of persons undergoing transplantation for other reasons (p = 0.002). In multivariate analysis controlling both for health insurance status and other factors known to affect survival after LT, patients with sarcoidosis were no more likely to die than persons undergoing transplantation for other conditions (adjusted odds ratio for death, 1.45; 95% confidence interval [CI], 0.84 to 2.48). Significant predictors of mortality included the following: undergoing combined heart-lung transplant, need for mechanical ventilation, treatment in an ICU at time of LT, pre-LT FEV(1), need for supplemental oxygen, and donor age. Both recipient race and donor race significantly affected short-term survival. African-American patients were nearly 50% more likely to die (adjusted odds ratio, 1.49; 95% CI, 1.01 to 2.20). This difference based on race persisted after excluding heart-lung recipients and after controlling for recipient-donor racial mismatch. The most frequent cause of death for patients with sarcoidosis was graft failure, while infection was the primary cause of death among other LT patients. CONCLUSIONS: Patients with sarcoidosis do as well as patients undergoing LT for other diseases. Race is an important factor affecting survival after LT.