Blacks as donors for transplantation: suboptimal outcomes overcome by transplantation into other minorities.

BACKGROUND: In 1977, Opelz et al (Transplant Proc 9:137, 1977) introduced research that identified ethnic disparities in the relative risk of graft loss when African American donors or recipients were targeted. Current research from the Organ Procurement and Transplantation Network (OPTN) reveals a continuation of these trends. While 1-year graft survival rates for a kidney are 92.1% for Caucasians, 94.1% for Asians, and 92.9% for Latinos, the comparative rate is 88.9% for African Americans. This study extends research on health disparities by examining relative differences in graft and patient survival rates when the organ donors are African American. A number of factors have been introduced as possible determinants of disparate outcomes by ethnicity in terms of graft survival rates. This descriptive study was designed to test the hypothesis: There are no differences in the relative risks associated with graft survival rates and mortality based upon differences in the ethnicity of the donors. MATERIALS AND METHODS: Data were obtained from the OPTN/United Network for Organ Sharing (UNOS) Registry from April 1, 1994 to December 31, 2000. A total of 118,769 transplants were analyzed, including 77,689 living and deceased donor kidney transplants, 26,124 deceased donor liver transplants, and 14,956 deceased donor heart transplants. A multivariate Cox regression model was used to determine the relative risk of graft loss and cardiac transplant mortality for different ethnicities when the organ donors were African American. RESULTS: The study found that the relative risk of kidney graft loss was 21.3% (P < .01) higher between African American donors and Caucasian recipients than between Caucasian donors and other recipients. With liver transplants, the use of an African American donor increased the risk of graft loss by 21.5% (P < .001). When African American donors gave kidneys and livers to other African Americans, the relative risks of kidney graft loss were 50.9% higher for a kidney (P < .001) and 36.6% higher for a liver (P < .001) if both the donors and recipients were African American. The relative risk of mortality was 51.3% higher (P < .001) when African American hearts were transplanted into other African Americans. No significant differences existed in terms of the relative risk of cardiac mortality (P < .29) when African American hearts were transplanted into Caucasian recipients. When African American donors provided kidneys and livers to Latinos and Asians, the relative risk of graft loss fell below the rates for Caucasian donors and recipients. However, the differences were not statistically significant. CONCLUSIONS: Our data have identified a pressing need to conduct clinical and prospective research that can isolate the causes of these suboptimal outcomes. This is particularly important since the number of African American organ donors has escalated as a result of recent health outreach and education efforts.

Organ Donation in the United States: The Tale of the African-American Journey of Moving From the Bottom to the Top.

OBJECTIVE: The purpose was to review the increase of minority organ donation. METHODS: The methodology was based on the efforts of the DC Organ Donor Program and the Dow Take Initiative Program that focused on increasing donors among African Americans (AAs). From 1982 to 1988, AA donor card signings increased from 20/month to 750/month, and Black donations doubled. A review of the data, including face-to-face grassroots presentations combined with national media, was conducted. Gallup polls in 1985 and 1990 indicated a tripling of black awareness of transplantation and the number of blacks signing donor cards. Based on the applied successful methodologies, in 1991, the National Minority Organ Tissues Transplant Education Program was established targeting AA, Hispanic, Asian, and other ethnic groups. A review of the United Network for Organ Sharing (UNOS) database from 1990 to 2010 was accomplished. RESULTS: Nationally, ethnic minority organ donors per million (ODM) increased from 8-10 ODM (1982) to 35 ODM (AA and Latino/Hispanics) in 2002. In 1995, ODMs were white 34.2, black 33.1, Hispanic 31.5, and Asian 17.9. In 2010, Black organ donors per million totaled 35.36 versus white 27.07, Hispanic 25.59, and Asian 14.70. CONCLUSIONS: Based on the data retrieved from UNOS in 2010, blacks were ranked above whites and other ethnic minority populations as the number one ethnic group of organ donors per million in the US.

Characterization of Hepatitis B and C Among Liver Transplant Recipients With Hepatocellular Carcinoma: An Analysis of the Nationwide Inpatient Sample Database.

INTRODUCTION: Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections account for most hepatocellular carcinoma (HCC) and subsequent liver transplant cases. Racial/ethnic disparities exist in access to liver transplantation and post-transplantation survival, and we sought to compare and explore potential disparities in HBV and HCV-related liver transplant populations. METHOD: The Nationwide Inpatient Sample database was used (2001 to 2010). RESULTS: In this study, 2269 liver transplant recipients were included: 56% HCV, 6% HBV, and 37% non-HV. HBV and HCV patients were mostly Asian/Pacific Islander (API) and white, respectively. Within HBV transplant recipients, the mean age was youngest in black patients (P = .02); variation of mean age was not seen within HCV patients. Regarding the transplant recipients' income and insurance, most API and white patients were in the highest income quartile, whereas most black and Hispanic patients were in the lowest income group (P < .001). The most common form of payer across all racial/ethnic groupings was private insurance (P < .001). The mean length of hospitalization was longest in Hispanic patients (P = .008); they had a significantly longer stay compared with white patients (P = .02). The liver transplantations were mostly performed in teaching hospitals, located in urban areas in the West region of the United States (P < .001). CONCLUSION: Differences were found in the HBV and HCV-associated liver transplant populations. More work needs to be done to elucidate disparities regarding black and Hispanic liver transplant recipients as they receive transplants at younger mean ages, are in lower income quartiles, and have longer lengths of hospitalization compared with other racial/ethnic groupings.

An assessment of the effectiveness of the Mottep model for increasing donation rates and preventing the need for transplantation--adult findings: program years 1998 and 1999.

The National Minority Organ Tissue Transplant Education Program (MOTTEP) evaluated the effects of a community-implemented health education program for adult members of minority population groups to affect attitude, knowledge, and intent to change behavior. In addition, this study represents 1 of the first major initiatives to formally address prevention as a strategy to contribute to reducing the need for organ/tissue transplantation among minorities in the United States. The study targeted students (youth) and adults representing different ethnic groups (African-Americans, Alaskan Natives, Filipinos, Latinos, and Native Americans) who attended health education presentations addressing organ tissue donation, transplantation, and illness prevention in 15 different cities in churches, schools, and other sites. A cross-sectional study that used questionnaires was designed for collecting data from all participants. This article presents data on the adult sample only. Preintervention and postintervention data were collected from 914 adult participants to determine any immediate effects of the intervention. By using data from matched sets of the preintervention and postintervention questionnaires for all adult participants, there were significant increases in (P < or =.000) trust in doctors, future plans to become organ donors, and in participants' spiritual/religious beliefs about organ/tissue donation. There was also a significant increase (P <.05) in participants' awareness of the perceived need for organ/tissue donation. African-American participants were significantly more likely (P < or =.000) to report trust in doctors, future plans to donate organs/tissue, and perceive the need for donation as a result of MOTTEP presentation. Caucasian participants showed a significant increase (P < or =.007) in trust in doctors, perceived need for organ donation (P < or =.05), and in shifting spiritual/religious beliefs about organ/tissue donation (P < or =.02). Attitudes, knowledge, beliefs, and behavioral intentions about organ/tissue donation and illness prevention can be affected by culturally appropriate health education programs designed for targeted population groups. Sustained changes in behavioral intentions toward organ donation and illness prevention may require multiple educational interventions in different community settings to increase donation rates and improve behavioral health practices to prevent illness.

Successful pregnancy with sickle cell disease and renal transplantation.

Renal transplantation has been very effective in the treatment of end-stage renal disease. Over 750 cases of successful pregnancies in these patients have been reported, and only 15 patients with sickle cell disease (homozygous hemoglobin S) have had renal allografts. The present study documents the first case of a successful pregnancy in a patient with sickle cell disease and renal transplantation. The combined complications increase the risks in view of the susceptibility of certain vital organs in pregnancy. Careful multidisciplinary management enhances successful outcome.

Organ donation in blacks: a community approach.

Our intent is to educate the black community about the dangers of hypertension and the need for kidney organ donors in a population that is uniquely affected by renal failure. The desired goal then is to stimulate the black community to: have annual blood pressure checks so that an early diagnosis of high blood pressure (hypertension) can be made and early treatment can be received; and become better informed about the "Gift of Life" concept and have family meetings in which donating organs after death is strongly considered. The adoption of these recommendations will likely result in a decrease in the incidence of renal disease, since the leading cause of renal disease in blacks is hypertension. This silent unrecognized killer produces renal failure in blacks 17 times more often than in whites. We expect that increasing the number of black organ donors will result in an improved success rate in black recipients of transplants from recently decreased persons. It is clear that the black community can play a major role in elucidating and, perhaps, eradicating this serious medical problem.

A national minority organ/tissue transplant education program: the first step in the evolution of a national minority strategy and minority transplant equity in the USA.

1. These successful education programs initially aimed at the AA community are being expanded into other minority groups such as Native American (Alaskan and American Indian), Hispanic (Latino), and Asian-Pacific Islander populations; and if the same modus operandus, ie, a minority-targeted message delivered by ethnically and culturally similar and sensitive messengers is used, this will have equal applicability to the majority population. MOTTEP, the first grass roots national transplant education program, while directed first to the minority population, can when presented to the majority population help all groups address the number one problem in transplantation today--the shortage of donors. 2. Active inclusion and involvement of minorities at all levels of problem resolution (resource allocation, research, and education), emphasizing community participation, education, and empowerment are the important next steps to allow for minority transplant equity in America. 3. The emergence of ASMHTP as the responsible brain trust for future minority-related efforts along with MOTTEP, a community based, empowering transplant education program, highlights the importance of a national strategy necessary for the survival of minority communities. This will enhance the interaction between minority transplant health professionals and the minority community and requires minority inclusion at all decision making levels of problem resolution within the transplant community.

New profile of cadaveric donors: what are the kidney donor limits?

The need for donor organs is increasing more rapidly than the number of organs available from present resources using today's techniques. While efforts to improve consent rates through education and various incentives should continue, and while recovery and utilization of kidneys from donors at the extremes of age can further improve, we believe that the greatest potential for future expansion of the donor resource lies in the non-heart-beating donor. The combination of effective in situ preservation and ex vivo pulsatile preservation allows donation to occur from uncontrolled asystolic donors and provides a mechanism for both evaluation and resuscitation of the recovered kidneys. This approach, if fully utilized, can double the number of kidneys available for transplantation.

Effect of concanavalin A and phytohemagglutinin on the modification of immunogenicity of canine kidney allografts.

Mongrel dog kidneys were allografted to unrelated nephrectomized recipients which were then treated with subimmunosuppressive doses of azathioprine (2.5 mg/kg/day). Dog kidneys treated in vitro with perfusates containing concanavalin A (Con A) or phytohemagglutinin-P (PHA) survived as long as 60 days (mean 39.8 +/- 4.3) after transplantation, whereas normal kidneys survived less than 16 days. The optimal prolongation was achieved by perfusing the kidneys with 500 ml Ringer's lactate containing 25 mg/L Con A, 25 4 degrees C. Lesser effects were achieved with higher or lower concentrations of Con A, or with perfusions carried out at 25 degrees C. Most evidence suggests that Con A and PHA bind to cell surfaces and interfere with the perception of the graft antigens by the host.

The story of the Howard University Transplant Center: (a project of the people).

It took almost two years for Howard University Hospital to receive certification as a kidney transplant hospital under the federal government's end-stage renal disease program, although Howard had a transplant program that was comparable to many in the country.By the time the Department of Health, Education, and Welfare approved Howard's program, many successful transplants had already been carried out there, largely on indigent patients who probably could not have received transplants elsewhere or on patients whose chances of survival, because of other complications, were so risky that other hospitals had turned them down. At first the high cost of these operations had to be absorbed by the University since the government reimbursed only those hospitals which had an approved transplant program.Howard has now received reimbursement (payments of more than $500,000) for its transplants because its certification was granted retroactive to July 1, 1973, when the federal program was started. So the Transplant Center is now enabled, and committed, to provide the best possible transplant care to the Washington, D.C. community which, incidentally, has one of the highest incidences of kidney failure in the country.

Ileosigmoid volvulus and acute external hemorrhoids: a new entity?

An unusual association of small bowel volvulus and sigmoid volvulus occurring concurrently and causing gangrene in both organs is presented. The clinical and pathological correlations and surgical management of this rare entity are discussed.

Spontaneous bladder rupture and cytomegalovirus infection complicating renal transplantation: cause or coincidence?

The high incidence of surgical complications following renal transplantation is well known. Urologic complications, however, present some of the most challenging problems to the transplant surgeon. The authors present here a detailed case report of spontaneous (delayed) bladder rupture (SDBR) which occurred 90 days after kidney transplantation in a recipient with cytomegalovirus infection (CMV). Urinary catheter drainage is recommended in preference to surgical intervention for the successful correction of SDBR. It is postulated further that, despite a negative bladder biopsy, CMV may have infiltrated the bladder and contributed to this "spontaneous" bladder wall rupture.

Organ donation in the African-American population: a fresh perspective with a simple solution.

Organ transplantation is seriously limited by a lack of available organs. This article focuses on the more pronounced lack of organ donation within the African-American population and discusses the consequences of this trend. The reasons for this population's continued reluctance to donate organs are reviewed in detail and current efforts to improve donation rates are outlined. The solution proposed in this article is to acknowledge and use resources already active in the community in efforts to increase organ donation rates within the African-American population. Social workers, teachers, religious leaders, and transplant donors, recipients, and their families would all provide a crucial addition to the multidisciplinary team already involved with organ donation efforts.

Pulmonary cavitation with Nocardia and Aspergillus in a renal transplant patient.

We present an autopsy case of concomitant pulmonary aspergillosis and nocardiosis undiagnosed during life in a long-term surviving renal transplant recipient. The patient had fever and a newly developed cavitary lesion on a chest x-ray. The working diagnosis was pulmonary tuberculosis with possible colonization by Aspergillus species. Cultures of bronchial washings became positive for Aspergillus fumigatus 1 day after death. The study of tissue from the lung cavity at autopsy revealed Aspergillus fumigatus (confirmed by postmortem culture) and the filaments of Nocardia species. Increased numbers of surviving immunosuppressed patients will require aggressive, comprehensive diagnostic techniques for the detection of polymicrobial infections.

Spontaneous rupture of the renal allograft.

Spontaneous renal allograft rupture, an unusual complication of renal transplantation, occurred in a 35-year-old woman 10 days after transplantation. Unusual localized pain and tenderness at allograft site, oliguria, and hypotension, a triad frequently seen in renal allograft rupture, were present. Management by transplant nephrectomy was inevitable because of the patient's downhill course. Histopathologic findings diagnostic of acute allograft rejection support current thinking that spontaneous rupture may be the final outcome, although unusual, of renal allograft rejection.

Lupus pancreatitis.

Among the many systemic manifestations of lupus is pancreatitis. It may be a part of the multiorgan lupus involvement or it may result as a complication of steroid therapy used in its management. A case of lupus pancreatitis following renal transplantation is presented. The difficulty in differentiating the diagnosis of lupus pancreatitis is illustrated. Emphasis is placed on rapid diagnosis to help decrease the high mortality associated with this disease process.

Pancreatic abscess: a major complication of cystogastrostomy.

Twelve cases of pancreatic abscess, managed at two hospitals in the District of Columbia, are analyzed. Forty-two percent of cases followed acute pancreatitis and infected pancreatic pseudocysts without previous surgical intervention. In 58 percent of the patients, pancreatic abscess was a complication of internal drainage of pancreatic pseudocysts. A discussion of management problems is presented.

Attitudes among blacks toward donating kidneys for transplantation: a pilot project.

PATIENTS REQUIRING KIDNEY TRANSPLANTS HAVE THREE POSSIBLE SOURCES: (1) a kidney from an individual who dies suddenly (approval for the transplant must be given by the next-of-kin of the deceased); (2) a kidney from a relative; and (3) a kidney from one who "willed" it to be transplanted following his or her death. Each of these circumstances requires decision making. On the basis of this information, a research program designed to determine the nature of attitudes of blacks toward kidney donations was developed. Results disclosed a lack of knowledge about kidney transplantation; disassociation and lack of communication between blacks and the medical community; religious fears; fears of premature death; and racism.

Malignant hypertension revisited: the role of bilateral nephrectomy.

Hypertension is the leading cause of renal failure in this dialysis and transplant center. When malignant hypertension is encountered, the symptom complex of cachexia and failure to thrive highlights its clinical presentation. The courses of 32 black renal hypertensive patients studied retrospectively demonstrated this symptom complex as well as prolongation of survival, when bilateral nephrectomy and renal transplantation were used as definitive treatment.

Prednisone when used as treatment for rejection correlates with poor outcome.

Since January 1974, 195 of 202 (95%) renal transplants have been performed on blacks at the Howard University Hospital Transplant Center. Hypertension is the most common cause of end-stage renal disease (ESRD) at this center (57%). The immunosuppressive regimens utilized were divided into four eras. The first era (1974-1980) consisted of the prophylactic administration of prednisone, Imuran (AZA), and Minnesota antilymphocyte globulin (MAG) with high prednisone dosage used to treat rejection. One-year, two-year, and five-year patient survival rates were 59% 54%, and 41%, respectively. Graft survival rates for the same period were 53%, 47%, and 36%. In the second era (1980-1983), the same immunoprophylaxis was used but only MAG was used to reverse rejection. One-year and two-year patient survival rates were 90% and 84%. Graft survival rates for the same period were 72% and 64%. When era 1 is compared with era 2, statistically significant improvement in patient survival is evident (P less than 0.005). Graft survival rates are statistically significant for one-year graft survival (P less than 0.05). In the third era (1983-1986), cyclosporine was the principal immunosuppressive agent used along with prednisone. Rejection in this era was treated by adjusting the cyclosporine dose to keep the level between 100 ng to 150 ng per mL and in addition to high prednisone. One-year patient survival and graft survival rates were 83% and 55%, respectively. The fourth era began April 1986 and was initiated because of previous bad experiences with high doses of prednisone to treat rejection in era 1.(ABSTRACT TRUNCATED AT 250 WORDS)