Effect of changing the priority for HLA matching on the rates and outcomes of kidney transplantation in minority groups.

BACKGROUND HLA typing and the time a patient has spent on the waiting list are the primary criteria used to allocate cadaveric kidneys for transplantation in the United States. Candidates with no HLA-A, B, and DR mismatches are given top priority, followed by candidates with the fewest mismatches at the HLA-B and DR loci; this policy contributes to a higher transplantation rate among whites than nonwhites. We hypothesized that changing this allocation policy would affect graft survival and the racial balance among transplant recipients. METHODS We estimated the relative rates of kidney transplantation according to race resulting from the current allocation policy and racial differences in HLA antigen profiles, using a Cox model for the time from placement on the waiting list to transplantation. Another model, also adjusted for HLA-B and DR antigen profiles, estimated the relative rates of kidney transplantation that would result if the distribution of these antigen profiles were identical among the racial and ethnic groups. We also investigated the effect of HLA matching on the risk of graft failure, using a Cox model for the time from the first transplantation to graft failure. The results of the two analyses were used to estimate the change in the racial balance of transplantation and graft-failure rates that would result from the elimination of HLA-B matching or HLA-B and DR matching as a means of assigning priority. RESULTS Eliminating the HLA-B matching as a priority while maintaining HLA-DR matching as a priority would decrease the number of transplantations among whites by 4.0 percent (166 fewer transplantations over a one-year period), whereas it would increase the number among nonwhites by 6.3 percent and increase the rate of graft loss by 2.0 percent. CONCLUSIONS Removing HLA-B matching as a priority for the allocation of cadaveric kidneys could reduce the existing racial imbalance by increasing the number of transplantations among nonwhites, with only a small increase in the rate of graft loss.

[1]  R. Wolfe,et al.  Differences in access to cadaveric renal transplantation in the United States. , 2000, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[2]  P I Terasaki,et al.  Twelve years' experience with national sharing of HLA-matched cadaveric kidneys for transplantation. , 2000, The New England journal of medicine.

[3]  P. Cleary,et al.  The effect of patients' preferences on racial differences in access to renal transplantation. , 1999, The New England journal of medicine.

[4]  C. Hollenbeak,et al.  The economic implications of HLA matching in cadaveric renal transplantation. , 1999, The New England journal of medicine.

[5]  G. C. Alexander,et al.  Barriers to cadaveric renal transplantation among blacks, women, and the poor. , 1998, JAMA.

[6]  R. Wolfe,et al.  Association of gender and access to cadaveric renal transplantation. , 1997, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[7]  E. Milford,et al.  Impact of racial genetic polymorphism on the probability of finding an HLA-matched donor. , 1995 .

[8]  E. Milford,et al.  IMPACT OF RACIAL GENETIC POLYMORPHISM ON THE PROBABILITY OF FINDING AN HLA‐MATCHED DONOR , 1995, Transplantation.

[9]  B D Kahan,et al.  The impact of HLA mismatches on the survival of first cadaveric kidney transplants. , 1994, The New England journal of medicine.

[10]  F. Port,et al.  Influence of race and gender on related donor renal transplantation rates. , 1993, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[11]  I. Ayres,et al.  Racial equity in renal transplantation. The disparate impact of HLA-based allocation. , 1993, JAMA.

[12]  B D Kahan,et al.  The impact of comorbid and sociodemographic factors on access to renal transplantation. , 1993, JAMA.

[13]  W. McClellan,et al.  Race and sex differences in the identification of candidates for renal transplantation. , 1992, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[14]  C. Kjellstrand.  Age, sex, and race inequality in renal transplantation. , 1988, Archives of internal medicine.

[15]  P. Eggers,et al.  Effect of transplantation on the Medicare end-stage renal disease program. , 1988, The New England journal of medicine.

[16]  Cecka Jm.  The UNOS Scientific Renal Transplant Registry. , 1999 .

[17]  A. Narva,et al.  Access of Native Americans to renal transplantation in Arizona and New Mexico. , 1996, Blood purification.

[18]  L. Agodoa,et al.  Recent trends in cadaveric renal transplantation. , 1990, Clinical transplants.

[19]  M. Pauly,et al.  Access to kidney transplantation. Has the United States eliminated income and racial differences? , 1988, Archives of internal medicine.