The Living Donation Coalition was created by the White House Organ Summit in June, 2016 to provide education and resources for potential donors to make informed decisions about living and deceased donation with a greater goal of eliminating the deficit of available kidneys.1 Central to the realization of this goal is an understanding of the impact of ethnic minorities and immigrants within the current framework of kidney donation. While studies have demonstrated geographic, social, financial, and ethnic contributions to the incidences of end-stage renal disease2 and renal transplantation,3–5 the impact of minorities and specifically immigrants within the framework of deceased and living donation kidney transplantation is not well understood.
To this end, we evaluated the impact of this population on kidney donation through the Scientific Registry of Transplant Recipient (SRTR) database for deceased donation (n = 273,424) and for living donation (n = 141,908) from 1990 to 2016. All statistical analyses were conducted in SAS 9.4 (Cary, NC) using chi-square tests to compare deceased versus living donors with an alpha set at P < 0.05. All graphs were created in SAS 9.4.
Within deceased donation, Caucasians constituted 72.6% of donors and 50.3% of recipients. Among the Caucasian recipients, 81.4% obtained a kidney from a deceased Caucasian donor (Table 1). While African Americans and Hispanics had a similar 13% rate of deceased donation, African Americans received 29% of deceased kidneys, compared with 13.9% amongst Hispanics. Asian and Pacific Islanders constituted 2.2% of deceased donors. Amongst Caucasian transplant recipients, 1.4% of deceased kidneys were of Asian or Pacific Islander origin. Amongst living donor kidney transplants, Caucasians composed 70.5% of donors and 68.1% of recipients, and 96% of Caucasian recipients obtained a kidney from a Caucasian donor. African Americans and Hispanics constituted the second and third largest cohort within live kidney donation, each constituting approximately 13% of living kidney donation and receipt. Asian and Pacific Islanders constituted 3.5% of living donors. Amongst Caucasian transplant recipients, 0.6% of living donors were of Asian or Pacific Islander origin.
Across all ethnicities, cross-over in donor-recipient ethnicity amongst white and non-whites occurred in 40.9% and 7.7% of deceased and living donation, respectively. Kidney donation from Hispanics to Caucasians has shown growth in both deceased (1.8 times increase in percentage) and living (2.6 times increase in percentage) categories over the past 30 years. Similar trends have been seen among African American deceased (1.6 times increase in percentage) and living (3.3 times increase in percentage) donation (Fig. 1). Within living donation, 7.1% (7133/99,994) of Caucasian donor kidneys were transplanted into minority recipients. In comparison, 9.0% (3839/41,805) of minority living donors donated their kidney to Caucasian recipients, with an increasing trend over time towards racial crossover.
An evaluation of citizenship status demonstrates 4.8% of deceased donations and 5.4% of live donations came from non-citizens (Table 2). Amongst non-citizen living donors (n = 7685), over half (57.4%, n = 4413) donated to US citizens. In comparison, almost all kidneys donated by US citizens were transplanted into fellow citizens (96.7%, n = 131,019). Similar and perhaps related to the growing trend of ethnic minority live kidney donation to Caucasians, non-US citizens have over recent years increasingly donated kidneys to US citizens (Fig. 2).
For kidney transplantation to be an effective treatment for end-stage renal disease, the number of organ donors and the supply of transplantable kidneys must grow. The ability of kidney paired donation, chains of transplantations, and most recently advanced donation to augment the impact of a single donor have been well-recognized.6,7 The impact of ethnic minorities and immigrants within this framework should not be overlooked. Ethnic minorities constitute a considerably smaller donor pool, but are almost 7 times more likely to donate to non-ethnic recipients. Conversely, over half of all noncitizen donors provided kidneys to US citizens.
A limitation of the present study is an inability to perform race-adjusted evaluations. In our analysis, we observed an increase in proportion of non-white living donors among all donors during the study period. A race-adjusted analysis of living and deceased donation trends over time would be of added value, and is indeed an area for further exploration in future studies. A paucity of data within the SRTR on all eligible donors over the study period limits our ability to perform a race-adjusted evaluation. Without these data to serve as a denominator, we cannot attribute our findings with certainty to an increase in non-white donors among all eligible donors. Beyond these limitations, the effects of transplant tourism and the underestimation of nonresident populations within national census databases are confounding variables that serve as barriers to the accurate interpretation of race-adjusted studies and should be considered in future studies.
Currently, federal restrictions limit access to federally funded healthcare programs for uninsured immigrants, and re-imbursements for the care of noncitizen patients depends largely on access to private insurance. Such reimbursement patterns may offer some insight as to why foreign-nationals donate to US citizens. Nevertheless, the growing trend amongst immigrants to donate, regardless of the citizenship status of the recipient, especially in the case of living donation, underscores their value within the current framework of kidney donation. While transplantation of organs to foreign nationals is a subject of debate, with arguments against it based on organ shortage and economic costs of post-transplantation care, the opposing debate about the donation of kidneys by foreign nationals is less hotly contested.8 Some issues surrounding organ donation by immigrants, especially in the case of living donation, is where these patients should be placed were they to need a kidney donation in the future. While further discussions are needed on this subject, the authors opine that citizenship status in this patient population should not play a role in the delivery of care. The realm of kidney transplantation demonstrates the ability to cross racial divides, proving that regardless of race or creed, all kidneys, ultimately, are pink.
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