Why don't More African-Americans on Dialysis Get Kidney Transplants

Literature Update 2, April 2004

It is well known that African-Americans with kidney failure are less likely to get renal transplants than Caucasians. This is true even when they are eligible, and insurance status and other illnesses are controlled for. Transplantation is now considered to be the optimal treatment for this condition. It allows patients to live a relatively normal life, free from the burden of four-hour dialysis sessions, several times a week that sap energy and lead to devastating long-term complications. So why aren’t more African-Americans getting transplants? A seminal article exploring this subject in 1999 found that African-Americans were slightly less likely to prefer kidney transplantation, but this was not enough to explain the disparities in their placement on transplantation lists by their physicians.

A new study led by the same physician-investigator, John Ayanian at Harvard Medical School, surveyed over 600 patients and 278 nephrologists to better understand their perspectives on this question. They found that nephrologists were less likely to believe transplantation improves survival for blacks than whites (69% versus 81%), but about equally likely to believe it improves quality of life (84% versus 86%). However, newer medications and techniques have diminished any differences in survival between races that were seen in earlier studies. This belief among physicians may contribute to the lower referral of African-Americans for transplantation. Physicians cited patients' preferences (66%) as another possible reason — though the earlier study goes against this being the case. Fewer physicians perceived patient-physician communication and trust (38%) or physician bias (12%) as important reasons. However, African-Americans were less likely than Caucasions to report receiving some or a lot of information about transplantation (55% versus 74%).

In order to assure the highest quality of care to people of all racial and ethnic backgrounds, clinicians must be aware of the disparities that exist, as well as the possible causes. While many clinicians may not be responsible for referring people for renal transplantation, similar disparities have been found in hundreds of studies across disciplines and disease types. It is crucial to carefully analyze our decision-making process and avoid assumptions about what people would or would not want. Instead we should engage in open dialogue and explore the person's perspectives — building trust and providing reassurance every step of the way.