The October 7 issue of JAMA brought mixed reports regarding organ transplantation. Although more organs are being transplanted and more patients are surviving longer than they did a decade ago, women, African Americans, and the poor have less access to cadaveric kidneys than other groups.
In one report (1998;280:1153-1160), Hung-Mo Lin, PhD, of the United Network for Organ Sharing and colleagues analyzed data reported by UNOS in 1997 that covered 97,587 solid organ transplants performed on 92,966 recipients at 742 transplant programs from January 1988 to April 1994. One-year and three-year survival rates ranged from highs of 91% and 86%, respectively, for kidney transplants to lows of 62% and 50%, respectively, for heart-lung transplants. However, the three-year conditional survival rate—defined as survival three years after a transplant only for the organs or recipients who survived one year—was about 90% for all organs except the lung and heart-lung. The figures indicate that "the major risk after transplantation occurs in the first year," the authors wrote.
When the authors divided the transplants into two eras—from January 1988 to April 1992 and from May 1992 to April 1994—they found that survival rates were better in the second era for all organs except the heart. Since UNOS first reported survival rates in 1991, the types of transplants that have increased the most include lung transplants at 213%; pancreas transplants, 92%; and liver transplants, 47%.
In the other report (1998;280:1148-1152), G. Caleb Alexander, MD, and Ashwini R. Sehgal, MD, of Case Western Reserve University in Cleveland conducted a prospective cohort study of 7,125 patients beginning long-term kidney dialysis between January 1993 and December 1996 in Indiana, Kentucky, and Ohio. The goal was to determine the relative importance of each of four steps in the transplantation process in explaining differences in cadaveric kidney transplantation rates:
Compared with whites, African Americans were 32%, 44%, and 50% less likely to complete steps B, C, and D, respectively. Women were about 10% less likely than men to complete each of the four steps. Poor individuals were 33%, 22%, and 23% less likely to complete steps A, B, and C, respectively, than wealthier patients. Poor individuals were defined as earning less than $11,000 per year.
Although Drs. Alexander and Sehgal did not explain why such differences exist, they urged their colleagues "to ensure that transplant candidates are identified equitably and then assisted through the transplantation process as expeditiously as possible." The equitable distribution of organs "must be pursued with the same vigor with which we seek new immunosuppressive medications or improved surgical techniques," they said.
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