An increased incidence of rejection episodes. One of the causes of worse kidney transplantation survival in black recipients

R. J. Tesi, M. Deboisblanc, C. Saul, G. Frentz and E. Etheredge
Tulane University Medical Center, New Orleans, La., USA.

OBJECTIVE: To evaluate the cause of worse kidney allograft survival in black recipients, which has been the source of considerable interest and debate. DESIGN: Three hundred ninety-two consecutive renal allografts (O HLA mismatch grafts excluded) were reviewed. Of the recipients, 57% were black, 27% received living donor grafts, and 86% received their first transplant. All recipients underwent an oral cyclosporine induction protocol with triple drug maintenance. Crude graft survival, the risk of rejection, and the need for dialysis were determined using donor and recipient demographic and immunologic variables. RESULTS: Graft survival was 84%, 67%, and 50% at 1, 3, and 5 years after the transplantation, respectively. The survival of black recipients was 4%, 11%, and 20% worse than that of white recipients at 1, 3, and 5 years, respectively (P < .002). When only pretransplantation variables were considered, black recipient race was the only variable that predicted graft loss in the multivariate analysis (relative risk [RR] = 1.6, P = .09). When posttransplantation and pretransplantation variables were used, cadaver donor (RR = 1.7), an episode of rejection (RR = 2.6), and the need for dialysis (RR = 2.7) were independent variables that predicted graft loss (P < .001). Black recipient race was a dependent variable. Four pretransplantation variables predicted the risk of dialysis: black race (RR = 3.6), male recipient (RR = 2.1), cadaveric donor (RR = 2.2), and a peak panel-reactive antibody level greater than 30% (RR = 2.8). Three pretransplantation variables predicted the risk of rejection: black race (RR = 1.7), male recipient (RR = 1.6), and a current panel-reactive antibody level greater than 30% (RR = 5.3). CONCLUSIONS: These data suggest that black recipient race is a dependent predictor of renal allograft survival when the posttransplantation events of rejection and dialysis are considered. Black recipients have more immunologic complications after renal transplantation that result in worse graft survival. These results confirm the importance of postallograft events as the major determinants of long-term graft survival and suggest that black recipients are receiving inadequate immunosuppression. These data support attempts to tailor immunosuppressive protocols to recipient pretransplantation risk profiles as a way to improve graft survival in the high-risk recipient.