You know I talk about dialysis a lot.  And, advocate that stem cell research should be allowed.

Not only could we provide an unlimited set of kidneys for transplant, but hearts, lungs, and a slew of other organs.  But, stem cell research is disallowed due to politics (read:  religious group lobbying).

Which means transplants require either the living or the dead to donate their organs.  Today I am going to share a bunch of facts about which- to be totally honest- I was unaware.

To start with, the costs of a kidney transplant.  They run about $ 440K (according to the Millman company, an actuarial and consulting firm).  Ok, that includes pre- and post- transplant visits and the non-stop anti-rejection meds (about $ 32K) the patient will take for life.  And, those drug costs are only covered for the first 3 years post transplant (at 80%) by Medicare.  Supplemental insurance (Medigap) is required- which still leaves a substantial bill for the patient (and its family).

When you couple those financial requirements with the dearth of available kidneys, you can see why so many folks are still undergoing dialysis and not getting kidney transplants. [If there is insufficient financial wherewithal, the patient never makes the transplant list!]  (Again- we need stem cell research allowed!)  But, this also leads to racial disparity among those obtaining transplants- because whether it’s politically correct or not, it is true that minorities tend to be in the lower economic strata in America.  (Yet another institutional racism issue, one that I am not going to discuss in this post. See the post earlier this week.)

And, our poorer citizenry are more likely to manifest diabetes and hypertension – which are the two leading causes of kidney failure.  (In general, Black subjects are 40% more likely to manifest hypertension and 60% more likely for diabetes. Hispanics are 1.7X more likely to manifest diabetes.) Compounding this, the poor are less likely to see physicians, so without knowledge of kidney problems, they progress to kidney failure without physician intervention.

This situation gets further complicated by the fact that Blacks are 3.7X times as likely to experience kidney failure as would White patients.  Then, nature adds to the whammy, with the fact that Blacks are more likely to reject the transplant in the five years post operation (Taber et. Al.  MUSC and VA Charleston.)

This lack of care, this lack of diagnosis is another compounding factor.  Because we know that preemptive transplants- transplanting a kidney BEFORE the patient ever undergoes dialysis greatly increases survivability and the quality of life.  (New criteria stipulate referrals should occur before a patient reaches Stage 5 kidney failure- when the GFR is below 30 but above 20. (This is when the kidneys are compromised, but haven’t totally failed; the patient is yet to undergo dialysis.)  Since between ¼ and ¹/₃ of the patients undergo their first dialysis without ever receiving a nephrologist’s prior care, that’s not highly likely- especially for the un- or under-insured. (Drs. S Fishbane and V Nair  published these results in the CJASN).

Speaking of GFR, there’s another problem.  One that blew me away.  It seems that for years as clinicians measured GFR (or estimated it from creatinine measurements), they added fudge factors for age, sex, and race.  RACE?  Yes.  The GFR was adjusted because it was assumed (yes, this did make an ass out of U and Me) that blacks have more muscle mass.  (OK.  I said I wasn’t going to discuss institutional racism.  But, it’s inescapable!)

Dr. Nwamaka Eneanya (from an article published in the Journal of General Internal Medicine, with co-authors Drs. S Ahmed [lead], C Nutt, P Reese, K Sivashanker, M Morse, T Sequist, and M Mendu) presented results disputing this crass assumption at the 2020 ASN (American Society of Nephrology) meeting in DC.  This racial adjustment was imposed because of three small, flawed studies effected some 30 to 50 years ago.  And no one ever questioned the eGFR computations until now.

This meant that while Blacks and Whites would have the same serum creatinine levels, the Black was assumed to have better functioning kidneys and, therefore, less deserving to receive a transplant kidney.  The article above (Ahmed and Eneanya et. al.), using 2225 Black patients determined that ¹/₃ belonged in a more severe stage of kidney failure by removing the ‘race-correction factor’, and causing more blacks to rise up on the transplant waiting lists, currently listing some 92000 desperate souls.  Yet, only a few medical systems have abandoned this racial coefficient.

Our biases extend all the way to transplant lists.

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