Achieving racial parity in pediatric kidney transplantation: Yes we can

In the United States, disparities in kidney transplant outcomes among racial and ethnic groups have been well studied in adults (1, 2). The influence of race on pediatric kidney transplant outcomes is a relatively new area of investigation with only a few studies focusing on the pediatric kidney transplant population. Minority pediatric kidney transplant recipients have been reported to suffer disproportionately from graft loss after transplantation compared to white children. Large studies using registry data comparing transplant outcomes between pediatric racial and ethnic groups have found African American race to be an independent risk factor for graft failure. In 2007, a review of 6287 children in the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) database found graft survival at three and five yr post-transplant to be significantly lower in African American than white recipients, even after controlling for confounding factors such as age, cause of end stage renal disease, rejection episodes, and estimated glomerular filtration rate at 30 days post-transplant (3). A recent report described racial disparity trends in 13 692 pediatric kidney transplant recipients over the past 25 yr utilizing United States Renal Data System (USRDS) data (4). Overall, the rate of graft failure was approximately twofold higher in African Americans compared to whites over the entire period. While African Americans had a slightly greater rate of improvement in one-yr graft failure rates than whites over the past 25 yr, this did not hold true for 2–5 yr graft failure rates (4). While the above studies have primarily focused on outcomes between African Americans and whites rather than Hispanics or Asians, the single center study from the University of Miami in the August issue of Pediatric Transplantation looks at outcomes over a 20-yr period in a predominantly Hispanic pediatric population (5). The authors retrospectively analyzed data from 120 recipients <18 yr of age at transplant that received 124 kidney transplants between 1985 and 2005 and that had at least three yr of allograft function. Although the data are not clearly stated as such, they report no statistically significant difference in graft survival for Hispanic compared to white children and improved graft survival for Hispanic and white children compared to African American children. While long-term outcomes in Hispanics were much better than African Americans, whites still demonstrated the best outcomes of the entire cohort. The Kaplan–Meier plots suggest divergence of curves between whites and Hispanics at about 15 yr for live donor recipients and at about 10 yr for deceased donor recipients. However, Hispanics had an advantage over African Americans with a median graft survival of 15 yr compared to five yr in African Americans. A previous report by Ishitani et al. from the UNOS Scientific Transplant Registry on 2418 pediatric livingrelated donor recipients transplanted between 1988 and 1994 also found decreased graft survival in African Americans compared to Hispanics (6). African Americans had twice the relative risk for graft loss compared to Hispanics and graft survival at seven yr was 14% lower in African Americans compared to Hispanics. Where the studies differ is in the finding of decreased graft survival in African American living donor recipients in the UNOS registry compared to Hispanics but not in the single center study reported in this issue of the journal. Further investigation of these differences is needed. The Muneeruddin et al. study highlights several factors leading to poorer graft survival for recipients. First, donor type is a significant risk factor for graft loss and African Americans were more likely to receive a graft from a deceased donor. Deceased donor grafts accounted for 60% Pediatr Transplantation 2010: 14: 807–808 2010 John Wiley & Sons A/S.