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Race Matters For Patients Awaiting Lung Transplants

A recent study published in the American Journal ofRespiratory and Critical Care Medicine finds that compared towhites, blacks with chronic obstructive pulmonary disease, or COPD,were lesslikely to receive a lung transplant. Blacks were also more likely thanwhites to die or beremoved from the transplant list.

Columbia University researcher David Lederer and colleagues analyzed280 non-Hispanic black adults and 5,272 non-Hispanic white adults whowere diagnosed with COPD or emphysema. All members of the sample wereawaiting lung transplants on the United Network for Organ Sharing(UNOS) list between 1995 and 2004. The researchers tracked patients tothe end of the study period until they died, received a transplant,were removed from the list, or were still living and awaitingtransplant. The results were examined with respect to age, sex, diseaseseverity, community poverty level, and transplant center volume.

After controlling for age, lung function, cardiovascular risk factors,transplant center volume, type of health insurance, and approximatepoverty level, Lederer and colleagues showed that “black patients withCOPD were less likely toundergo lung transplantation after listing than white patients in theUnitedStates during the late 1990’s and the early 2000’s”

They note that this finding and other “disparities are consistent withthose observed among patientsawaiting kidney and liver transplantation and among patients with otheradvanced lung diseases such as pulmonary arterial hypertension andpulmonary fibrosis.”

Blacks were also less likely to haveprivate insurance and more likely to live in poorer neighborhoods.Greater cardiovascular risk factors, such as diabetes, pulmonaryhypertension and lower six-minute walk distances were observed inblacks compared to whites. However, even these factors did not accountfor the differences between the two groups regarding lungtransplantation.

“Differences in insurance, socioeconomic status and cardiovascular riskfactors explained some but not all of the higher risk of death orremoval from the waiting list,” said Dr. Lederer.

The researchers also found that Hispanics hadsimilar outcomes to non-Hispanic blacks. During the ten-year studyperiod, only 280 black and 64 Hispanic patients with COPD were puton the lung transplant waiting list in the United States. Lederer addsthat “based on what we know about COPD, we expected that twice as manyblack patients would have been put on theling transplant waiting list. Our findings point to significantbarriers to accessing lung transplantation for minorities.”

The authors maintain that their findings “should alert primary carephysicians and pulmonologists toconsider referral of black patients with COPD for transplantation atthe earliest signs of advanced disease.” In addition, patients canprotect themselves from these racial differences by preparingthemselves for transplantation “by discussing all oftheir treatment options with their doctor. To be eligible for lungtransplantation, patients must quit smoking, use medications and oxygenas prescribed, and participate in a pulmonary rehabilitation program toincrease their strength and endurance.”

Since the study period, the organ allocation system has been replacedwith one that prioritizes patients based on the survival benefit of thetransplant. However, blacks will still be more likely to be removedfrom the transplant list or to die due to poorinsurance and poverty compared to whites, warns Lederer.

The authors conclude by calling for research that identifies “thespecific barriers that patientsencounter while trying to get on the waiting list for a lungtransplant. Once we figure out the root of the problem, we can begin toimprove access for all patients with COPD.”

Racial Differences in Waiting List Outcomes in ChronicObstructive Pulmonary Disease
David J. Lederer, Emma K. T. Benn, R. Graham Barr, Jessie S. Wilt,Genevieve Reilly, Joshua R. Sonett, Selim M. Arcasoy, and Steven M.Kawut
American Journal of Respiratory and Critical Care Medicine. Volume177, Issue 4.pp. 450-454, (2008)
doi:10.1164/rccm.200708-1260OC
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