AN INCREASED INCIDENCE OF REJECTION EPISODES - ONE OF THE CAUSES OF WORSE KIDNEY-TRANSPLANTATION SURVIVAL IN BLACK RECIPIENTS

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 allogra fts (O HLA mismatch grafts excluded) were reviewed. Of the recipients, 57% were black, 27% received living donor grafts, and 86% received th eir first transplant. All recipients underwent an oral cyclosporine in duction protocol with triple drug maintenance. Crude graft survival, t he risk of rejection, and the need for dialysis were determined using donor and recipient demographic and immunologic variables. Results: Gr aft survival was 84%, 67%, and 50% at 1, 3, and 5 years after the tran splantation, respectively. The survival of black recipients was 4%, 11 %, and 20% worse than that of white recipients at 1, 3, and 5 years, r espectively (P<.002). When only pretransplantation variables were cons idered, black recipient race was the only variable that predicted graf t loss in the multivariate analysis (relative risk [RR]=1.6, P=.09). W hen posttransplantation and pretransplantation variables were used, ca daver 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 pre transplantation 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 pretra nsplantation 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 surv ival when the posttransplantation events of rejection and dialysis are considered. Black recipients have more immunologic complications afte r renal transplantation that result in worse graft survival. These res ults confirm the importance of postallograft events as the major deter minants of long-term graft survival and suggest that black recipients are receiving inadequate immunosuppression. These data support attempt s to tailor immunosuppressive protocols to recipient pretransplantatio n risk profiles as a way to improve graft survival in the high-risk re cipient.