Racial equity in renal transplantation. The disparate impact of HLA-based allocation.

KIDNEY transplantation from either a living related or cadaveric donor is optimal treatment for most patients with end-stage renal disease (ESRD).1 However, due to a critical shortage of organ donors, while more than 23 000 Americans await a suitable cadaveric kidney, fewer than 8000 receive transplants each year.2,3 Approximately one third of ESRD patients in this country are African American (black), a proportion threefold greater than the representation of this racial group in the general population (12%).1 Recently, the Inspector General reported that blacks are less likely than whites to receive a transplant, with almost double the waiting time.4 Currently, cadaveric kidneys are allocated according to a federally mandated system based on quality of HLA matching. This policy is based on evidence that antigenic similarity between donor and recipient may enhance cadaveric graft survival and should be the primary factor influencing distribution.5 Gjertson and colleagues6 have proposed that there be even greater emphasis on HLA matching in organ allocation, with all cadaveric kidneys to be placed in a single national pool and distributed to the transplant candidate with the "best" HLA match. In the face of a critical (and growing) shortage of transplantable kid¬ neys, current directives place potential black recipients at a significant disad¬ vantage; extension of HLA-based allo¬ cation will magnify racial disparity. We