Transplant surgeons at Johns Hopkins who have reviewed the medical records of more than 20,000 heart transplant patients say that it is not simply racial differences, but rather flaws in the health care system, along with type of insurance and education levels, in addition to biological factors, that are likely the causes of disproportionately worse outcomes after heart transplantation in African Americans.
In a report on the review to be published in the Annals of Thoracic Surgery online June 1, the Johns Hopkins team showed that race matching donor hearts did nothing to extend the life in organ recipients. Race matching is the practice of transplanting donor hearts into patients of the same ethnic group. White donors would be matched to white recipients, and the same would apply to blacks, Hispanics or Asians.
"It does not matter whether a white, black, Hispanic or Asian donor heart is transplanted into a patient of any other particular race," says senior study investigator and Johns Hopkins transplant surgeon Ashish Shah, M.D. "Other factors must be the reason for any differences in how well people do after transplantation, in particular, why blacks have poorer outcomes."
In what is believed to be the largest and most detailed review of medical records ever conducted on the subject, the Johns Hopkins team combed 20,185 North American transplant patients' records. All received a donor heart between 1997 and 2007.
Researchers found that 61 percent of heart recipients were race matched (12,381). Among blacks, the death rate after five years was the same, at 35 percent, whether donors and recipients were race matched or not. The same was true among whites, at 26 percent, and among Hispanics, at 28 percent. (Although trends appeared to be the same for Asians, the number of transplants in Asians was not statistically large enough to provide valid percentages.) Death or survival rates were consistent for all timeframes, within a month, three months, six months or a year after transplantation.
Study investigators found that race matching did little or nothing to close the significant gap in blacks' survival rates. Whether or not African Americans received a heart from a black donor, they faced a 46 percent higher chance of dying within 10 years after heart transplantation. Specifically, 45.8 percent of blacks were alive and well after 10 years, a rate 11.4 percent lower than for whites and 10.8 percent lower than for Hispanics.
Researchers say previous reports from nearly a dozen other academic medical centers offered conflicting accounts about any potential benefits from race matching. They say the latest study findings help set the clinical record straight by pooling data from more than 140 hospitals licensed to perform heart transplants instead of relying on data within individual hospitals.
Shah says the data "really prompts us to re-evaluate everything that we do for our more vulnerable patients and to tailor our efforts to the specific needs of each patient, especially African Americans, if we hope to fix racial disparities in surviving heart transplantation.
"This problem is not just about biology or race, it is also about the health system that supports our patients," says Shah, an associate professor at the Johns Hopkins University School of Medicine and its Heart and Vascular Institute.
He also notes that transplant patients can now put their minds at ease that having a racially matched donor heart will not help or hurt them.
Lifting survival rates among blacks, who represent 15 percent of all heart transplants, will, Shah says, require further study of which life-extending factors may work, such as antirejection drug dosages, more stringent follow-up to ensure patient compliance with drug regimens and scheduled appointments, and education about early signs of infection and possible organ rejection, including fever, shortness of breath, fatigue, and swelling in the arms and legs.