Kidney transplantation is considered the most desirable form of RRT, but rates of kidney transplant are limited worldwide by organ availability. Many studies find that transitional and disadvantaged populations have less access to kidney transplantation than the majority population (147,148).
In the United States, African Americans undergo renal transplantation less often than whites, in part because they are less likely to want a kidney transplant, but also because African Americans who do want a kidney transplant are less likely to be referred to transplant centers, even after adjusting for coexisting morbidity (149). Moreover, once referred, African Americans are less likely than whites to complete the evaluation necessary before being listed for transplant (150,151). Barriers to completion include limited access to transportation, child-care responsibilities, and lack of available time away from work; factors that affect transitional and disadvantaged populations disproportionately. After receiving a kidney transplant, African Americans have shorter graft survival than whites (152).
In Australia and New Zealand, the proportion of indigenous patients, including Pacific Islanders, who are referred for kidney transplantation is lower than among non-indigenous patients. Furthermore, once accepted for transplantation, indigenous people are less likely to receive a graft. This finding is due, in part, to lower rates of living donation among Aboriginal patients, but among the Maori rates of living donation are equal to those of non-indigenous donation and Pacific Islanders are actually more likely to participate in living donation than non-indigenous families. Among those who received cadaveric grafts, indigenous people receive fewer well-matched grafts (146).
In the United Kingdom, Indo-Asian patients are slightly less likely to be referred for transplant than whites, their rates of transplantation are lower, and they are more likely to receive grafts with less human leukocyte antigen matches. Transplant survival is also lower among Indo-Asians than whites in the United Kingdom (153).
In Pakistan, kidney transplantation offers the best hope for survival for many patients with kidney failure. Given the absence of governmental funding for dialysis, patients with ESRD and a paid or otherwise willing donor can receive a kidney transplant at a fraction of the cost of dialysis. One program in Pakistan funds kidney transplantation through a community-government partnership. Through this program, more than 100 kidney transplants have been performed each year since 1995 and free immunosuppressive drugs are given to those who receive a transplant (154). Partnerships of this sort may offer hope to people with kidney failure in many parts of the developing world, where the costs of dialysis are beyond reach.
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