Renal Transplantation and African Americans

Clive O'Callendar, M.D.

Edited by Kenneth W. Jones, M.D.

The information contained in this article is the result of the collaborative efforts of the Minority Organ Tissue Transplant Education Program, an organization of African American transplant professionals under the leadership of Clive O. Callender, M.D., F.A.C.S.  Article submitted by Kenneth W. Jones, M.D., F.A.C.S.
 
Renal transplantation, the treatment of choice for end-stage renal disease, is an increasingly common procedure. Of the more than 21,000 organs transplanted in the U.S. in 1998, 57% were kidney transplants and an additional 5% were kidney-pancreas transplants.1 Short-term outcomes for kidney transplant recipients continue to be better than long-term results, however. In 1997, for example, the 1-year graft survival rate was nearly 90%, while the 3-year rate was just 76%.

Although African Americans traditionally have been identified as a high-risk group with respect to long-term graft survival, it is less clear to what extent members of this ethnic* group are still high-risk candidates. This lecture focuses on the current outlook for African Americans with respect to kidney transplantation and will:

  • evaluate access to transplantation across patient groups
  • assess differences in kidney graft survival rates among ethnic groups
  • review immunologic and nonimmunologic factors that affect outcomes
  • summarize new developments in immunosuppression
  • address issues of organ donation in minority communities
  • discuss methods to prevent renal disease

*Because the term "race" has often been used in a derogatory and divisive manner and because the biological concept of race is no longer tenable, 2,3 the term "ethnicity" is used throughout this lecture to distinguish among demographically distinct populations. This usage is in keeping with the September 1999 resolution of the Minority Affairs Committee of the United Network for Organ Sharing (UNOS).

Ethnicity and Access to Renal Transplantation

Ethnic disparities in access to renal transplantation are long-standing and may be increasing. Although 30% of patients on renal transplant waiting lists in 1989 were African American, that proportion increased to 36% by 1996.1 In the same time period, median waiting times increased among African Americans from 21 to 43 months and among Caucasians from 12 to 22 months. 1 Thus, while half of African Americans on the waiting list remained there for more than 3.5 years, half of the Caucasians on the list awaited a renal allograft for fewer than 2 years.

Unfortunately, these figures actually underestimate barriers to access confronted by African Americans. Ayanian et al.4 found that African Americans of both genders were significantly less likely than Caucasians to want a renal transplant, to be certain about their preference, to be referred for evaluation for transplantation, or to be placed on waiting lists. The authors concluded that educational programs that target medical professionals and patients with end-stage renal disease should focus on making renal transplantation available to all clinically viable candidates who desire the procedure.4

African Americans also face barriers to renal retransplantation. Using data for patients registered with the U.S. Renal Data System between 1985 and 1995, 5-year retransplantation rates among African Americans and Caucasians were found to be 15% and 29%, respectively, while median waiting times were 90 and 32 months, respectively.5 Adjusted for potential confounders, the likelihood of repeat transplantation was 53% lower among African Americans than among Caucasians even though the difference in the rates at which patients in the two ethnic groups were registered on waiting lists was small.5

Kidney Graft Survival

Throughout the 1990's, more than 85% of renal transplant patients from all ethnic groups survived for 5 years or more.1,6 Moreover, cadaveric graft survival improved among African Americans, Caucasians, and Asians between 1988-90 and 1994-96.7 In fact, 3-year graft survival rates for African Americans increased from 57% to 67%, and graft half-lives increased from 5.1 to 6.5 years during the respective time periods. Despite these improvements, the gap between the 2-year graft survival rates for African Americans vs Caucasians remained at 5% in the mid-1990s (down from 9% in the earlier period), and graft half-lives for African-American recipients remained approximately half that of Caucasians.7 Furthermore, recent analyses found that African-American ethnicity was a significant independent predictor of early graft loss even when other potential negative effects were statistically controlled.8

Factors that may help explain these continuing relatively poor long-term renal allograft survival rates among African-American patients include:

  • histocompatibility and acute rejection
  • delayed graft function and acute rejection
  • comorbid conditions — especially hypertension
  • noncompliance
  • immune responsiveness and immunosuppressant pharmacokinetics

Histocompatibility and Sensitization

HLA mismatching negatively affects long-term first renal allograft survival overall with a difference of 17% between best- and worst-matched cases after 3 years.9 HLA matching has improved slightly for African Americans in recent years with the percentage of zero-mismatched kidneys going to African Americans increasing from 5% in 1987-90 to 7% in 1991-95. In addition, as this lecture demonstrates, 1-year graft survival has become comparable across ethnic groups within HLA mismatch category.9 Interestingly, HLA matching (except when there is zero incompatibility) has less influence on kidney survival among African Americans than among patients in other ethnic groups.10

Graft survival at all levels of HLA mismatching is significantly lower (P<0.001) among sensitized (panel-reactive antibodies [PRA] >20%) than among unsensitized recipients.11 Although there was substantial improvement in graft survival between 1989-90 and 1995-96 among both sensitized and unsensitized patients, a higher percentage of African-American than Caucasian patients are strongly sensitized.11 Moreover, broad sensitization (PRA >50%) may somewhat more negatively affect kidney graft survival among African Americans than among Caucasians.6 Among sensitized Caucasian patients, 4-year graft survival rates were 3% lower than among their less sensitized (PRA 0-10%) counterparts, while the corresponding difference among sensitized vs unsensitized African-American renal allograft recipients was 5%.

Delayed Graft Function and Acute Rejection

Both delayed graft function (at least one dialysis treatment in the first posttransplant week) and acute rejection episodes continue to be associated with lower renal allograft survival rates.7,12 In the period 1994-96, for example, the graft half-life for transplant recipients who experienced delayed graft function was 42% lower than that for patients who did not experience a delay in functioning (6.7 vs 11.5 years, respectively). In the same period, patients with early rejection episodes had graft half-lives 12% lower than those without early rejection (9.1 vs 10.3 years, respectively).7

A study of two-haplotype matched living-related donor renal transplant recipients found that African Americans were more likely than Caucasians to have delayed graft function (P<0.07) and to suffer an acute rejection episode (P<0.01).13 Five-year graft survival was significantly lower in African Americans without acute rejection compared to Caucasians without such rejection (78% vs 86%, respectively, P<0.01); among patients with acute rejection, the 5-year graft survival rate was 50% in African Americans and 76% among Caucasians (P<0.01). Because acute rejection was associated with a 36% decrease in 5-year graft survival among African Americans but only a 12% decline among Caucasians, the authors concluded that acute rejection was associated with a 36% decrease in 5-year graft survival among African Americans but only a 12% decline among Caucasians, the authors concluded that acute rejection continues to negatively affect graft outcomes especially among African-American recipients.13

Comorbid Conditions

The most common comorbid conditions among renal transplant patients are glomerular diseases, insulin dependent diabetes mellitus, and hypertensive nephrosclerosis. Five-year patient survival rates for cadaveric kidney recipients with these conditions range from 64% for patients with glomerular diseases to 58% for those with diabetes or hypertension.1

The negative effect of hypertension on graft survival among African-American renal allograft recipients has been well-documented. For example, a study by Cosio, et al.14 of more than 500 African-American and Caucasian first cadaveric renal allograft recipients followed for at least 3 years found the prevalence of post transplant hypertension (mean arterial blood pressure [mean arterial blood pressure [Map] ³107 mm Hg) to be similar in the two ethnic groups. However, Hypertensive African-American recipients had significantly lower allograft survival compared with normotensive African-American recipients and with either hypertensive or normotensive Caucasians (P<0.0001 vs all groups). In fact, mean allograft survival was eight times shorter (3.1 years) among African Americans with hypertension than among hypertensive Caucasians (24.6 years), even though allograft survival was similar among normotensive patients between groups. Importantly, patient compliance, based on objective measures, was not different between hypertensive African-American patients and other groups of patients.14

Recent research that included 116 African-American first cadaveric kidney recipients found posttransplant Mean Arterial Pressure (MAP) to be significantly correlated with pretransplant MAP (R=0.4, P<0.0001) and documented an association between reduced graft survival and poorly controlled MAP either pretransplant or posttransplant.15 The authors concluded that pretransplant MAP can be used to identify patients at high risk for developing severe posttransplant hypertension and for early graft loss.

Compliance

Long-term graft survival requires a life-long commitment to complying with immunosuppressant medication regimens. The association between noncompliance and renal allograft loss was demonstrated in a retrospective study of 260 patients, which found that 91% of patients who were noncompliant with both medication and follow-up either lost their grafts or died during the study compared with 18% of compliant patients.16 Results of studies reported in the early 1900s associated many factors with medication noncompliance including relative youth, male gender, unemployment, large numbers of prescribed medications, low socioeconomic status, and African-American ethnicity.16-18

Research that controlled for socioeconomic status did not find ethnicity to be a significant predictor of noncompliance,16 however, a result substantiated by a recent large (n=1402), multiinstitutional study of medication noncompliance in renal transplant patients with functioning grafts.19 Potential predictors of noncompliance (measured by patient reports of medication usage within the previous 4 weeks) included patient and transplant characteristics, posttransplant symptoms, and beliefs regarding the efficacy of and need for immunosuppression. Multivariate analyses revealed that younger age, not having a white-collar occupation, longer time since transplant, and weak beliefs concerning the efficacy of/need to take immunosuppressants were most predictive of noncompliance. African-American ethnicity was not a significant predictor of medication noncompliance.19

Immune Responsiveness and Immunosuppressant Pharmacokinetics

Some evidence suggests that African Americans have higher immune responsiveness to transplanted organs than do Caucasians. The effect of ethnicity on pretransplant immune responder status and subsequent graft survival was studied in 124 African-American and 241 Caucasian first cadaveric renal allograft recipients.20 All patients received cyclosporine and prednisone, and HLA matching was performed. Pretransplant tests of immunity found that 90% of African-American patients vs 66% of Caucasians were strong immune responders. Although 3-year patient survival rates were identical (94%), 3-year graft survival was significantly lower among African Americans than among Caucasians (55% vs 75%, respectively, P<0.01). Importantly, 1-year graft survival among strong responders was 67% for African Americans vs 80% among Caucasians (P<0.01), but the difference between ethnic groups among weak responders was not significant (90% vs 83%, respectively, n.s.). The authors concluded that African Americans with end-stage renal disease appear to be more likely than their Caucasian counterparts to be strong immune responders, a status that puts them at an immunological disadvantage with respect to renal allograft survival.20

Immunosuppressant pharmacokinetics also may be dissimilar in African-American vs Caucasian kidney recipients. Among 30 African-American and 50 Caucasian renal transplant recipients, African Americans exhibited significantly lower bioavailability of cyclosporine both pre- and posttransplantation than did Caucasians.21 In addition, African Americans have been found to require higher doses of mycophenolate mofetil (MMF) than do Caucasians in order to prevent acute rejection.22

New Developments in Immunosuppression

Tacrolimus, which inhibits T-lymphocyte activation and proliferation, may provide the stronger immunosuppression that many African-American renal transplant patients appear to require. A meta-analysis of four randomized trials compared tacrolimus and cyclosporine for immunosuppression in renal transplantation.23 Tacrolimus showed no significant effect on 1-year patient or graft survival. Tacrolimus therapy was associated, however, with significantly lower risks of acute rejection (odds ratio: 0.52; 95% confidence interval [C1]: 0.36 to 0.75) and of the need for antilymphocyte antibodies to treat rejection (odds ratio: 0.37; 95% C1: 0.25 to 0.56).23 Given that acute rejection has been associated with long-term graft loss,7,12 the impact of the observed reduced risk of acute rejection on graft survival among tacrolimus-treated patients may require more than a single year of follow-up to detect. Although the meta-analysis also demonstrated an increased risk of posttransplant diabetes mellitus with tacrolimus therapy, such an association was not confirmed by results of a recent study of tacrolimus/MMF vs cyclosporine/MMF therapies in which the incidence of diabetes was 7% in both treatment groups.24 These disparate results suggest that additional research is needed to clarify whether there is a relationship between tacrolimus therapy and diabetes.

Ethnic Differences in Outcomes with Tacrolimus vs Cyclosporine

The efficacy and safety of tacrolimus among African-American renal allograft recipients were demonstrated in a multicenter, randomized clinical trial that included 205 patients who received tacrolimus (27% African-American, 56% Caucasian) and 207 who received cyclosporine (23% African-American, 59% Caucasian).25 All patients received induction therapy, azathioprine, and a corticosteroid. There were no differences between treatment or ethnic groups with respect to 1-year patient or graft survival. Incidences of acute rejection and of antilymphocyte treatment for rejection within one year of transplantation were significantly lower in both African American and Caucasian patients treated with tacrolimus vs cyclosporine. Among African Americans, significantly lower proportions of tacrolimus-treated vs cyclosporine-treated patients experienced biopsy-proven acute rejection (23% vs 48%, respectively; P=0.025) or required antilymphocyte treatment for rejection (6% vs 27%, respectively; P=0.0005). No African-American patient experienced moderate or severe acute rejection with tacrolimus. Similar to previous studies that found immunosuppressant pharmacokinetics to be different between ethnic groups, African-American patients in this analysis were found to require 37% higher mean doses of tacrolimus than Caucasian patients to reach comparable blood concentrations.25

Treatment groups were similar with respect to safety parameters except that African Americans treated with tacrolimus had lower lipid levels but an increased incidence of diabetes mellitus compared to those treated with cyclosporine.25 The latter result was not confirmed, however, in a recent study of African-American renal allograft recipients treated with tacrolimus/MMF vs cyclosporine/MMF in which no significant relationship between treatment and the incidence of diabetes was found. (Data on file)

The efficacy of sirolimus (rapamycin), which is structurally related to tacrolimus, also has been studied among African Americans. Two randomized, double-blind, multicenter trials compared short-term outcomes among African-American renal allograft recipients receiving adjunctive sirolimus therapy at the recommended dosage of 2 mg/day vs either azathioprine or placebo. In the initial study, rates of failure (biopsy-confirmed acute rejection episode, graft loss, or death) in the first 6 posttransplant months were similar among patients administered sirolimus vs azathioprine; the second study found no significant difference after 6 months in rates of failure between those who received sirolimus and those given placebo.26

Barriers to Organ Donation

Improvement in organ matching and in immunosuppressant therapies cannot alone solve the problems of access and graft survival among African Americans.27 The donor-recipient supply-demand disparity is a particular problem. Barriers to organ donation include:

  • Institutionalized racism (behavior that acts out the conscious or unconscious belief that a particular "race" is superior or inferior to others) continues to pervade our society and our health care system. For example, a recent study found the odds that a hospital staff member had discussed organ donation with the family of a deceased African-American patient medically suitable for donation was half that for a family of a similar Caucasian patient.28
  • Lack of information/awareness: The African-American community traditionally has been less aware of the need for organ donation because educational programs have been lacking.
  • Inequitable organ allocation: In the past, UNOS relied heavily on HLA matching which fosters imbalances because HLA antigens are differentially distributed across ethnic groups.29 New guidelines may help ameliorate this problem.27
  • Suboptimal use of the community as a change agent: Community-based programs to foster organ donation are being developed, but more are needed.
  • Religious myths and misunderstandings: Some members of the community (incorrectly) believe that organ donation is not sanctioned by religious organizations.
  • Inadequate funds for donation education efforts: More funds from governmental and private sources are needed to enhance community education programs.
  • Distrust of the health care system by minorities: A history of discrimination and (in some instances) abuse of minorities by health care professionals has led to distrust and a reluctance to donate organs.

Programs to Increase Minority Organ Donations

Organized efforts to increase organ donations in minority communities began in 1982 with the District of Columbia Organ Donor Program (DCODP) and was augmented a few years later by the Dow Chemical Company Take Initiative Program (DOWTIP).30 The successes of these programs in educating minority communities about organ donation culminated in the development of the National Minority Organ Tissue Transplant Education Program (MOTTEP) in 1993. MOTTEP developed the first national minority strategic plan to increase donations from minorities and the first information center for community outreach with educational materials tailored to issues of minority transplantation and donation. MOTTEP programs are now active in 15 cities across the U.S.30

The efforts of MOTTEP and its predecessors have been richly rewarded by the responses of minority communities. Thus, in the past 15 years, there has been a 125% increase in the number of African-American organ donors in the Washington, D.C., area alone.31 Minority donations overall have increased dramatically during the past 20 years. For example, the number of organ donors increased from 8 to 28 per million among African Americans between 1982 and 1998 and from 9 to 20 per million among Hispanics between 1994 and 1998.32 In this latter time period, the number of organ donors per million doubled among Asian Americans and Pacific Islanders.

Several lessons have been learned concerning how best to educate minority communities about organ donation. Most importantly, the message must be understandable, customized to the target group, and delivered by appropriate community-based messengers. The best messengers are donors, organ recipients, and families of organ recipients who live and/or work in the community. In addition, public, professional, and political efforts must be combined to focus on the organ shortage problem.

Preventing Renal Disease

A primary goal of MOTTEP is to prevent renal disease among African Americans in order to reduce the incidence of end-stage renal disease and decrease the need for renal transplantation. In particular, MOTTEP educational programs focus on behavior and lifestyle changes that can reduce hypertension, diabetes, alcohol and drug abuse, smoking, and obesity — all conditions that are more prevalent among African Americans than Caucasians.31,32

  • Blood pressure checks: African Americans are advised to have their blood pressure checked twice a year after age 12 and more often for those with known hypertension or diabetes. Behaviors known to reduce high blood pressures or maintain normal blood pressures are explained and recommended.33
  • Careful monitoring of diabetes: Community residents with diabetes are encouraged to carefully monitor blood sugar levels, have regular blood pressure checks, and follow diet and exercise regimens that will help keep blood glucose levels under control.34
  • Avoidance of alcoholic beverages and drugs: Education concerning the short- and long-term health hazards of excessive drinking and the use of drugs is provided.35,36
  • Cessation/avoidance of smoking: The prevalence of smoking-attributable diseases among adults and youth in our communities is reviewed; the effects of second-hand smoke on young children is discussed.37
  • Weight control, exercise, and good nutritional practices: The beneficial effects of these behaviors is stressed both overall and with respect to renal disease.33,37

Outlook for African Americans Needing Renal Transplants

Overall, it is reasonable to conclude that the outlook for African-American recipients of renal transplants has improved in the past 5 years. Access to organs remains unequal, however, and graft survival still lags behind that of Caucasians. Although graft survival for comparable levels of organ histocompatibility has become similar across ethnic groups, African Americans still are less likely to receive zero-mismatched organs. Moreover, African Americans who suffer acute rejection episodes are more likely than their Caucasian counterparts to lose their grafts, while hypertension takes a disproportionate toll on African-American kidney recipients.

We have learned that African Americans are not more likely than members of other ethnic groups to be noncompliant with immunosuppressive medications (when other factors are controlled), and we have learned that African Americans may be more immune responsive than Caucasians and may need higher doses of immunosuppressants to achieve therapeutic levels. New therapies — especially tacrolimus — appear to hold out particular hope for African Americans, although the side-effect profiles of these agents remain to be clarified.

The African-American community and its caregivers cannot rely entirely on technological and pharmacological progress to further improve the outlook for minority renal transplant patients. The real key to better outcomes rests in focused, ongoing educational efforts by medical professionals and by political and community leaders that will increase the minority donor pool and — more importantly — prevent disease among African Americans.

References

  1. UNOS/OPTIN Scientific Registry, 1999 Annual Report. http://www.unos.org/Data/anrpt99/ar99.
  2. Freeman HP. The meaning of race in science—considerations for cancer research. Cancer 1998:82:219-25.
  3. Odocha O. Race and racialism in scientific research and publication in the Journal of the National Medical Association. J Natl Med Assoc 2000;92:96-8.
  4. Ayanian JZ, Cleary PD, Weissman JS, et al. The effect of patients' preferences on racial differences in access to renal transplantation. N Engl J Med 1999;341:1661-9.
  5. Ojo AO, Wolfe RA, Agodoa LY et al, Prognosis after primary renal transplant failure and the beneficial effects of repeat transplantation. Multivariate analyses from the United States Renal Data System. Transplantation 1998;66:1651-9.
  6. Katznelson S. Giertson DW, Cecka JM. The effect of race and ethnicity on kidney allograft outcome. In: Clinical Transplants 1995. Cecka JM and Terasaki PI, eds. Los Angeles, CA: UCLA Tissue Typing Laboratory; 1996:379-94.
  7. Cecka JM. The UNOS scientific renal transplant registry-ten years of kidney transplants. In: Clinical Transplants 1997. Cecka JM and Terasaki PI, eds. Los Angeles, CA:UCLA Tissue Typing Laboratory; 1998:1-14.
  8. Gjertson DW. A multi-factor analysis of kidney graft outcomes at one and five years posttransplantation: 1996 UNOS update. In: Clinical Transplants 1996. Cecka JM and Terasaki PI, eds. Los Angeles, CA:UCLA Tissue Typing Laboratory;1997:343-59.
  9. Hata Y, Ozawa M, Takemoto SK, et al. HLA matching. In: Clinical Transplants 1996. Cecka JM and Terasaki Pi, eds. Los Angeles, CA:UCLA Tissue Typing Laboratoiry; 1997:381-96.
  10. Scantlebury V, Gjertson D, Eliasziw M, et al. Effect of HLA mismatch in African-Americans. Transplantation 1998;65:586-8.
  11. Katznelson S, Bhaduri S, Cecka JM. Clinical aspects of sensitization. In: Clinical Transplants 1997. Cecka JM and Terasaki PI, eds. Los Angeles, CA:UCLA Tissue Typing Laboratory; 1998:285-96
  12. Hariharan S. Johnson CP, Bresnahan BA, et al, Improved graft survival after renal transplantation in the United States, 1988 to 1996. N Engl J Med 2000;342:605-12.
  13. Ojo AO, Port FK, Held PJ, et al. Interior outcome of two-haplotype matched renal transplants in blacks: Role of early rejection. Kidney Int 1995;48:1592-9.
  14. Cosio FG, Dillon JJ, Falkenhain ME, et al. Racial differences in renal allograft survival: The role of systemic hypertension. Kidney Int 1995;47:1136-41.
  15. Cosio FG, Falkenhain ME, Pesavento TE, et al. Relationships between arterial hypertension and renal allograft survival in African-American patients. Am J Kidney Dis 1997;29:49-27.
  16. Schweizer RT, Rovelli M, Palmeri D, et al. Noncompliance in organ transplant recipients. Transplantation 1990;49:374-7.
  17. Butkus DE, Meydrech EF, Raju SS. Racial differences in the survival of cadaveric renal allografts. Overriding effects of HLA matching and socioeconomic factors. N Engl J Med 1992;327:840-5.
  18. Kiley DJ, Lam CS, Pollak R. A study of treatment compliance following kidney transplantation. Transplantation 1993;55:51-6.
  19. Greenstein S, Siegal B. Compliance and noncompliance in patients with a functioning renal transplant: a multicenter study. Transplantation 1998;66:1718-26.
  20. Kerman RH, Kimball PM, Van Buren CT, et al. Possible contribution of pretransplant immune responder status to renal allograft survival differences of black versus white recipients. Transplantation 1991;51:338-42.
  21. Lindholm A, Welsh M, Rutzky L, et al. The adverse impact of high cyclosporine clearance rates on the incidences of acute rejection and graft loss. Transplantation 1993;55:985-93.
  22. Neylan JF, et al. Immunosuppressive therapy in high-risk transplant patients: dose-dependent efficacy of mycophenolate mofetil in African-American renal allograft recipients. Transplantation 1997;64:1277-82.
  23. Knoll GA, Bell RC, Tacrolimus versus cyclosporin for immunosuppression in renal transplantation: meta-analysis of randomized trials. BMJ 1999;318:1104-7.
  24. Johnson C, Ahsan N, Gonwa T, et al. Randomized trial of tacrolimus (Prograf) in combination with azathioprine or mycophenolate mofetil versus cyclosporine (Neoral) with mycophenolate mofetil after cadaveric kidney transplantation. Transplantation 2000;69:1-8.
  25. Neylan JF, et al. Racial differences in renal transplantation after immunosuppression with tacrolimus versus cyclosporine. Transplantation 1998;65:515-23.
  26. Product Information: sirolimus (Rapamune). Wyeth-Ayerst Pharmaceuticals, Inc., 2000.
  27. Callender CO. Transplant policy developments. Minority Health Today 1999;1:10-4.
  28. Guadagnoli E, McNamara P, Evanisko MJ, et al. The influence of race on approaching families for organ donation and their decision to donate. Am J Public Health 1999;89:244-7.
  29. Gaston RS, Ayres I, Dooley LG, et al, Racial equity in renal transplantation: the disparate impact of HLA-based allocation. JAMA 1993;270:1352-5.
  30. Callender CO, Washington AW. Organ/tissue donation the problem! Education the solution: a review. J Nall Med Assoc 1997;89:689-93.
  31. Callender CO, Preventive aspects in related health programs. Presented at Medical Roundtable on Transplant. Renal Transplantation in African-Americans: Access and Outcome. March 14-15, 1997:Key West, FL, pp4-5.
  32. Callender CO, Ethnicity and matching for organ and tissue donation and transplantation. Minority Health Today 1999;1:6-9.
  33. How to prevent high blood pressure. http://www.nhlbi.nih.gov/health/public/heart .
  34. The prevention and treatment of complications of diabetes mellitus: a guide for primary care practitioners. Department of Health and Human Services. http://www.cdc.gov.diabetes.
  35. American Heart Association guidelines on alcohol consumption. http://www.ncadd.org/heart.
  36. National Council on Alcoholism and Drug Dependence, Inc. http://www.ncadd.org.
  37. Chronic disease prevention. National Center for Chronic Disease Prevention and Health Promotion. Centers for Disease Control and Prevention. http://www.cdc.gov/nccdphp.

Jacksonville Medicine / January 2001

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