Self-reported Race as a Criterion of Anti-Thymocyte Globulin induction

Abstract: Race has been used clinically as a proxy for genetic differences that impact susceptibility to certain diseases and responses to medication. Race has also been used as a shortcut to estimating societal impacts on health following historically disparate access to care. Its continued use in medical decision making is controversial because some argue that it perpetuates stereotypes of race having a biological impact on disease. One such medical decision is the use of anti-thymocyte globulin (ATG) for induction in kidney transplants. ATG is a rabbit-derived antibody that depletes T cells to prevent graft rejection in transplant patients with high immunological risk. ATG is not without its risks–patients receiving this treatment have a permanently altered CD4/CD8 (T cell subtype) ratio, increasing risk for infection and malignancy.
KDIGO, a large non-profit and leader in kidney disease, lists African American (AA) race in the USA only as an independent criterion of high immunological risk. This recommendation is reflected in policies at large tertiary care centers that list AA race as an indication for ATG. This criterion was instituted due to widely reported inferior outcomes for AA organ recipients and donors. Its implementation in the USA only suggests its serving as a proxy for social impact of race, and not genetic differences. However, transplant surgery is uniquely positioned to evaluate social adaptability independently of race with an extensive pre-procedural evaluation that is already standard practice. This paper will explore adequacy of race as a criterion for ATG induction, and options for alternative risk stratification.

Christian Vercler – Michigan Medicine Plastic Surgery; Jeffrey Punch – Michigan Medicine Transplant Surgery