More research needed on cardiovascular disease in Asian-Americans

There are marked differences in heart disease risk and occurrence among Asian-American subgroups, but data on these subgroups is limited, prompting the American Heart Association to call for more research on this fastest-growing racial/ethnic group in the U.S., according to a scientific statement published in Circulation: Journal of the American Heart Association.......(ATC Says: Yeah think about that whitey and the healthy well-being of your offspring when you choose to mix with non-white races! Not only are you annihilating your race and your cultural heritage, but it is your children who will have to suffer the ramifications of your deluded ideology of multiculturalism both psychologically, physiologically, and medically)

http://www.physorg.com/news201791431.html

"Available research shows that subgroups of Asian-Americans are at increased risk of complications and death from cardiovascular disease; however, Asian-Americans are often studied as a group, which masks the differences within this heterogeneous population," according to Latha Palaniappan, M.D., M.S., chair of the American Heart Association's Scientific Advisory on Cardiovascular Disease in Asian-Americans.

Asian-Americans represent 25 percent of all foreign-born people in the U.S. They are projected to reach nearly 34 million by 2050. Major federal surveys have only recently started to classify Asian-Americans into seven subgroups: Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese and Other Asian. The first six subgroups together constitute more than 90 percent of Asian-Americans in the U.S., according to the statement.

Palaniappan and her colleagues reviewed published research on Asian-Americans and cardiovascular disease, then identified gaps in knowledge and made recommendations.
"We found many disparities among subgroups," Palaniappan said. "If you group all Asian-Americans together, you do not detect these differences."

The statement cites some of the following risk differences between Asian-American subgroups:

• Asian Indians and Filipinos are at greater risk of coronary heart disease compared to the other subgroups.
  
• Japanese- and Chinese-Americans have lower rates of coronary heart disease but higher rates of stroke.
  
• Chinese-Americans have lower rates of peripheral arterial disease, or clotting diseases of the leg arteries, than other groups.

The statement identifies research showing that risk factors for Asian-Americans differ compared to Caucasians. For example, body mass index, a common tool for determining risk for cardiovascular disease, is considered normal when it's less than 25 kg/m2 for Caucasians. However, a BMI under 23 kg/m2 may be more appropriate for Asians, she said.

Some studies also show that Asian-Americans metabolize drugs, including those used to treat heart disease, differently than Caucasians and other racial/ethnic groups.

"Looking at this more closely gives us opportunities to improve health disparities among Asian-Americans," Palaniappan said. "We need changes in data collection."

Among the suggested changes: Instead of grouping Asian Pacific Islanders together, separate them into the appropriate groups for more accurate disease characterization.

This is already done in the U.S. Census, according to Palaniappan, but it is not done commonly in hospitals and clinics.

Other recommendations for improving the quality and quantity of data include developing standard Asian-specific measurement tools for things such as acculturation, which indicates how well a certain population has adapted to the U.S. culture, as well as diet.

"In Mexican-Americans and Spanish populations we often use language as a marker as acculturation. We say: Do you speak English at home? This is not such a great marker in Asian populations because English is often taught in the home countries. In India, for example, English is a national language," Palaniappan said. "Giving many Asian-Americans the typical American diet questionnaire does not lead to accurate data collection because these questions do not reflect culturally specific foods."

The committee also recommends that researchers should "over-sample" Asian-Americans in population-based and clinical trials to ensure that they are well-represented.

We've done an excellent job in researching disparities in other minority groups, but great gaps remain in our knowledge about Asian-Americans," Palaniappan said. "We are making a call to action for national funding organizations that the study of Asian-Americans should be a priority."




(ATC Says: Well, well, so it would seem that Asians are not a medically homogeneous group!)



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Donor–Recipient Race Mismatch and Graft Survival After Pediatric Heart Transplantation

Kirk R. Kanter, MD^a,_*, Alexandria M. Berg, MSN^b, William T. Mahle, MD^b, Robert N. Vincent, MD^b, Patrick D. Kilgo, MS^c, Brian E. Kogon, MD^a, Paul M. Kirshbom, MD^a

^a Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
^b Emory University School of Medicine, Atlanta, Georgia
^c Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia

Accepted for publication September 29, 2008.

^_* Address correspondence to Dr Kanter, Pediatric Cardiac Surgery, Emory University School of Medicine, 1405 Clifton Rd, Atlanta, GA 30322 (Email: kkanter@emory.edu).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.

http://ats.ctsnetjournals.org/cgi/content/full/87/1/204

Abstract

Background: Black recipient race has been shown to predict poorer graft survival after pediatric heart transplantation. We analyzed our single-center experience comparing graft survival by race and the impact of donor–recipient race mismatch.

Methods: One hundred sixty-nine consecutive primary pediatric heart transplant patients were analyzed by donor and recipient race (white recipient, 99; black recipient, 60; other, 10). The groups were similar in preoperative characteristics. There were fewer donor–recipient race matches in blacks compared with whites (10 versus 71; p <>

Results: Although 30-day and 6-month graft survival was similar for black and white recipients (93.9% and 85.8% versus 93.3% and 83.3%, respectively), overall actuarial graft survival was significantly lower in blacks (p <> incidence of positive retrospective crossmatch (n = 26, 43%) than whites (n = 29, 29%), but this was not statistically significant (p = 0.053). The median graft survival for black recipients was 5.5 years compared with 11.6 years for whites. Donor–recipient race mismatch predicted poorer graft survival (5-year graft survival 48.9% versus 72.3%; p = 0.0032). The median graft survival for donor–recipient race-matched patients was more than twice that for mismatched patients (11.6 years versus 4.4 years). Cox proportional hazard analysis showed that donor–recipient race mismatch neutralized the effect of race on graft survival.

Conclusions: Graft survival after pediatric heart transplantation is inferior for black recipients compared with white recipients. These differences may be explained by a high incidence of donor–recipient race mismatch, which also predicts poorer outcome for all racial groups with pediatric heart transplantation. These data may have implications for future donor allocation schemes.

Introduction

There are many factors that influence patient and graft survival after cardiac transplantation in children. It has been reported that black race is a risk factor for increased mortality after pediatric cardiac transplantation [1]. In adult heart transplant recipients, there are several reports that suggest that black recipient race is a predictor not only for increased mortality after cardiac transplantation [2–8] but also for increased risk of rejection [4, 9, 10] and increased incidence of transplant coronary artery disease [11]. On the other hand, others have shown no statistical difference in outcomes between black heart transplant recipients compared with nonblacks [12–15]. To address this question, we analyzed our single-institution experience with pediatric heart transplantation from 1988 through 2007 examining 169 consecutive primary pediatric heart transplant patients to determine the influence of race on graft survival.

Patients and Method

Approval for this retrospective study was obtained from the Emory University School of Medicine Human Investigation Committee, which waived the need for patient consent.

Patient Population
From 1988 through December 2007, 201 cardiac transplants were performed at Children's Healthcare of Atlanta at Egleston, the pediatric hospital affiliated with Emory University School of Medicine. We excluded 29 repeat transplants and 3 primary transplants in patients older than the age of 18. This left 169 primary heart transplants in children younger than 18 years of age for analysis. Of the 169 pediatric primary heart transplant recipients, 99 patients were white, 60 were black, and 10 were from other ethnic and racial groups (5 Hispanic, 4 Asian, and 1 of mixed race). The preoperative characteristics of the three groups are depicted in Table 1. The groups were similar in age, congenital diagnosis (as contrasted with idiopathic cardiomyopathy or acquired cardiomyopathy), incidence of prior operation, United Network for Organ Sharing (UNOS) status at the time of transplantation, and days on the heart transplant waiting list. The incidence of class I and class II preformed antibodies were also compared and found to be not different among the groups (Table 1).

View this table: [in a new window] Table 1 Recipient Characteristics by Racial Group

The race of the donor for each recipient was also categorized as described above as black, white, or other. There were 121 white donors, 30 black donors, and 18 donors from other ethnic and racial groups (14 Hispanic, 3 Asian, and 1 mixed race). White recipients had significantly fewer donor–recipient race mismatches (28%) compared with blacks (83%) and others (100%) as shown in Table 1 (p <>

Immunosuppression and Rejection Surveillance

All patients had identical immunotherapy regimens regardless of race consisting of triple-drug immunosuppression. Early in this series, the patients were treated with cyclosporine, azathioprine, and a weaning dose of steroids. Efforts were made to wean off steroids entirely within a year of transplantation based on negative endomyocardial biopsies. After 1992, mycophenolate was used routinely in place of azathioprine. Induction immunotherapy was not used until 2005 when we routinely added daclizumab to the standard triple-drug therapy.

Periodic surveillance endomyocardial biopsies were performed on all patients, as were routine annual coronary arteriograms. Rejection episodes were treated with pulsed steroids. Only recurrent, refractory, or hemodynamically compromising rejection episodes were treated with monoclonal antibodies such as OKT-3. Diagnostic intravascular ultrasound of the coronary arteries was not used routinely. Some patients who had unacceptable side effects from cyclosporine or who had persistent rejection episodes were converted to tacrolimus. Calcineurin antagonist dosage therapy was adjusted according to blood levels. There were no differences by recipient race in immunosuppressant treatment strategies among the patients.

Statistics

Continuous variables were compared by analysis of variance and are presented as mean ± standard deviation. Nominal variables were compared by ² analysis with Fisher's exact test. Life-table analysis was done by the Kaplan–Meier survival method with significance determined by log-rank analysis. To determine the effect of race or donor–recipient mismatching on long-term graft or patient survival, a Cox proportional hazards regression model was constructed that modeled the hazard of graft failure (death or retransplantation) as a function of these variables adjusted for other covariates such as age, congenital heart disease, prior operation, UNOS status at time of transplant, and preoperative antibody levels. Hazard ratios, along with 95% confidence intervals, were computed for each variable in the model. The proportional hazards assumption was tested and verified for all variables using Schoenfeld residual correlation analysis. All statistical tests were considered significant if the probability value was less than 0.05.

Results

Black recipients were more likely to have a positive retrospective crossmatch (n = 26, 43%) than white recipients (n = 29, 29%) and other recipients (n = 1, 10%), but this did not achieve statistical significance (p = 0.053).

Kaplan–Meier actuarial survival curves stratified by recipient race are shown in Figure 1. White recipients tended to have better graft survival than black or other recipients, which approached statistical significance (p = 0.056). When one compares only white and black recipients, the survival differences do become statistically significant (p = 0.019 by log-rank test). Early graft survival was similar for all three groups at 30 days (white recipients 93.9%, black recipients 93.3%, other racial groups 90.0%) and at 6 months (white recipients 85.8%, black recipients 83.3%, other racial groups 90.0%), indicating that the differences in rates of graft or patient loss associated with recipient race occurred after the immediate posttransplant surgical period. The median graft survival for black recipients was 5.5 years compared with a median graft survival for white recipients of 11.6 years and a median graft survival for other recipients of 2.9 years.

View larger version (16K): [in a new window] Fig 1. Kaplan–Meier actuarial freedom from death or retransplantation (graft survival) by recipient race. The median graft survival was 11.6 years for white recipients (), 5.5 years for black recipients (), and 2.9 years for other recipients (). When the 10 nonwhite and nonblack recipients (other group) were excluded from the analysis, the graft survival for whites versus blacks was statistically different (p = 0.019).

Kaplan–Meier actuarial survival curves for donor–recipient race match and mismatch are shown in Figure 2. Freedom from death or retransplantation was significantly lower for patients who had a donor–recipient mismatch compared with those with donor–recipient match by race (p = 0.003). After excluding the 10 recipients who were neither black nor white (other racial recipient group), there were no statistically significant differences in graft survival (p = 0.33) comparing black matched recipients (n = 10) with white matched recipients (n = 71) as shown in Figure 3. Examining freedom from death or retransplantation for white and black recipients with a donor–recipient race mismatch, there was no significant difference (p = 0.69) for white mismatched recipients (n = 28) compared with black mismatched recipients (n = 50; Fig 4). The median graft survival was also similar for these donor–recipient mismatched groups (white = 4.9 years, black = 4.3 years).

View larger version (15K): [in a new window] Fig 2. Kaplan–Meier actuarial freedom from death or retransplantation (graft survival) by donor–recipient match. The median graft survival was 11.6 years for matched recipients () compared with 4.4 years for mismatched recipients ().

View larger version (14K): [in a new window] Fig 3. Kaplan–Meier actuarial freedom from death or retransplantation (graft survival) comparing white recipients () versus black recipients () who had a donor–recipient race match showing no statistical difference in graft survival. The 10 nonwhite and nonblack recipients (other group) were excluded from this analysis.

View larger version (15K): [in a new window] Fig 4. Kaplan–Meier actuarial freedom from death or retransplantation (graft survival) comparing white recipients () versus black recipients () who had a donor–recipient race mismatch showing no statistical difference in graft survival. The 10 nonwhite and nonblack recipients (other group) were excluded from this analysis. The median graft survival was 4.9 years for mismatched white recipients compared with 4.3 years for mismatched black recipients.

Looking at only white recipients, graft survival (freedom from death or retransplantation) tended to be worse in white recipients who received a heart from a racially mismatched donor (n = 28) compared with those who had a match between the donor race and the recipient race (n = 71; Fig 5), but this did not achieve statistical significance (p = 0.064). Analyzing only black recipients for donor–recipient match (Fig 6), those with matched donors (n = 10) did not have a statistically different survival compared with black recipients who received a mismatched donor (n = 50), although these curves may not have achieved statistical difference because of the small numbers of black matched patients.

View larger version (15K): [in a new window] Fig 5. Kaplan–Meier actuarial freedom from death or retransplantation (graft survival) comparing white recipients who had a donor–recipient race match () with white recipients who had a donor–recipient race mismatch (). Although there was a tendency to poorer graft survival in the mismatched group, this did not achieve statistical difference (p = 0.064). The median graft survival was 11.7 years for matched white recipients compared with 4.9 years for mismatched white recipients.

View larger version (14K): [in a new window] Fig 6. Kaplan–Meier actuarial freedom from death or retransplantation (graft survival) comparing black recipients who had a donor–recipient race match () with black recipients who had a donor–recipient race mismatch (). There were no statistically significant differences between the two groups although the black donor–recipient matched group was small (n = 10).

A multivariable Cox proportional hazards regression analysis was performed examining the white and black recipients (excluding the 10 recipients in the other race category). Two variables reached statistical significance (p <> race mismatch and older recipient age as a continuous variable (Table 2). Recipient race (black versus nonblack) did not achieve statistical significance in the Cox proportional hazards model (p = 0.297), suggesting that the differences in graft survival seen between blacks and whites were related to donor–recipient race mismatch rather than race per se because so few blacks received matched donors (n = 10; 17%).

View this table: [in a new window] Table 2 Multivariable Cox Proportional Hazards Regression Estimates

Although the Cox proportional hazards model suggested that increasing age was a risk factor for decreased graft survival after pediatric heart transplantation, the association was fairly weak with a hazard ratio of only 1.049 (Table 2). On further analysis, we were unable to find a statistical difference in graft survival by recipient age. The patients were divided into quartiles by age at time of transplant. The four quartiles were then compared using a Kaplan–Meier survival analysis. No significant differences in graft survival between age groups were demonstrated (log-rank p value = 0.41).

Ten of the 169 children in this study were of a race other than black or white (5 Hispanic, 4 Asian, 1 mixed race). We further analyzed the results of this study by adding these patients to the black group and comparing the groups of white recipients versus nonwhite recipients. We also grouped the nonwhite and nonblack recipients with the white recipients and analyzed black recipients versus nonblack recipients. Neither of these analyses gave statistical results that were much different from the results described above for white recipient versus black recipient.

Comment

Since the report of Opelz and colleagues [16] in 1977 showing different graft survival after kidney transplantation in patients of dissimilar ethnic background, there has been ongoing interest in the effect of race on graft and patient outcomes after transplantation. Although there are a handful of single-center experiences with adult heart transplant recipients showing no significant effect of race on patient survival [12, 14, 15], there are multiple reports from the adult multiinstitutional Cardiac Transplant Research Database that do show a significant impact of black race on mortality after cardiac transplantation [3, 6]. There are also some single-institution studies that have shown a detrimental effect of black race on graft survival in adults after cardiac transplantation [2, 7]. Other studies from the Cardiac Transplant Research Database show that black race is a risk factor for earlier time to first rejection [4], incidence of late rejection [10], and rejection with hemodynamic compromise [9]. Further reports from the Cardiac Transplant Research Database have shown that blacks are more prone to develop obesity after cardiac transplantation, which has been shown to be a risk factor for late mortality [17], as well as being more likely to experience angiographically significant coronary artery disease, which is also a risk factor for mortality [11].

Looking at the pediatric heart transplant population, Leman and colleagues [13] reported no association of race with mortality in their series of 152 pediatric transplants. On the other hand, we previously have reported a significant disparity in outcomes of black pediatric heart transplant recipients compared with nonblack recipients, when looking at the UNOS database [1]. In this paper, we were unable to show an unfavorable association with lower income or socioeconomic status. Lee and associates [18] also looked at the UNOS database and found that blacks had a higher incidence of renal failure after pediatric cardiac transplantation. This has been associated with decreased survival. This was corroborated by a recent single-institution report from the University of Arkansas that also showed that blacks were more likely to develop renal failure after pediatric heart transplantation [19].

Rejection also seems to be more common in black pediatric heart transplant recipients. Studies from the Pediatric Heart Transplant Study group have shown that blacks are at greater risk for recurrent rejection [20], late rejection [21], and severe rejection associated with hemodynamic compromise [22]. Rejection with heart failure after pediatric cardiac transplantation has also been shown to be more common in blacks as reported by the St. Louis group [23].

It is not entirely clear why blacks fare more poorly after cardiac transplantation, although there are multiple theories. Although it has been suggested that socioeconomic factors play a role, our review of the UNOS database did not demonstrate that this was statistically significant [1]. Experience with adult patients has shown that black heart transplant recipients are more likely to have a high donor–recipient HLA mismatch [4, 7, 8]. Interestingly, in the adult Cardiac Transplant Research Database analysis, although white patients with fewer HLA mismatches had a longer time to first rejection, the black patients had a shorter time to first rejection compared with white recipients regardless of whether they had few or many HLA mismatches [4]. It has been suggested that blacks have a greater heterogeneity of their major HLA antigens to account for this difference [24].

Along these lines, a recent multicenter study looking at 364 pediatric heart transplant recipients at six centers showed that African Americans have a genetic background that may predispose to proinflammatory or a lower regulatory environment as measured by the presence of single-nucleotide polymorphisms [25]. These authors suggested that blacks may have a genetic predisposition to an unfavorable transplant environment, which can also affect the pharmacokinetics of immunosuppressive drug therapy. This has also been suggested by Mehra and colleagues [26, 27] from the Ochsner Clinic, who showed that adult black heart transplant recipients treated with cyclosporine fared worse than whites. When the immunosuppressive regimen in the blacks was changed to tacrolimus and mycophenolate, the survivals between blacks and whites were equivalent.

In the current study, we too showed unfavorable graft survival in black pediatric heart transplant recipients. On further analysis, this difference was neutralized when one takes into consideration whether or not the race of the donor and the race of the recipient were matched or mismatched (Fig 2). On Cox proportional hazards testing, the effect of recipient race was completely overshadowed by donor–recipient mismatching. Importantly, even whites who received donor–recipient mismatched organs had inferior graft survival compared with whites who received matched organs (Fig 5), although this did not achieve statistical significance (p = 0.064) in our patient set.

The data from this study cannot with certainty explain this large difference in graft survival based on donor–recipient racial matching. One can certainly speculate as to the cause. Certainly, as has been mentioned above, HLA matching does appear to influence survival after cardiac transplantation [4, 7, 8]. It makes sense that donors and recipients from the same racial group would more likely have more similar HLA antigens than those from mismatched groups and therefore experience less rejection, which could translate into better graft and patient survival. In our series, black recipients tended to have a higher incidence of a positive retrospective crossmatch compared with white recipients (43% versus 29%; p = 0.053), supporting the theory that the graft survival differences can be attributed to immunologic factors.

When one looks at donor–recipient racial matching, the difference between black recipients and white recipients is even more striking (10% versus 72%; p <> part, this is related to the fact that although blacks constituted 36% of our recipients, only 18% of the donors were black, making it much more likely that a black would receive a mismatched heart. One could speculate that the reason for the negative effect of donor–recipient racial mismatching has to do with increased likelihood of rejection and consequently graft loss. An early paper by Park and colleagues [7] from the Medical College of Virginia looking at adult male cardiac transplant recipients reported that blacks had much worse survival than whites. It is worth noting that only one of their 76 black recipients had a black donor. In contrast, other studies (including our review of the UNOS database) have shown no significant effect of donor–recipient race mismatch on pediatric heart transplant survival [1, 12].

In conclusion, this retrospective review of our experience with 169 pediatric primary heart transplant recipients has shown a significant decrease in graft survival in black patients. This effect seems to be explainable mostly by donor–recipient racial mismatches. These data may have implications for future donor allocation schemes. Certainly, it gives impetus to efforts to expand black organ donation in hopes of reducing the incidence of donor–recipient racial mismatching.

Discussion

DR JAMES K. KIRKLIN (Birmingham, AL): I would like to congratulate Dr Kanter and his colleagues on a very elegant presentation and a nice analysis that further elucidates the potential impact of race on outcome after cardiac transplantation. Their finding of race mismatch as a risk factor is provocative in terms of potential allocation algorithms, but I would like to suggest at least a cautionary note based on our own analysis of a large multiinstitutional database. Although recipient black race has consistently been identified as a risk factor for both overall mortality and fatal rejection, we have not been able to identify either donor race or donor–recipient race mismatch as a risk factor.

(Slide) This is a depiction of freedom from late rejection in a large database, and one can see that the greatest freedom from late rejection is in nonblack recipients, irrespective of the race of the donor, and the worst freedom from late rejection, at least in this analysis, was in black recipients, again, irrespective of donor race.

Examination of data on over 2,000 patients over a 13-year period indicates that the best survival was in white recipients, 79% and 77%, irrespective of the donor race, and the worst survival at 5 years was among black recipients, again, irrespective of donor race.

Furthermore, the impact of black race as a risk factor has gradually decreased over the years. Solution of a multivariable equation for fatal rejection indicates that in 1990 there was a great impact of black recipient race, which has gradually decreased over the following decade.

So for Dr Kanter I have three questions. In view of the differences between your findings, with a high proportion of African American recipients and the overall PHTS (Pediatric Heart Transplant Study) database, did you examine the possibility of an era effect, that is, could the effect of racial matching be less apparent in the current era?

Secondly, did you find any differences in the causes of death in your four groups, which could shed light on possible mechanisms?

And third, given the likely immunologic basis, as you stated, for the decrease in black recipient survival, have you adopted any specific immunosuppression strategies to improve their survival?

I would like to thank the Society very much for discussing this excellent paper.

DR KANTER: Thank you, Jim. I certainly cannot argue with the larger multiinstitutional database from the Pediatric Heart Transplant Study Group. However, I cannot resolve the differences between those findings and the findings that we had, which were particularly striking. One thought that I may have is that perhaps the genetic milieu of the African American population in the South is perhaps more homogeneous and different from the white patients than it is in other parts of the country. Certainly the UCLA group has shown no effect of donor or recipient race after pediatric transplantation, and one wonders if we are dealing with more heterogeneous HLA antigens.

As far as era effect is concerned, we did look at the early era versus later era divided by 50% and saw no effect on the analysis.

We did not analyze the causes of death or graft failure specifically, but the vast majority of the patients died either of acute or chronic rejection or required retransplantation for transplant coronary artery disease or graft dysfunction. Remember that 29 of our patients had retransplantation. These retransplants were excluded from the analysis since we looked at only primary transplantation.

Finally, have we modified our immunosuppressive regimen in these patients? Actually this analysis is only 6 months old and we are still trying to determine how to change our therapy. There is a series of papers from the Ochsner Clinic in Louisiana that suggests that blacks do better with tacrolimus as compared with cyclosporine, and perhaps that is a strategy that we should adopt.

References

1. Mahle WT, Kanter KR, Vincent RN. Disparities in outcome for black patients after pediatric heart transplantation J Pediatr 2005;147:739-743.[Medline]
2. Felkel TO, Smith AL, Reichenspurner HC, et al. Survival and incidence of acute rejection in heart transplant recipients undergoing successful withdrawal from steroid therapy J Heart Lung Transplant 2002;21:530-539.[Medline]
3. Higgins R, Kirklin JK, Brown RN, et al. To induce or not to induce: do patients at greatest risk for fatal rejection benefit from cytolytic induction therapy? J Heart Lung Transplant 2005;24:392-400.[Medline]
4. Jarcho J, Naftel DC, Shroyer TW, et al. Influence of HLA mismatch on rejection after heart transplantation: a multiinstitutional study. The Cardiac Transplant Research Database Group. J Heart Lung Transplant 1994;13:583-595.[Medline]
5. Kirklin JK, Naftel DC, Bourge RC, et al. Evolving trends in risk profiles and causes of death after heart transplantation: a ten-year multi-institutional study J Thorac Cardiovasc Surg 2003;125:881-890.[Abstract/Free Full Text]
6. Lubitz SA, Baran DA, Alwarshetty MM, et al. Improved survival with statins, angiotensin receptor blockers, and steroid weaning after heart transplantation Transplant Proc 2006;38:1501-1506.[Medline]
7. Park MH, Tolman DE, Kimball PM. Disproportionate HLA matching may contribute to racial disparity in patient survival following cardiac transplantation Clin Transplant 1996;10:625-628.[Medline]
8. Park MH, Tolman DE, Kimball PM. The impact of race and HLA matching on long-term survival following cardiac transplantation Transplantation Proc 1997;29:1460-1463.[Medline]
9. Mills RM, Naftel DC, Kirklin JK, et al. Heart transplant rejection with hemodynamic compromise: a multiinstitutional study of the role of endomyocardial cellular infiltrate. Cardiac Transplant Research Database. J Heart Lung Transplant 1997;16:813-821.[Medline]
10. Stehlik J, Starling RC, Movsesian MA, et al. Utility of long-term surveillance endomyocardial biopsy: a multi-institutional analysis J Heart Lung Transplant 2006;25:1402-1409.[Medline]
11. Costanzo MR, Naftel DC, Pritzker MR, et al. Heart transplant coronary artery disease detected by coronary angiography: a multiinstitutional study of preoperative donor and recipient risk factors. Cardiac Transplant Research Database. J Heart Lung Transplant 1998;17:744-753.[Medline]
12. Cohen O, De La ZD, Beygui RE, Hekmat D, Laks H. Ethnicity as a predictor of graft longevity and recipient mortality in heart transplantation Transplant Proc 2007;39:3297-3302.[Medline]
13. Leman NR, Levi DS, Alejos JC, Wetzel GT. Predictors of graft longevity in pediatric heart transplantation Pediatr Cardiol 2005;26:762-767.[Medline]
14. Moore DE, Feurer ID, Rodgers Jr S, et al. Is there racial disparity in outcomes after solid organ transplantation? Am J Surg 2004;188:571-574.[Medline]
15. Radovancevic B, Konuralp C, Vrtovec B, et al. Factors predicting 10-year survival after heart transplantation J Heart Lung Transplant 2005;24:156-159.[Medline]
16. Opelz G, Mickey MR, Terasaki PI. Influence of race on kidney transplant survival Transplant Proc 1977;9:137-142.[Medline]
17. Grady KL, Naftel D, Pamboukian SV, et al. Post-operative obesity and cachexia are risk factors for morbidity and mortality after heart transplant: multi-institutional study of post-operative weight change J Heart Lung Transplant 2005;24:1424-1430.[Medline]
18. Lee CK, Christensen LL, Magee JC, Ojo AO, Harmon WE, Bridges ND. Pre-transplant risk factors for chronic renal dysfunction after pediatric heart transplantation: a 10-year national cohort study J Heart Lung Transplant 2007;26:458-465.[Medline]
19. Sachdeva R, Blaszak RT, Ainley KA, Parker JG, Morrow WR, Frazier EA. Determinants of renal function in pediatric heart transplant recipients: long-term follow-up study J Heart Lung Transplant 2007;26:108-113.[Medline]
20. Chin C, Naftel DC, Singh TP, et al. Risk factors for recurrent rejection in pediatric heart transplantation: a multicenter experience J Heart Lung Transplant 2004;23:178-185.[Medline]
21. Webber SA, Naftel DC, Parker J, et al. Late rejection episodes more than 1 year after pediatric heart transplantation: risk factors and outcomes J Heart Lung Transplant 2003;22:869-875.[Medline]
22. Pahl E, Naftel DC, Canter CE, Frazier EA, Kirklin JK, Morrow WR. Death after rejection with severe hemodynamic compromise in pediatric heart transplant recipients: a multi-institutional study J Heart Lung Transplant 2001;20:279-287.[Medline]
23. Flippin MJ, Balzer DT, Murphy PR, et al. Rejection with heart failure after pediatric cardiac transplantation Ann Thorac Surg 1999;68:176-180.[Abstract/Free Full Text]
24. Lazda VA. The impact of HLA frequency differences in races on the access to optimally HLA-matched cadaver renal transplants. The Medical Advisory Committee. Transplantation 1992;53:352-357.[Medline]
25. Girnita DM, Webber SA, Ferrell R, et al. Disparate distribution of 16 candidate single nucleotide polymorphisms among racial and ethnic groups of pediatric heart transplant patients Transplantation 2006;82:1774-1780.[Medline]
26. Mehra MR, Uber PA, Scott RL, Prasad AK, Park MH. Racial differences in clinical outcome using tacrolimus and mycophenolate mofetil immunosuppression in heart transplantation Transplant Proc 2001;33:1613-1614.[Medline]
27. Mehra MR, Uber PA, Scott RL, Park MH. Ethnic disparity in clinical outcome after heart transplantation is abrogated using tacrolimus and mycophenolate mofetil-based immunosuppression Transplantation 2002;74:1568-1573.[Medline]

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Consequences of Race-Mixing

By Dr. Ed Fields

All of organized society trumpets the tremendous growth of a once-unheard of phenomenon in America the appalling surge in the number of racially mixed couples and their inter-racial offspring. Movies, television, magazines, newspapers, ministers and popular music all promote this new mixing of the bloods. What is behind this great wave of inter racial breeding? Is it good for America, the White race or your children? Are there ulterior motives behind this massive campaign to boost this previously forbidden activity? Is it something that responsible citizens should promote or oppose? As late as 1950, mixed marriage between Whites and Negroes (or Asiatics) was banned in the following states: Ale. Ariz. Ark. Calif. Cole. Del. Fla,. Ga. Id. Ind. Ky. La. Md. Miss. Mo. Mont. Nebr. Nev. N.C. N.D. Okla. Ore. S.C. S.D. Tenn. Tex. Ut. Va. W.Va and Wyo. This ban continued in the southern states until outlawed by a liberal Supreme Court on June 12, 1967. In order to better understand the debate on the desirability of inter-racial breeding, one should understand several terms totally censored from the English language today:

1. Mongrelization: The inter-breeding of different races into a hybrid (mixed) race.
2. Miscegenation: Same definition as above, used to describe the many now, invalid state laws prohibiting White / Black liaisons.
3. Mulatto: The offspring of a White/Black inter racial couple (half Negro).
4. Quadroon: Person who has one black grandparent (one-fourth Negro).
5. Octoroon: Person having one Black great grandparent (one-eighth Negro).
6. Dysgenics: (or down-breeding): The process of increased negative genetic changes (retrogression) in a species. An example being an intelligent high l.Q. White woman giving birth to a low I.Q. mulatto baby.

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To young people of the late 1990's, it seems Inconceivable that all of organized society once actively opposed the mating of Whites with non-Whites. Those few who dared voice support for such an abomination were generally regarded as depraved crack pots. Most states had Anti-Miscegenation laws that forbade sexual relations between the races. One could be imprisoned for mating outside of the White race. This changed with Franklin Roosevelt and the onset of the Civil Rights era. In 1967, the U.S. Supreme Court invalidated all state laws forbidding inter racial marriage. From that time on, there has been an ever growing campaign in the popular culture to promote and expand this irreversible race-mixing

Why?

Inter-Racial Breeding Threatens All

Some might ask: Why should the government ever have regulated the behavior of two consenting individuals?
Do they not have the right to mate with whomever they choose?
Our forefathers recognized the vast gulf which exists between the White and Black races in terms of equality. They recognized the Negro African race to be an inferior race, child-like, capricious, impulsive and cruel, yet useful for manual labor under the constant direction of the White man. They also recognized the inherent danger in the presence of a large Negro population in contact with Whites because it invariably leads to inter racial sexual relations. They saw the hideous results of low-class White men mating with plantation negro females. They knew that every civilization in history that had used Negro slaves eventually succumbed to the corruption of inter racial breeding, leading to the collapse of that society. Therefore, the founders of America passed laws forbidding White-Black marriage. This was the real motivation behind the segregation laws which existed in the pre civil rights era South. They did not want their civilization to decay and fall due to inter breeding with inferior racial stock!

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Problems of Mixed Couples

1. Black males are 20 times more likely to be bi-sexual than are White males. They are also many times more likely to be users of intravenous drugs than are Whites. The obvious implication here is that the White female who chooses a non-White mate drastically increases her chances of exposure to the dread HIV-AIDS plague and the hideous death that inevitably follows. According to medical sources in 1996, one out of every 33 young Black males is infected with AIDS in comparison to one in 100 young males as a whole. Were this one fact common knowledge, inter racial mating would cease overnight!
2. Negro genes are dominant over that of the White by a four-to-one ratio. This means that any offspring from such a union will always favor the Black parent, even if the Black parent is not a full-blooded Negro.
3. Domestic violence is far more prevalent among mixed couples than among Whites. We need only to cite the O.J. Simpson-Nicole Brown marriage as evidence for this. White parents will often dis-own a child who enters into an inter-racial relationship. They are in fact despised by the general public of both races.
4. When an inter racial baby is conceived, a White family line, thousands of years old, has instantly ceased to exist. In fact, one could say that the only reason an individual is White today is because all of their ancestors mated only with other Whites.
5. Inherited health problems of the Negro race, such as sickle-cell anemia, can be passed along to the mix-breed offspring of an inter racial couple.
6. The low I.O. of Negroes has been scientifically proven to be hereditary. Low-I.Q. people breed only more low-I.Q. offspring and usually have large numbers of offspring, further polluting the White gene pool. Blacks score 15 to 20 I.Q. points lower than Whites on every intelligence test ever given. Blacks have brains which exhibit primitive features such as small size, light weight, and fewer convolutions ('wrinkles' linked to intelligence). For this reason, the offspring of inter racial couples will have lower intelligence than if the White partner had a child by another White person. The divorce rate of inter-racial marriages is 75%. It is believed that many who engage in mixed unions have profound emotional problems and/or are drug users. Often they seek to mock society's norms or are in rebellion against their parents.
7. The Racial Throwback: This is when one parent in a mixed marriage suddenly learns that he or she has distant black ancestors. THE TRUTH AT LAST has carried several shocking stories about 'White" couples having a black baby. One was Abraham Laing, whose daughter was born black. After her birth, he discovered that he had one mulatto grandparent.

   The book, America's Greatest Problem, by the eminent Prof. R.W. Shufeldt and published by the F.A. Davis Co. Shufeldt wrote:

"A young American artisan of excellent racial background met a pretty girl in Virginia and in due course married her. At the end of a year a boy was born. He was black as coal. The hair was kinky with all the typical Negro facial features. The mother swore that the husband was the father. He then quietly went to work to trace his wife's ancestors. After much trouble and expense, he finally ascertained that her great-grandmother was a Negro. It was in this stock, through cross breeding with Whites, that his young wife saw her pedigree. Her first child was simply a reversion to the black ancestry on her maternal side. I have heard of several other well-authenticated cases of this nature."

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What The HOLY BIBLE Says About Race Mixing

Liberal ministers have had a very difficult time reconciling the Holy Bible with their crusade to promote inter-racial marriage. Quite frankly, the Bible demands Segregation of the different races.
The Apostle Paul: Acts 17:24-28 says that God made man and hath determined the bounds of their habitation." Genesis 28:1, says that the Canaanites (blacks) were the "servants of servants" and Isaac called Jacob and said unto him, "Thou shalt not take a wife of the daughters of Canaan."
Jeremiah 13:23 stresses the fact that we can not make white people out of the Negroes in these words: "Can the Ethiopian change his skin, or the leopard his spots." This could be interpreted as a warning that Negroes could breed Whites down into mongrels but that we can never breed them up into Whites.

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Inter-Breeding of The Races Destroys Civilization

It is an historical fact that every nation in the history of the world in which the White population mixed its gene pool with that of the lower races lost its civilization. Prime examples are India, (where the Aryans interbred with the dark skinned Dravidians of the South), Egypt (where the Caucasian builders of the Pyramids inter-bred with their Nubian / Sudanese slaves) and Brazil, a nation far richer in natural resources than the U.S.
Brazil's teeming, poverty wracked northern half has self destructed due to massive racial inter-breeding. In sharp contrast, only the southern part of Brazil, with a White majority in Sao Paulo, maintains a productive society.
Carthage and the other great White civilizations of North Africa all vanished due to inter-breeding with the Negro. The great explorer Stanley stated that black history in Africa did not begin until they came in contact with the White colonial powers, who built modern civilization for them.
Today, with the withdrawal of the Whites, "African Civilization" has collapsed as brutal, superstitious and illiterate chiefs, generals and witch doctors struggle for power and a brief but violent reign as "president for life". There is not one truly freely elected leader in all of Africa.
A renowned historian, Sir Arthur Reith wrote:

"In our brief experience of the world we have never found that Negro people are gifted with inventiveness or have ever manifested a strong desire to improve their material culture." Prof. Arthur De Gobineau, in his book, The Inequality of Human Races, writes: "We look at all of the achievements of the European people and then try and find some semblance of a civilization in black Africa. We are unable to find any advanced art, science, religion, morality, philosophy, history or even one single civilization"

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Great Men Speak On Inter racial Marriage

Abraham Lincoln, in his debate with Senator Douglas at Quincy, IL, on Oct. 13, 1858 and quoted in Abraham Lincoln - Complete Works, published by The Century Co., 1894, Vol. I, page 273 stated:

"I will say, then, that I am not, nor ever have been, in favor of bringing about in any way the social and political equality of the White and Black races - that I am not, nor ever have been, in favor of making voters or jurors of Negroes - nor of qualifying them to hold office, nor to inter-marry with White people; and I will say in addition to this that there is a physical difference between the White and Black races which will ever forbid the two races living together on terms of social and political equality, and in as much as they cannot so live, while they do remain together, there must be the position of superior and inferior, and I, as much as any other man, am in favor of having the superior position assigned to the White race."

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Take Your Choice - Separation or Mongrelization

Senator Theodore G, Bilbo, of Mississippi wrote the famous book with the aforementioned title just prior to his death in 1947. Sen. Bilbo called for a permanent solution to the Negro problem. Like Lincoln, he said that they should be repatriated back to Africa. He said that race was "America"s greatest problem." Bilbo warned that by allowing integration to proceed, the amalgamation of the races would result.

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Communist Party and Roosevelt Promoted Race-Mixing

The inter racial breeding of the races was not promoted as an issue until Roosevelt became President with Communist Party support. Roosevelt issued the first "civil rights law" on June 25, 1941 in the form of Executive Order No. 8802. This established the Fair Employment Practice Committee (FEPC). It banned discrimination based on "race, color or creed" among all private businesses receiving defense contracts.
His wife Eleanor was the first prominent White woman to join the NAACP. She was also the first to approve inter racial marriage in a speech to Negro students at Howard University. She said: "Marriage between Whites and Negroes is an individual and personal matter. I would never say yes or no to inter marriage." She also opposed Sen. Bilbo"s repatriation plan which led him to offer her the position of "Queen of Liberia".
Communist Party chairman Earl Browder supported the Roosevelts and issued this statement: "We must, as a war necessity, proceed to the systematic and relentless wiping out of every law, custom and habit of thought, which in flagrant violation of our Constitution enforces an unequal status between Negro and White citizens.
Famous scientists warned that inter racial breeding would lower the quality of the White Race. It is known that the Negro has an I.Q. 15 to 20 points lower than the average White and this is an inherited trait. Their racial features are those of primitive man, such as:

1. The Negro arms are two inches longer than the White.
2. The Negro jaw juts forward giving him a facial angle of 70%, compared with the White of 82%.
3. The Negro skull is thicker and their brain weighs 1249 grams compared to 1380 far the White.
4. The mouth, jaw and teeth are much larger than the White.
5. The skin is thicker and their sweat glands emit a strong oder when perspiring. The body is mostly hairless.
6. The mouth has thick protruding lips, often showing the inner red mucus membrane inside the mouth. Likewise, the flat nose in pure Negroes has the nostril often showing the inner red mucus membrane.
7. The eyes are always black and the white part frequently is tinged with yellow. At birth, the Negro skull sutures close much earlier than any other race which retards the development of the fore brain - where the centers of intelligence lie.

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Inter racial Breeding Destroys The White Race

Race Traits and Tendencies, by Dr. F.L. Hoffman, found that:

"The mulatto may be superior to the Negro but he certainly is inferior to the Caucasian in intellectual ability. At best, amalgamation can improve the Negro only at the expense of the White race. Amalgamation is not, therefore, desirable on scientific grounds."

The Corruption of The Blood, by Prof. W.B. Smith states that:

"Who, then, would have the fool hardiness to make this experiment of race amalgamation - an experiment which , once made, is made forever, whose consequences could never be undone - when there is, at least, and at the very lowest, an undeniable possibility, not to say a certainty, that those consequences would be disastrous in the extreme? Can we imagine a more wanton folly ? Would such an experiment be seen any other place so well as in a madhouse ?"

Sen. Theodore G. Bilbo summed up every argument on how inter racial marriage will destroy America"s civilization with the words;

"Take Your Choice - Separation or Mongrelization."

"If our buildings, our highways, our railroads should be wrecked, we could rebuild them. If our cities should be destroyed, out of the very ruins we could erect newer and greater ones. Even if our armed might should be crushed, we could rear sons who would redeem our power. But if the blood of our White race should become corrupted and mingled with the blood of Africa, then the present greatness of the United States would be destroyed and all hope for the future would be forever lost. The maintenance of American civilization would be as impossible for a negroid America as would be the redemption and restoration of the White man's blood which has been mixed with that of the Negro."

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Let our slogan be - Whites should mate only with Whites for the preservation and expansion of nature"s finest - The White Race!

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