Deceased donor kidney and liver transplantation to nonresident aliens in the United States

Distinct Phenotypes of Non-Citizen Kidney Transplant Recipients in the United States by Machine Learning Consensus Clustering

BACKGROUND

Better understanding of the different phenotypes/subgroups of non-U.S. citizen kidney transplant recipients may help the transplant community to identify strategies that improve outcomes among non-U.S. citizen kidney transplant recipients. This study aimed to cluster non-U.S. citizen kidney transplant recipients using an unsupervised machine learning approach; Methods: We conducted a consensus cluster analysis based on recipient-, donor-, and transplant- related characteristics in non-U.S. citizen kidney transplant recipients in the United States from 2010 to 2019 in the OPTN/UNOS database using recipient, donor, and transplant-related characteristics. Each cluster's key characteristics were identified using the standardized mean difference. Post-transplant outcomes were compared among the clusters; Results: Consensus cluster analysis was performed in 11,300 non-U.S. citizen kidney transplant recipients and identified two distinct clusters best representing clinical characteristics. Cluster 1 patients were notable for young age, preemptive kidney transplant or dialysis duration of less than 1 year, working income, private insurance, non-hypertensive donors, and Hispanic living donors with a low number of HLA mismatch. In contrast, cluster 2 patients were characterized by non-ECD deceased donors with KDPI <85%. Consequently, cluster 1 patients had reduced cold ischemia time, lower proportion of machine-perfused kidneys, and lower incidence of delayed graft function after kidney transplant. Cluster 2 had higher 5-year death-censored graft failure (5.2% vs. 9.8%; p < 0.001), patient death (3.4% vs. 11.4%; p < 0.001), but similar one-year acute rejection (4.7% vs. 4.9%; p = 0.63), compared to cluster 1; Conclusions: Machine learning clustering approach successfully identified two clusters among non-U.S. citizen kidney transplant recipients with distinct phenotypes that were associated with different outcomes, including allograft loss and patient survival. These findings underscore the need for individualized care for non-U.S. citizen kidney transplant recipients.

Pediatric kidney transplant in undocumented immigrants: An American perspectives

Kidney transplant in undocumented immigrants remains controversial. While in the United States the National Organ Transplant Act does not prohibit inclusion of these patients as transplant candidates, legislative and financial barriers and ethical concerns remain. The purpose of this article was to review the legal and financial barriers to kidney transplant for children with ESKD who are undocumented immigrants and consider arguments for and against inclusion of these children as kidney transplant candidates. While this discussion is largely restricted to the experience in the United States and its unique healthcare system, the themes and ideas may be more generalizable to the experience in many high-income countries. We conclude that access to kidney transplant is legal, ethically justifiable, and clearly in the best interest of these children. Transplant professionals should continue to advocate for changes in policy and greater resources to support these patients.

Biomarkers of Renal Injury in Cirrhosis: Association with Acute Kidney Injury and Recovery after Liver Transplantation

BACKGROUND

To define urine or serum biomarkers in predicting renal function recovery after liver transplantation (LT).

METHODS

Adults listed for LT (February 2011-July 2014) and with modified diet for renal disease-6 (MDRD-6) <60 mL/min provided urine/blood samples at baseline and serially until LT for biomarkers in serum (pg/mL) and urine (pg/mg creatinine).

RESULTS

Of 271 LT listed patients (mean age 57 years, 63% males, median listing MELD 17.5), 1 year acute kidney injury (AKI) probability was 49%, with odds of 1.3-, 3.0-, 4.6-, and 8.5-fold times for listing MELD 16-20, 21-25, 26-30, and >30, compared to MELD <16. Thirty-seven people died over 1 year from the time of listing, with twofold increased odds with AKI. Among 67 patients with MDRD <60, only urinary epidermal growth factor was different comparing AKI (increase in serum creatinine ≥0.3 mg/dL from baseline within past 3 months) vs. no AKI (2,254 vs. 4,253, p = 0.003). Differences between acute tubular necrosis (ATN) and hepatorenal syndrome could not be ascertained for a small sample of 3 patients with ATN. Analyzing 15 of 43 receiving LT and MDRD-6 <30 prior to LT, biomarkers were not different comparing 5 patients recovering renal function (MDRD-6 >50 mL/min) at 6 months vs. 10 without recovery.

CONCLUSIONS

AKI is common among LT listed patients, with a negative impact on transplant-free survival. Serum and urine biomarkers are not associated with the recovery of renal function after LT. Multicenter studies are suggested to (a) develop strategies to reduce the development of AKI and (b) derive novel biomarkers for use in accurately predicting renal recovery after LT.

Liver Allocation to Non-U.S. Citizen Non-U.S. Residents: An Ethical Framework for a Last-in-Line Approach

The incidence of non-U.S. citizen non-U.S. resident patients coming to the United States specifically for deceased donor liver transplantation raises compelling ethical questions that require careful consideration. The inclusion of these often financially and/or socially privileged patients in the pool of potential candidates for an absolutely scarce and life-saving liver transplant may exacerbate disparities already existing in deceased donor liver allocation. In addition, their inclusion on organ transplant waiting lists conflicts with recognized ethical principles of justice and reciprocity. Moreover, preliminary data suggest that public awareness of this practice could discourage organ donation, thereby worsening an already profound supply-demand gulf. Finally, U.S. organ allocation policies and statutes are out of step with recently promulgated international transplant guidelines, which prioritize self-sufficiency of organ programs. This article analyzes each of these ethical conflicts within the context of deceased donor liver transplantation and recommends policy changes that align the United States with international practices that discourage this scenario.

Should we perform kidney transplants on foreign nationals?

In Canada, there are currently no guidelines at either the federal or provincial level regarding the provision of kidney transplantation services to foreign nationals (FN). Renal transplant centres have, in the past, agreed to put refugee claimants and other FNs on the renal transplant waiting list, in part, because these patients (refugee claimants) had health insurance through the Interim Federal Health Programme to cover the costs of medication and hospital care. However, severe cuts recently made to this programme have forced clinicians to question whether they should continue with transplants for FNs, for financial and ethical reasons. This paper first examines different national policies (eg, in Canada, USA, France and the UK) to map the diversity of approaches regarding transplantation for FNs, and then works through different considerations commonly used to support or oppose the provision of organs to these patients: (1) the organ shortage; (2) the free-rider problem; (3) the risk of becoming a transplant destination; (4) the impact on organ donation rates; (5) physicians' duties; (6) economic concerns; (7) vulnerability. Using a Canadian case as a focus, and generalising through a review of various national policies, we analyse the arguments for and against transplantation for FNs with a view to bringing clarity to what is a sensitive political and clinical management issue. Our aim is to help transplant centres, clinicians and ethicists reflect on the merits of possible options, and the rationales behind them.

Transplant tourism: a modern iteration of an ancient problem

PURPOSE OF REVIEW

To explore the scope and implications of emerging global problem of transplant tourism, a practice in which patients seek transplant services (most commonly kidney allografts) in countries other than their permanent residence. Potential remedies that must be implemented if abuses are to be curbed are also offered.

RECENT FINDINGS

Although traveling abroad for medical services may not be problematic from a number of perspectives, what makes transplant tourism so troubling is its link with organ trafficking and transplant commercialism. Unlike many illegal markets, however, this one is driven by the need of patients with irreversible kidney failure, who, along with kidney vendors, are the most vulnerable participants in the process in terms of medical and financial outcomes.

SUMMARY

This review explores the scope and implications of transplant tourism, and offers potential remedies that must be implemented if abuses are to be curbed.

Sharing organs with foreign nationals

Organs for transplantation are an absolute scarcity throughout the world, and many countries do not offer transplantation. Developed countries with transplant programs receive requests to list foreign nationals for transplantation. Any national standard deserves justification by a thorough exploration of the issues. In this article, the issues regarding organ transplantation for foreign nationals in Canada are explored. Currently Canada has no policy on listing foreign nationals for transplantation. Three topics are reviewed: (1) arguments for and against the transplantation of organs from deceased donors to foreign nationals, (2) relevant legislation and position statements, and (3) relevant practices in other countries. Finally, practical policy options are suggested. This article's analysis of the issues will provide guidance for health care professionals and policy makers in Canada and developed countries exploring listing foreign nationals for transplantation.

Sharing Organs with Foreign Nationals

Organs for transplantation are an absolute scarcity throughout the world, and many countries do not offer transplantation. Developed countries with transplant programs receive requests to list foreign nationals for transplantation. Any national standard deserves justification by a thorough exploration of the issues. In this article, the issues regarding organ transplantation for foreign nationals in Canada are explored. Currently Canada has no policy on listing foreign nationals for transplantation. Three topics are reviewed: (1) arguments for and against the transplantation of organs from deceased donors to foreign nationals, (2) relevant legislation and position statements, and (3) relevant practices in other countries. Finally, practical policy options are suggested. This article's analysis of the issues will provide guidance for health care professionals and policy makers in Canada and developed countries exploring listing foreign nationals for transplantation.

Trend and outcome of Korean patients receiving overseas solid organ transplantation between 1999 and 2005

The disparity between patients awaiting transplantation and available organs forced many patients to go overseas to receive a transplant. Few data concerning overseas transplantation in Korea are available and the Korea Society for Transplantation conducted a survey to evaluate the trend and outcome of overseas transplantation. The survey, conducted on June 2006, included 25 hospitals nationwide that followed up patients after receiving kidney transplant (KT) or liver transplant (LT) overseas. The number of KT increased from 6 in 2001 to 206 in 2005 and for LT from 1 to 261. The information about overseas transplant came mostly from other patients (57%). The mean cost for KT was $21,000 and for LT $47,000. Patients were admitted for 18.5 days for KT and 43.4 days for LT. Graft and patient survival was 96.8% and 96.5% for KT (median follow up 23.1 months). Complication occurred in 42.5% including surgical complication (5.3%), acute rejection (9.7%) and infection (21.5%). Patient survival for LT was 91.8% (median follow up 21.2 months). Complication occurred in 44.7% including 19.4% biliary complication. Overseas KT and LT increased rapidly from 2001 to 2005. Survival of patients and grafts was comparable to domestic organ transplantation, but had a high complication rate.

Medical tourism

Searches of the literature or Internet using the term "medical tourism" produce two sets of articles: travel for the purpose of delivering health care or travel for the purpose of seeking health care. The first usage primarily appears in the medical literature and is beyond the scope of this article, which focuses on travel to seek health care. Still, there are some aspects these two topics have in common: both are affected by ease and speed of international travel and communication associated with globalization, and both raise questions about continuity of care as well as issues related to cultural, language, and legal differences; both also raise questions about ethics. This article describes some of the motivating factors, contributing elements, and challenges in elucidating trends, as well as implications for clinicians who provide pretravel advice and those who care for ill returning travelers.