Transplants in Foreign Countries Among Patients Removed from the US Transplant Waiting List

Effect of citizenship status on access to pediatric liver and kidney transplantation

Transplantation of non-US citizen residents remains controversial. We evaluate national trends in transplant activity among pediatric noncitizen residents (PNCR). Pediatric liver and kidney transplant data were obtained from the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. Data on transplanted organs, region, waitlist additions, procedures, and citizenship status were analyzed from 2012-2022. Rates of PNCR transplantation activity were compared with population rates from the US Census Bureau. On average, 713 ± 47 pediatric liver and 1039 ± 51 kidney patients were added to the waitlist, with 544 ± 32 liver and 742 ± 33 kidney transplants performed annually. Of these, PNCR comprised 1.5% and 3.3% of liver and kidney waitlist additions and 1.5% and 2.9% of liver and kidney transplant procedures, respectively. There were no significant changes in waitlist or transplant activity nationwide over the study period. There was a significant geographic variation in the percentage of waitlist additions and transplants across the United Network for Organ Sharing regions among the PNCR for liver and kidney transplantation. This is the first study to evaluate national trends in transplantation activity among PNCRs. The significant regional variation in transplantation activity for PNCR may suggest multilevel structural and systemic barriers to transplant accessibility.

International Travel for Liver Transplantation: A Comprehensive Assessment of the Impact on the United States Transplant System

BACKGROUND

International travel for transplantation remains a global issue as countries continue to struggle in establishing self-sufficiency. In the United States, the United Network for Organ Sharing (UNOS) requires citizenship classification at time of waitlisting to remain transparent and understand to whom our organs are allocated. This study provides an assessment of patients who travel internationally for liver transplantation and their outcomes using the current citizenship classification used by UNOS.

METHODS

Adult liver UNOS data from 2003 to 2019 were used. Patients were identified as citizens, noncitizen, nonresidents (NCNR), or noncitizen residents (NC-R) according to citizenship status. Descriptive statistics compared demographics among the waitlisted patients and demographics and donor characteristics among transplant recipients. A competing risks model was used to examine waitlist outcomes. The Kaplan-Meier method and Cox proportional hazards were used for posttransplant outcomes.

RESULTS

There were significant demographic differences according to citizenship group among waitlisted (n = 125 652) and transplanted (n = 71 536) patients. Compared with US citizens, NCNR was associated with a 9% increase in transplant (subdistribution hazard ratio [SHR], 1.09; 95% confidence interval [CI], 1.00-1.18; P = 0.04), and NC-R was associated with a 24% decrease in transplant (SHR, 0.76; 95% CI, 0.72-0.79; P < 0.0001) and a 23% increase in death or removal for being too sick (SHR, 1.23; 95% CI, 1.14-1.33; P < 0.0001). US citizens had significantly inferior graft and patient survival (P < 0.001).

CONCLUSIONS

Though the purpose of the citizenship classification system is transparency, the results of this study highlight significant disparities in the access to and outcomes following liver transplantation according to citizenship status.

Current state of medical tourism involving liver transplantation-the risk of infections and potential complications

Liver transplant has been shown to significantly improve mortality and quality of life in various liver diseases such as acute liver failure, end-stage liver disease, and liver cancer. While the organ transplant demand is continuing to rise, the organ donation supply remains unmatched. The organ shortage, high cost, and long waiting lists have stimulated a desire for routes that may be unethical. This process which is named transplant tourism is the term used to describe traveling to another country to purchase an organ for transplant. Liver transplant tourism has been associated with post-transplant complications and higher mortality compared to a domestic liver transplant. Improper pre-and post-transplant infectious screening, inadequate opportunistic infection prophylaxis, and loss to follow-up were noted in patients who travel abroad for a liver transplant. It is crucial to understand the risk of transplant tourism to prevent morbidity and mortality.

Infectious Complications of Transplant Tourism

PURPOSE OF REVIEW

To outline the impact of transplant tourism on the type and severity of post-transplant infections that may be seem in returning transplant tourists. This review outlines infections that might be expected and provides recommendations on screening tests that may assist in the diagnosis and management of such patients.

RECENT FINDINGS

Transplant tourists may develop unusual or resistant infections that pose a public health risk in their home country. The practice of transplant tourism is associated with a significantly increased risk of surgical and infectious complications after transplant. Returning transplant tourists require a thorough evaluation for active and latent infections. Transplant centers must be vigilant for new and emerging pathogens in this population.

Factors Related to International Travel for Transplantation Among U.S.-Listed Kidney Transplant Candidates

Factors related to travel for transplantation were examined using data from the Scientific Registry for Transplant Recipients. Candidates who traveled abroad for a kidney transplant had higher odds of being male, Asian or Hispanic, college-educated, employed, privately insured, and a non-U.S. citizen/non-U.S. resident. Candidates with a body mass index greater than 30, a calculated panel reactive antibody (cPRA) greater than 80%, and a history of more than two years of hemodialysis or peritoneal dialysis had lower odds of traveling abroad for a kidney transplant. Geographically, candidates listed in the northeastern region of the United States (New York and Western Vermont) had the highest odds of traveling abroad for a kidney transplant. Findings of this study can be used to guide practice and education with transplant candidates, and to direct further investigation in this understudied but growing area of transplantation.

Travel medicine, transplant tourism, and the solid organ transplant recipient-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review recommendations for prevention and management of travel-related infection in solid organ transplant (SOT) recipients as well as risks associated with transplant tourism. Counseling regarding travel post-transplant should be included during the pre-transplant evaluation, and all SOT recipients should be seen by a travel medicine specialist prior to traveling to destinations with higher rates of infection. Patients should be advised on vaccine-preventable illnesses as well as any need for prophylaxis (ie, malaria) based on their individual travel itineraries. Information with regards to specific recommendations for vaccines and prophylactic medications, along with drug-drug interactions, is summarized. Counseling should be provided for modifiable risks and exposures (ie, food and water safety, and insect bite prevention) as well as non-infectious travel topics. These guidelines also briefly address risks associated with transplant tourism and specific infections to consider if patients seek care for transplants done in foreign countries.

The Ethics of Organ Tourism: Role Morality and Organ Transplantation

Organ tourism occurs when individuals in countries with existing organ transplant procedures, such as the United States, are unable to procure an organ by using those transplant procedures in enough time to save their life. In this paper, I am concerned with the following question: When organ tourists return to the United States and need another transplant, do US transplant physicians have an obligation to place them on a transplant list? I argue that transplant physicians have a duty not to relist organ tourists. Specifically, I contend that we should locate physicians' duties in these cases within the new role of "transplant physician." This role results from transplant physicians' participation in a system that depends on organ donors' voluntary act of donation.

On Patients Who Purchase Organ Transplants Abroad

The international transplant community portrays organ trade as a growing and serious crime involving large numbers of traveling patients who purchase organs. We present a systematic review about the published number of patients who purchased organs. With this information, we discuss whether the scientific literature reflects a substantial practice of organ purchase. Between 2000 and 2015, 86 studies were published. Seventy-six of these presented patients who traveled and 42 stated that the transplants were commercial. Only 11 studies reported that patients paid, and eight described to what or whom patients paid. In total, during a period of 42 years, 6002 patients have been reported to travel for transplantation. Of these, only 1238 were reported to have paid for their transplants. An additional unknown number of patients paid for their transplants in their native countries. We conclude that the scientific literature does not reflect a large number of patients buying organs. Organ purchases were more often assumed than determined. A reporting code for transplant professionals to report organ trafficking networks is a potential strategy to collect and quantify cases.

Outcomes of Kidney Transplantation Abroad

Context:

An increasing demand for kidney transplantation has enticed some patients with end-stage renal disease (ESRD) to venture outside their country of residence, but their posttransplant outcomes may be suboptimal.

Objective:

We compared the risks and clinical outcomes among tourists, or patients who pursue a kidney transplant abroad, versus patients who received a transplant at the Toronto General Hospital (TGH).

Methods:

A single-center, 1:3 matched (based on age at transplant, time on dialysis, and year of transplant) cohort study was conducted. Forty-five tourists were matched with 135 domestic transplant recipients between January 1, 2000, and December 31, 2011. Multivariable Cox proportional hazards models were fitted to assess graft and patient outcomes.

Results:

Among the 45 tourists, the majority (38 of 45) traveled to the Middle East or Far East Asia, and most received living donor kidney transplants (35 of 45). Multivariable Cox proportional hazards models showed that tourists had a higher risk for the composite outcome of acute rejection, death-censored graft failure, or death with graft function (DWGF; hazard ratio [HR] 2.08, 95% confidence interval [CI]: 1.06-4.07). Tourists also showed a higher risk for the individual end points of acute rejection, DWGF, and posttransplant hospitalizations.

Conclusion:

Patients going abroad for kidney transplantation may have inferior outcomes compared to domestic patients receiving kidney transplants. Patients who are contemplating an overseas transplant need to be aware of the increased risk of adverse posttransplant outcomes and should be appropriately counseled by transplant professionals during the pretransplant evaluation process.

Transplant tourism: understanding the risks

Transplant tourism is commonly defined as travel abroad for the purpose of transplantation, but the term evokes ethical and legal concerns about commercial transplantation. Due to the mismatch in supply and demand for organs, transplant tourism has increased over the last several decades and now accounts for 10 % of transplants worldwide. Patients from the USA who pursue transplantation abroad do so most commonly for renal transplantation, and travel mostly to China, the Philippines, and India. Transplant tourism puts the organ recipient at risk for surgical complications, poor graft outcome, increased mortality, and a variety of infectious complications. Bacterial, viral, fungal, and parasitic infections have all been described, and most concerning are the high rates of blood-borne viral infections and invasive, often fatal, fungal infections. Transplant and infectious diseases physicians should have a high degree of suspicion for infectious complications in patients returning from transplantation abroad.

Carbapenem-resistant Enterobacteriaceae and Acinetobacter baumannii: assessing their impact on organ transplantation

PURPOSE OF REVIEW

This review highlights the impact of carbapenem-resistant Enterobacteriaceae and carbapenem-resistant Acinetobacter baumannii on patients who have undergone organ transplantation and explores both available and potential agents to treat infections caused by these multidrug-resistant (MDR) pathogens.

RECENT FINDINGS

Few antimicrobials exist to treat carbapenem-resistant Gram-negative infections, and resistance to salvage therapies is escalating. Organ transplantation appears to be a risk factor for infections with Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Isolation of these MDR bacteria is increasing and may be associated with allograft failure and mortality. In the majority of cases, aminoglycosides, polymyxins, and tigecycline have been employed to treat these infections. Anecdotal successes exist but these antibiotics may be unreliable. Few novel agents are in development.

SUMMARY

Bacterial infections remain a leading cause of posttransplantation morbidity and mortality. Carbapenem resistance is a significant threat to allograft and patient survival. With few antimicrobials being developed, transplant centers may be forced to make decisions regarding surveillance, empiric antimicrobial regimens, and transplant candidacy in the setting of carriage of MDR pathogens. There is an urgent need for collaborative studies to address the clinical impact of these infections on transplantation.

Investigation of features of patients in renal transplantation waiting list: Who wants much more of what for renal transplantation?

Background and Objective: Renal transplant is the best form of treatment for most patients with end-stage renal disease (ESRD), because that therapy improves quality of life, prolongs survival, and is cost-effective. The objective of the study being reported was to compare the sociodemographic characteristics and registration status for renal transplantation of ESRD patients in Turkey who were registered for transplant or not.

Methods: The study was conducted between June and September 2012 on patients of several Dialysis Centers. They all were informed in a one on one interview about the risks and benefits of renal transplants; they were also asked to fill out the questionnaires given to them. The study questionnaire was designed with the help of already published reports to include among others the patient’s age, sex, waiting time and educational status.

Results: Patients who had been registered in the cadaver kidney waiting list were aged 43.85±13.48 in the average, with a balanced sex ratio, average dialysis duration 57.30±51.46 months. Of these patients 45 had finished high school, 87 lived in rural areas and 67 had an income equivalent to expenses.

Conclusion: There was a significant difference among the groups depending on the patients’ residence in an urban or rural environment. Such a difference might be following the greater ease of obtaining relevant information in the urban areas.

The globalization of healthcare: implications of medical tourism for the infectious disease clinician

Travel abroad for healthcare has increased rapidly; interventions include organ transplant; cardiac surgery; reproductive care; and joint, cosmetic, and dental procedures. Individuals who receive medical care abroad are a vulnerable, sentinel population, who sample the local environment and can carry home unusual and resistant infections, documented in many reports. Medical tourists are at risk for hospital-associated and procedure-related infections as well as for locally endemic infections. Patients may not volunteer details about care abroad, so clinicians must inquire about medical procedures abroad as well as recent travel. Special infection control measures may be warranted. Healthcare abroad is associated with diverse financial, legal, ethical, and health-related issues. We focus on problems the infectious disease clinician may encounter and provide a framework for evaluating returned medical tourists with suspected infections. A better system is needed to ensure broad access to high-quality health services, continuity of care, and surveillance for complications.

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.

Key issues in transplant tourism

Access to organ transplantation depends on national circumstances, and is partly determined by the cost of health care, availability of transplant services, the level of technical capacity and the availability of organs. Commercial transplantation is estimated to account for 5%-10% (3500-7000) of kidney transplants performed annually throughout the world. This review is to determine the state and outcome of renal transplantation associated with transplant tourism (TT) and the key challenges with such transplantation. The stakeholders of commercial transplantation include: patients on the waiting lists in developed countries or not on any list in developing countries; dialysis funding bodies; middlemen, hosting transplant centres; organ-exporting countries; and organ vendors. TT and commercial kidney transplants are associated with a high incidence of surgical complications, acute rejection and invasive infection which cause major morbidity and mortality. There are ethical and medical concerns regarding the management of recipients of organs from vendors. The growing demand for transplantation, the perceived failure of altruistic donation in providing enough organs has led to calls for a legalised market in organ procurement or regulated trial in incentives for donation. Developing transplant services worldwide has many benefits - improving results of transplantation as they would be performed legally, increasing the donor pool and making TT unnecessary. Meanwhile there is a need to re-examine intrinsic attitudes to TT bearing in mind the cultural and economic realities of globalisation. Perhaps the World Health Organization in conjunction with The Transplantation Society would set up a working party of stakeholders to study this matter in greater detail and make recommendations.

Addressing the shortage of kidneys for transplantation: purchase and allocation through chain auctions

Transplantation is generally the treatment of choice for those suffering from kidney failure. Not only does transplantation offer improved quality of life and increased longevity relative to dialysis, it also reduces end-stage renal disease program expenditures, providing savings to Medicare. Unfortunately, the waiting list for kidney transplants is long, growing, and unlikely to be substantially reduced by increases in the recovery of cadaveric kidneys. Another approach is to obtain more kidneys through payment to living "donors," or vendors. Such direct commodification, in which a price is placed on kidneys, has generally been opposed by medical ethicists. Much of the ethical debate, however, has been in terms of commodification through market exchange. Recognizing that there are different ethical concerns associated with the purchase of kidneys and their allocation, it is possible to design a variety of institutional arrangements for the commodification of kidneys that pose different sets of ethical concerns. We specify three such alternatives in detail sufficient to allow an assessment of their likely consequences and we compare these alternatives to current policy in terms of the desirable goals of promoting human dignity, equity, efficiency, and fiscal advantage. This policy analysis leads us to recommend that kidneys be purchased at administered prices by a nonprofit organization and allocated to the transplant centers that can organize the longest chains of transplants involving willing-but-incompatible donor-patient dyads.

Outcomes of renal patients from the Ivory Coast transplanted abroad: time for a local kidney transplantation program

BACKGROUND

The outcomes of transplanted kidney recipients from "transplant tourism" have been reported to be alarming. The present study was an attempt to examine the results of renal patients from the Ivory Coast transplanted abroad returning home for follow-up.

PATIENTS AND METHODS

This retrospective analysis includes renal patients from the Ivory Coast transplanted abroad between 1995 and 2009 and followed up by our nephrology clinic. We collected pre- and posttransplant parameters for statistical analyses.

RESULTS

The 16 patients had a median age of 48 years (range = 32.5-53.75). The median age of kidney donors was 44 years (range = 30.75-51.25). Initial kidney disease was hypertension in 10 patients (62.5%) and diabetes in three patients (18.8%). They received organs from living donors (37.5% related [LRD] and 37.5% unrelated [LURD]). Initial immunosuppression consisted of induction (72.7%), tacrolimus (75%), and mycophenolate mofetil (100%). Two patients (12.5%) experienced late acute rejections, resulting in graft loss. The overall graft survival was 93% at 1 year and 80% at 5 years. Five patients died over the study period, corresponding to an overall mortality rate of 9.25/100 patient-years. The overall median patient survival was 6.25 years (range = 4.19-7.58). Patient survivals at 1 and 5 years were 93% and 53%, respectively. No factors seemed to influence survival (either graft or patient) upon multivariate analysis. Comparison between LRD and LURD recipients revealed no statistical difference among posttransplant characteristics and survivals.

CONCLUSION

Mortality of renal patients from the Ivory Coast transplanted abroad is high. Financial exhaustion after transplantation renders follow-up precarious. A local kidney transplantation program in the Ivory Coast appears more urgent than ever.

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.

Organ trafficking for live donor kidney transplantation in Indoasians resident in the west midlands: high activity and poor outcomes

INTRODUCTION

Some Indoasian (IA) patients with established renal failure travel abroad for commercial kidney transplantation. We compared the 1-year outcomes of IA patients from one UK region who received overseas transplants with IA patients receiving local living donor (LD) kidney transplantation, deceased donor (DD) transplantation, and dialysis.

METHODS

Between 1996 and 2006, 40 adults were transplanted overseas; 38 were IA, and follow-up data were available on 36 patients. Forty IA patients received LD transplants, and 156 patients received DD transplants locally. A cohort of 120 prospective dialysis patients was also used as a comparator group.

RESULTS

In the overseas cohort, 20 patients (56%) were not active in the UK transplant waiting list at the time of kidney transplantation overseas. One-year graft survival was 87%, and 1-year patient survival was 83%. Composite graft and patient survival was 69.5% at 1 year. In the local LD transplant recipients, patient survival was 97.5% (39 of 40; P=0.03), and graft survival was 97.5% (39 of 40; P=0.06). Composite graft and patient survival was 95% (P=0.003). In the overseas group, 42% had major infections compared with 15% in the local group (P=0.02). One-year graft survival for DD transplant was 84.6% (132 of 156), and 1-year patient survival was 93% (145 of 156; P=NS and P=0.06, respectively). In the dialysis group, 1-year patient survival was 96.7% (116 of 120; P=0.001).

CONCLUSION

IA patients who choose to travel overseas for kidney transplantation have poor clinical outcomes and should be counseled accordingly.

Transplant tourism

PURPOSE OF REVIEW

Because of the ongoing organ donor shortage, transplant tourism is occurring at an increasing rate both in the USA and abroad. To date, there have been little published data to help guide the programmatic philosophy of the USA transplant centers regarding transplant tourism.

RECENT FINDINGS

We summarize position statements from several transplant societies regarding transplant tourism and specifically transplantation occurring in China (because of the use of executed prisoners as organ donors). Transplant tourism is ever increasing and patients may be at risk for greater post-transplant morbidity as well as inadequate follow up care. Transplant centers require some guidance with regard of how to deal with these patients.

SUMMARY

Transplant tourism is an increasing reality facing the USA transplant centers. Most professional societies do not condone it yet cannot abrogate a physician's right to care for such patients. Ethical principles mandate transplant physicians provide adequate care for returning transplant tourists. Better ways of assessing the scope of the problem are necessary. Transplant tourism may exist because of the disparity between the need for organ donors and their availability and is thus is likely to continue into the future.

Transplant tourism in China: a tale of two transplants

The use of organs obtained from executed prisoners in China has recently been condemned by every major transplant organization. The government of the People's Republic of China has also recently made it illegal to provide transplant organs from executed prisoners to foreigners transplant tourists. Nevertheless, the extreme shortage of transplant organs in the U.S. continues to make organ transplantation in China an appealing option for some patients with end-stage disease. Their choice of traveling to China for an organ leaves U.S. transplant programs with decisions about how to respond to the needs of patients who return after transplantation. By discussing two cases that raised this dilemma, we argue for upholding medicine's commitments to traditional principles of beneficence and nonjudgmental regard in sorting out the policies that a transplant program should adopt. We also explain how position statements that aim for the high ground of moral purity fail to give appropriate weight to the needs and suffering of present and future patients in the U.S. and in China.

The dilemma and reality of transplant tourism: an ethical perspective for liver transplant programs

Transplant programs are likely to encounter increasing numbers of patients who return after receiving an organ transplant abroad. These patients will require ongoing medical care to monitor their immunosuppression and to provide treatment when the need arises. Transplant societies have condemned transplantation with organs purchased abroad and with organs procured from executed prisoners in China. Nevertheless, transplant programs require guidance on how to respond to the needs of returning transplant tourists and to the needs of patients who may choose to become transplant tourists. This discussion presents a case that raised such issues in our program. It goes on to offer reasons for considering a program's responses in terms of the most relevant principles of medical ethics, namely beneficence and nonjudgmental regard.

Liver transplantation: Issues for the next 20 years

The growing numbers of potential transplant recipients on waiting lists is increasingly disproportionate to the supply of cadaveric donor organs. The hope for the next 20 years is that supply will satisfy demand. This requires both a reduction in indications for the procedure and an increase in the transplants performed. A multi-pronged approach is needed to increase cadaveric organ donation, generating enthusiasm for donation among both the general public and hospital staff. Accurate assessment of marginal grafts with stringent criteria known to predict graft function will diminish wastage of organs. Methods of rehabilitating marginal grafts during extracorporeal perfusion will increase organ availability. Supply of non-heart beating donors can be greatly expanded and protocols developed with ethical consent to optimize their initial function despite warm ischemia. Splitting livers that fulfill selection criteria, thus providing for two recipients, should be universally applied with acceptable incentives to those units who do not directly benefit. A proportion of recipients, though not those transplanted for autoimmune disease, will be spared the side-effects of immunosuppression thanks to immune tolerance. Protocols for close monitoring of those patients for rejection during treatment withdrawal must be carefully observed. In addition to gene therapy, it is highly likely that hepatocyte transplantation will replace orthotopic grafting in patients without cirrhosis, especially for inherited metabolic diseases. It is much more difficult to envisage that heterologous stem cell transplantation or xenotransplantation will have clinical impact in the next 20 years, although research in those areas has obvious long-term potential.

Sociological and ethical issues in transplant commercialism

PURPOSE OF REVIEW

'Global transplant commercialism' (practices and policies involving international trade in organs from living vendors, e.g., 'transplant tourism') is currently subjected to unprecedented criticism. In parallel, the debate around 'local transplant commercialism' (practices and policies that confine trade in organs from living vendors to national markets or economic unions) is heating up. In an attempt to assess the potential outcomes of these trends, this article reviews and discusses some sociological and ethical issues, ending with a proposal for a reinvigorated anticommercialist strategy.

RECENT FINDINGS

The current international campaign against global transplant commercialism is conducted by an ad hoc alliance between strange bedfellows, proponents of local transplant commercialism on the one hand and opponents of any transplant commercialism on the other. Disparities in the rigor of the respective ethical discourses, the expanding list of precedents of legitimized commerce in the human body, and the political economy of transplantation, all suggest that the former have the upper hand.

SUMMARY

Recent achievements in the struggle against international organ trafficking may not herald the abolition of transplant commercialism but rather presage its reconfiguration in deglobalized forms. In light of such a prospect, those who wish to prevent the pervasive commodification of the human body from entering the gates of transplant medicine should consider devising a new, perhaps more radical, strategy.

Follow-up of Chinese liver transplant recipients in Hong Kong

The outcome of liver transplantation in China remains speculative. From 1998 to 2007, 177 adult Hong Kong patients underwent liver transplantation in China and were subsequently followed up at Queen Mary Hospital, Hong Kong. One hundred six (59.9%) patients had hepatocellular carcinoma (HCC). The grafts were probably derived from uncontrolled non-heart-beating donors. The 1-month mortality rate was 4.0%. The 1-, 3-, and 5-year overall survival rates were 73.9%, 59.0%, and 53.9%, respectively. The 5-year overall survival rates for non-HCC, HCC, HCC (within the Milan criteria), and HCC (beyond the Milan criteria) patients were 66.3%, 44%, 58%, and 26.2%, respectively. The long-term survival was compromised by the high incidence of HCC recurrence and graft failure secondary to diffuse intrahepatic biliary strictures. The overall survival rate of the entire group was lower than that of the patients receiving deceased donor liver grafts at Queen Mary Hospital in the same period. For non-HCC patients, however, the 5-year survival rate of 66.3% was comparable to that of recent reports from the Western world.

Renal Transplantation in Singapore

Introduction: Renal transplantation is the best treatment for kidney failure. As the demand far exceeds the supply, various legislative measures have been put into place in Singapore to increase kidney transplant rates. This paper evaluates the impact of these measures and reports on the outcomes for kidney transplant recipients in Singapore. Materials and Methods: Patient demographics, recipient and donor characteristics, and co-morbidities occurring in incident transplant patients were extracted from Singapore Renal Registry (SRR) Reports from 1997 to 2006, tabulated and summarised. Graft and patient survivals data, which were calculated by Kaplan-Meier analysis until return to dialysis/pre-emptive renal re-transplant or patient death respectively, were extracted from SRR Reports. Published data from the United States Renal Data System (USRDS) and Organ Procurement and Transplantation Network (OPTN) were used for comparisons with data from the SRR. Results: The introduction of the Human Organ Transplant Act increased the rate of deceased donor (DD) kidney transplants from 4.7 per year from 1970 to 1988, to 41.4 per year from 1988 to 2004. In 2006, the overall DD and living donor (LD) rate for kidney transplants performed locally for Singaporeans and permanent residents of Singapore was 22.6 per million population (pmp); taking into account overseas kidney transplants, the kidney transplant rate was 33.0 pmp. One and 5-year graft survivals for local LD and DD transplanted between 1999 and 2006, as reported by the SRR, were 98.1% and 95.3% versus 88.9% and 81.3%, respectively (P <0.001). Patient survivals at 1 and 5 years were likewise significantly better for LD versus DD (99.4% and 96.6% vs. 96% and 89.1%, respectively; P = 0.005). Conclusions: The local kidney transplant rates were lower than those reported by the USRDS for the USA, Spain, Norway and Australia but higher than other Asian countries. While 1-year outcomes for transplants reported to the SRR were similar to that reported by the OPTN, 5-year survivals were significantly higher, possibly due to the selection of patients with fewer co- morbidities for kidney transplantation in Singapore. These results suggest that while outcomes are excellent, there is much more to be done to increase kidney transplantation rates in Singapore so as to meet the needs of end-stage renal failure patients in the country. Key words: Presumed consent, Singapore Renal Registry, Living donor, Kidney transplant, Deceased donor kidney transplant, Graft survival

Commercial transplants in local Pakistanis from vended kidneys: a socio-economic and outcome study

Donor shortage and absence of transplant law lead to unrelated commercial transplants in Pakistan. We report the socio-economic and outcome parameters of 126 local recipients of unrelated kidney vendor transplants presenting to our institute between 1997 and 2007. Their outcome was compared with 180 recipients of living-related donor transplants matched for age, gender and transplant duration as controls. Age of commercial recipients was 35.63 +/- 11.57 years with an M:F ratio of 2.4:1. Majority (92%) were transplanted in northern Pakistan paying US$7271 +/- 2198. All were educated with 50% being graduates or above and rich earning a monthly salary of US$517 +/- 518 with 44% earning >US$500. Comparison of commercial recipients with controls showed high comorbidities 35 (28%) vs. 14 (8%) (P = 0.0001) with diabetes, hepatitis-C and cardiovascular diseases. Donor age was 29.97 +/- 6.16 vs. 32.63 +/- 9.3 years (P = 0.035). Biologic agents induction in 101 (80%) vs. 14 (8%) (P = 0.0001), acute rejections in 42 (33%) vs. 31 (17%) (P = 0.005), 1-year creatinine 1.84 +/- 1.28 vs. 1.27 +/- 0.4 mg/dl (P = 0.0001), surgical complications 28 (22%) vs. 14 (8%) (P = 0.001), tuberculosis 14 (11%) vs. 6 (6%) (P = 0.007), acute hepatitis 20 (16%) vs. 3 (2%) (P = 0.0001), cytomegalovirus 33 (26%) vs. 21 (11%) (P = 0.001) and recurrent urinary tract infection 35 (28%) vs. 30 (16%) (P = 0.034). Overall 1- and 5-year graft survival was 86% and 45% vs. 94% and 80%, respectively (P = 0.00001). Total deaths were 34 (27%) vs. 12 (6.0%) (P = 0.001). In conclusion, recipients of the vended kidneys are poor candidates, educated, rich and often self-selecting. Their outcome is poor, which will leave them poorer still and back to dialysis if not death.

Transplant tourism: a growing phenomenon

Medical tourism is increasing owing to high costs of care, lack of availability or long waits for procedures, and improvements in technology and standards of care in many countries. Transplant tourism is one example of medical tourism that has been attracting increasing attention because of concerns over poor treatment and outcomes of both donors and recipients. Most such cases involve vended kidneys obtained from vulnerable populations, and both donors and recipients receive inferior care by US standards. This commentary discusses a paper by Gill et al. that compared outcomes of 33 transplant tourists with those of patients transplanted at a US center. Fewer complications and better outcomes were seen in patients transplanted in the US center than among transplant tourists. Large transplant centers with long waiting times are increasingly likely to see patients return newly transplanted from overseas; such patients require urgent attention, with particular consideration to infectious complications.

Transplant tourism to China: the impact on domestic patient-care decisions

Organ procurement in China has been criticized because of its reliance on executed prisoners as donors. We aimed to assess the influence of perceptions about organ procurement practices in China on domestic patient-care decisions.

METHODS

An anonymous internet administered case-based questionnaire was used to survey a sample of healthcare professionals with affiliations to hepatology and transplantation professional societies.

RESULTS

Of 674 completed surveys, the vast majority (93%) of the respondents were physicians, surgeons or allied transplant professionals actively caring for liver transplant patients and 81% practiced in the US. A strong majority believed procurement practices were ethically sound in the US and Europe (87% and 73%) but fare fewer believed that procurement practices were ethically sound in China (4%, p < 0.001). In case-based questions, lack of confidence in the ethical standards of organ procurement in China predicted patient-care decisions. The majority would provide post-transplantation care for patients who underwent liver transplantation at another domestic center, in a foreign country and in China (90%, 78%, and 63%, respectively, p < 0.001) yet respondents who suspected unethical procurement practices in China were more reluctant to do so (p < 0.001).

CONCLUSIONS

Transplant professionals expressed concern about organ procurement practices in China which influenced their patient-care decision-making.

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.

Transplant tourism in the United States: a single-center experience

BACKGROUND AND OBJECTIVES

Transplant "tourism" typically refers to the practice of traveling outside the country of residence to obtain organ transplantation. This study describes the characteristics and outcomes of 33 kidney transplant recipients who traveled abroad for transplant and returned to University of California, Los Angeles (UCLA) for follow-up.

DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS

Posttransplantation outcomes were compared between tourists and a matched cohort of patients who underwent transplantation at UCLA (matched for age, race, transplant year, dialysis time, previous transplantation, and donor type). Median follow-up time was 487 d (range 68 to 3056).

RESULTS

Compared with all patients who underwent transplantation at UCLA, tourists included more Asians and had shorter dialysis times. Most patients traveled to their region of ethnicity with the majority undergoing transplantation in China (44%), Iran (16%), and the Philippines (13%). Living unrelated transplants were most common. Tourists presented to UCLA a median of 35 d after transplantation. Four patients required urgent hospitalization, three of whom lost their grafts. Seventeen (52%) patients had infections, with nine requiring hospitalization. One patient lost her graft and subsequently died from complications related to donor-contracted hepatitis B. One-year graft survival was 89% for tourists and 98% for the matched UCLA cohort (P = 0.75). The rate of acute rejection at 1 yr was 30% in tourists and 12% in the matched cohort.

CONCLUSIONS

Tourists had a more complex posttransplantation course with a higher incidence of acute rejection and severe infectious complications.