March 2007 | Back to Table of Contents

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Transplant Travel Guide

A Minnesota researcher sheds light on the medical risks of overseas transplants.

Nephrologist Muna Canales’s introduction to transplant tourism began with a call from the aunt of one of her patients.

Canales hadn’t seen the Somali man, who was in his early 20s and suffering from kidney failure, for about a month, as he had been visiting family in Pakistan. “I got a call from his aunt, saying, ‘Could we see him? He’s back in town, he’s not feeling well, and by the way he got a kidney transplant,’” she says.

The man’s body was rejecting the kidney he bought in Pakistan. Three months and one wasted kidney later, he was back on dialysis.

The case made Canales, who is completing the last year of a fellowship at the University of Minnesota, wonder if all foreign transplants went this badly and how she should advise patients in the future about the medical risks of buying a kidney overseas. She searched the literature and didn’t find answers. So she decided to conduct her own study, which was published in the December 27, 2006, issue of Transplantation.

Organ Sales The availability of organs in other countries is driving transplant tourism. But many in this country have ethical concerns about the source of organs in countries with less stringent procurement regulations than those of the United States. China, for example, has been criticized for using the organs of executed prisoners without their consent. And Nancy Scheper-Hughes, Ph.D., a medical anthropologist at the University of California, Berkeley, and director of the human rights project Organs Watch, has reported on people in the Philippines and Moldova being tricked into selling their organs. Some U.S. physicians say the bad practices of other countries should not be used as a reason why organs can’t be sold ethically. In fact, Arthur Matas, M.D., director of the University of Minnesota Renal Transplant Program, has been vocal about his belief that the United States could create an ethical and safe system of selling organs that would eliminate the waiting list for kidneys. He would like to see a center established to manage a well-regulated process. Potential donors would receive medical and psychological evaluations. Those who are accepted into the program would receive a fixed tax-free payment plus an option for short- or long-term health and life insurance in exchange for a kidney. And he would like to see an allocation process similar to the one now used for organs from deceased donors, so that everyone on the waiting list would have the same chance of getting an organ. Matas believes people should be allowed to decide for themselves if they want to sell a kidney. He compares the decision with that of a woman deciding to be a surrogate mother, which is legal. Finally, he believes a regulated system could prevent U.S. residents from becoming involved in a shady global kidney market. “If we eliminate the waiting list, we would also eliminate the need for transplant tourism,” he says.—S.D.S.

Canales surveyed colleagues at Hennepin County Medical Center and the University of Minnesota Medical Center-Fairview and found 10 patients who had overseas kidney transplants between September 2002 and June 2006. They were all foreign-born, with eight being from Somalia, one from Iran, and one from China. The Somalis all went to Pakistan for their transplants; the other two returned to their home countries.

Nine of the patients received kidneys from living donors. The Chinese patient received a kidney from a deceased donor. Eight of the 10 were on a U.S. transplant list, and all had health insurance that would have paid for the procedure here.

The Waiting Game
What motivated the patients to go overseas was a desire to get off dialysis. The average wait for a cadaver kidney in the United States is four to five years. Patients on dialysis have an annual mortality rate of up to 20 percent, Canales says. In 2004, nearly 4,000 patients died while waiting for a kidney, according to the National Kidney Foundation. So for those 10 patients, spending $20,000 or more out of pocket for an overseas kidney transplant seemed preferable to years of dialysis and the possibility of dying before receiving an organ.

So, how did the traveling transplant recipients fare? Their graft and overall survival rates were comparable to those of U.S. transplant patients. One died from a fungal infection in the brain three months after his transplant, and Canales’ Somali patient rejected his kidney.

But other concerns emerged.

Communication between physicians at the transplant institution and the patients’ doctors in the United States was poor. In the majority of cases, the patients’ U.S. physicians received little information about induction therapy, immunosuppression, and the patient’s response to the new organ. This made it harder for them to do follow-up treatment.

Infection was another concern, as four patients contracted six serious infections. Why so many? It’s not clear, Canales says, but some speculate it’s a result of early overimmunosuppression of recipients (in order to compensate for poor matching between the donor organ and the recipient), poor hygiene, substandard surgical practices, and inadequate education of patients regarding the risks of infection.

Weighing the Pros and Cons
Canales says because of what she learned from the study, she feels somewhat better armed to advise patients about the medical risks of seeking a kidney overseas.

But the ethical issues still remain pretty “hairy,” she says. For example, should U.S. physicians treat patients once they return from overseas? She thinks they should but notes that some doctors in California are choosing not to add such patients to their caseloads. Should doctors try to dissuade patients from going overseas because of concern about the source of organs and the care provided in hospitals? On the other hand, do doctors have an obligation to tell patients about overseas transplantation as a potentially life-saving option?

“I can’t deny that some patients do well,” Canales says. “However, I personally have concerns about the consequences of kidney transplantation abroad using organs for sale not only from the perspective of the donor but also with regard to the safety and health of the recipient.”—Scott D. Smith