Transplant Tourism—An Update Regarding the Realities

Author:  Francis L. Delmonico
Posted: 05/16/2011; Nat Rev Nephrol. 2011;7(5):248-250. © 2011 Nature Publishing Group
http://www.medscape.com/viewarticle/742184?src=mp&spon=17

Abstract
"A recent article exposes the ongoing industry of transplant tourism in China, where foreign patients can receive vendor organs recovered from executed prisoners. Concerning data reveal the long-term complications of kidney transplant tourism, particularly the increased risk of malignancy. These findings relay an important message to transplant communities and physicians worldwide."

Introduction
"A paper published recently in Kidney International draws attention to the practice of transplant tourism from Taiwan to mainland China, where transplant tourists receive vendor organs that have been recovered from executed prisoners.[1] The authors evaluated medical records of 215 Taiwanese patients who underwent commercial transplantation in China, comparing their outcomes with those of a cohort of domestic transplant recipients who received legitimate renal transplants from deceased donors in Taiwan over the same time period. The graft and patient survival rates were better for the domestic group than for the tourist group 10 years after transplantation, but the differences between the groups were not statistically significant. However, the authors focus on transplant tourism as an independent risk factor for post-transplantation malignancy—attributed to the tourist recipients generally being older, to induction immunosuppressive treatment as a factor contributing to malignancy, and to the absence of, or inadequacy of, pretransplantation cancer screening of the donor.

This study is one of several that have been published regarding the hazards of transplant tourism.[2,3,3–5] The data reveal either poor medical care of the tourist or an increased rate of complications, but the data are also alarming regarding the health of the vendor donor. The Sindh Institute of Urology and Transplantation in Karachi, Pakistan, followed vendor kidney donors from the time of nephrectomy and found that many had compromised renal function and a high risk of developing chronic renal failure in the long term.[6] These donors who receive no proper medical care and follow-up may some day be in need of a kidney transplant themselves. Unethical practices are now well known to be part of the commercialism of transplant tourism. A widely referenced program from Iran has reported its misgivings to conclude that the impaired quality of life of the vendor—both before and after nephrectomy—necessitates careful assessment before making a commercial program of unrelated transplantation the centerpiece of policy.[7]

The Declaration of Istanbul Custodian Group has developed a brochure for individuals contemplating transplantation in a foreign destination. This patient brochure is readily available at the Declaration of Istanbul website[8] and the hazards of transplant tourism are made clear.

Recently, the dangers of medical and transplant tourism have intensified following the identification of esoteric bacteria carrying the New Delhi metallo-β-lactamase-1 (NDM-1) multiple antibiotic resistance gene, originally found in India and Pakistan (frequent destinations of transplant tourists), but now observed in patients in the UK and other countries around the world.[9]

Meanwhile, the transplant procedure that is performed in China using organs from executed prisoners is not a procedure of transparency with regulatory oversight. Many transplant professionals have visited China in recent years, yet none has witnessed this unethical process spanning the execution and transplantation. The facilities in China that are performing such transplantations wish to conceal the numbers and outcomes of their experience. No mandate is available to assess quality improvement when the transplantation is obviously carried out for commercial purposes, victimizing both the vulnerable donor being executed and the recipient who is receiving inadequate care.

The report from Taiwan exemplifies the anticipated consequences of transplant tourism for the transplant centers and for the transplant recipients. For the transplant centers, the expansion of this type of unregulated tourism necessitates increased resources to be unpredictably available for care of the transplant tourist after transplantation. For the individual 'tourist', the report reveals the inadequate perioperative transplant care and the different post-transplantation medical care compared to patients who undergo kidney transplantation in their home country.

Canadian professional societies have published a helpful policy statement in concert with the Declaration of Istanbul regarding the responsibilities of the physician for transplant tourists.[10] Physicians have a duty to advocate for their patients in obtaining a transplant, but as members of the medical community they also have a duty to prevent harm to their patients and other individuals—in this instance the kidney donor. The policy also recognizes that physicians have an obligation to care for the transplant tourist who has an acute complication; however, in nonemergency situations, physicians may elect to defer the care of the transplant tourist to another physician, especially in circumstances in which the hazards of undergoing transplantation in a foreign country have been explained in advance.[10]

The alternative to patients needing to leave their country for transplantation is national self-sufficiency: fulfilling the organ donation needs of a nation by utilizing resources from within the country. The World Health Assembly Resolution of 2010 calls upon all countries to address those needs and not foster transplant tourism. In that regard, Israel has taken a commendable step in prohibiting insurance companies from supporting Israeli patients who undergo illegal transplantation in foreign countries. It is now illegal for a foreign national to undergo transplantation in China. Transplant tourism systematized with the cooperation of governments and its embassies sustains the commercialism while setting aside responsibility of government to develop a program of deceased donation for its own people. This issue should not be overlooked by state governments. Recently, the State of Arizona decided to no longer provide Medicaid funding for its residents to undergo transplantation. The result was the reported interest of a brokerage group to outsource transplantation to Mexico. Of course, immediate questions arise—where are the organs going to come from and what would such a program mean for Mexicans in need of transplants?

The experience of centers in the care of transplant tourists must continue to be reported in the medical literature to provide revealing information and affirm an international standard—that transplant tourism is not ultimately advantageous for the patient or acceptable to the physician accountable for medical care."

References

1.Tsai, M.-K. et al. De novo malignancy is associated with renal transplant tourism. Kidney Int. doi: 10.1038/ki.2010.500.

2.Padilla, B. S. Regulated compensation for kidney donors in the Philippines. Curr. Opin. Organ Transplant. 14, 120–123 (2009).

3.Khamash, H. A. & Gaston, R. S. Transplant tourism: a modern iteration of an ancient problem. Curr. Opin. Organ Transplant. 13, 395–399 (2008).

4.Rizvi, S. A. Commercial transplants in local Pakistanis from vended kidneys: a socio-economic and outcome study. Transpl. Int. 22, 615–621 (2009).

5.Prasad, G. V., Shukla, A., Huang, M., D'A Honey, R. J. & Zaltzman, J. S. Outcomes of commercial renal transplantation: a Canadian experience. Transplantation 82, 1130–1135 (2006).

6.Naqvi, S. A. et al. Health status and renal function evaluation of kidney vendors: a report from Pakistan. Am. J. Transplant. 8, 1444–1450 (2008).

7.Nejatisafa, A. A. et al. Quality of life and life events of living unrelated kidney donors in Iran: a multicenter study. Transplantation 86, 937–940 (2008).

8.The Declaration of Istanbul on Organ Trafficking and Transplant Tourism [online], http://www.declarationofistanbul.org/index.php?option=com_content&view=article&id=113&Itemid=41 (2008).

9.Moellering, R. C. Jr. NDM-1—a cause for worldwide concern. N. Engl. J. Med. 363, 2377–2379 (2010).

10.Gill, J. S. et al. Policy statement of Canadian Society of Transplantation and Canadian Society of Nephrology on organ trafficking and transplant tourism. Transplantation 90, 817–820 (2010).

Source:
http://www.medscape.com/viewarticle/742184?src=mp&spon=17