WTC: Black Market Kidney Surgery Offers No Guarantees

BOSTON, July 26 -- Shopping abroad for black market donor kidneys to bypass lengthy North American organ queues can come back to haunt recipients, investigators reported here.

It's called "commercial transplantation," or "transplant tourism" and it's a booming business, according to surgeons who discussed the practice and its pitfalls at the World Transplant Congress.

Trafficking in human organs is illegal in the United States, Canada, Europe, and, ostensibly, in most of the world. But the practice of medical tourism -- traveling to another country to buy medical care that's either unavailable or more costly at home -- is not.

"Obviously if we more had more donations in this country, we would have less transplant tourism," commented Arthur Matas, M.D., of the University of Minnesota in Minneapolis and author of a highly controversial proposal for a government regulated system of compensated organ donation.

Setting aside the issues of queue jumping or the ethics of exchanging cash for body parts, the practice, which is nearly always performed with the recipient blinded to the identity of the donor or to the quality of the organ, may be quite risky, cautioned G.V. Ramesh Prasad, M.D. and colleagues, of the University of Toronto and St. Michael's Hospital, also in Toronto.

Many medical tourists return home bearing new kidneys from live donors, fresh surgical scars, and something else they never bargained for -- surgical complications, systemic fungal infections, and compromised grafts that in some cases require nephrectomy, leaving the patients back at square one, or even dead, Dr. Prasad and colleagues wrote.

"Patients considering this method of acquiring live-donated kidneys should be counseled of the inherent risks and possible serious adverse outcomes including diminished dialysis-free graft and patient survival," the authors noted in a poster presentation. "Worsening organ shortages and lengthening wait-times are likely to increase the frequency of this phenomenon in the near future,".

They reported the outcomes of 22 Canadians who went abroad for transplants from "non-biologically or non-emotionally related donors," and compared them with results from 175 biologically related donations and 75 emotionally-related donations performed at their center during the same period (1998 to 2005).

In all, about 5% of the renal transplant recipients they treated purchased a kidney abroad. Twelve of those grafts were performed in South Asia, five in East Asia, four in the Middle East, and one in Southeast Asia.

They found that of the 22 patients who went abroad for kidneys but returned to Canada for care after the transplant, 33% had no medical documentation of the procedures, and the remaining 77% often had incomplete records. The authors also had anecdotal reports of three additional patients who went abroad for surgery, but did not return to Canada and were lost to follow-up.

One third of all the patients transplanted outside of Canada required immediate hospitalization, primarily for sepsis, and one-third required hospital admissions, with stays averaging 19 + 36 days (range 4 to 113 days). Two patients required allograft nephrectomy.

The litany of infectious and surgical complications included opportunistic infections in 52%, pyelonephritis (including multi-drug resistant E. coli infections) in 38%, cytomegalovirus in 23%, fungal infections in 19%, tuberculosis in 14%, cerebral and spinal abscesses (5% each), wound infections in 25%, allograft nephrectomy (10%), wound dehiscence (10%), lymphocoele (10%), plus obstructive hydronephrosis, urine leak, and metastatic cancer (5% each).

In comparison with the patients who received their transplants in Toronto, the transplant tourists also had significantly worse three-year graft survival. Among patients who received kidneys from relatives, three-year graft survival was 98%, and among those who got kidneys from friends or from "emotionally related" donors, survival was about 86%, compared with about 62% for the non-biologically or emotionally-related kidney recipients.

When they looked at three-year, death-censored graft survival, they found that virtually all of the patients in the two control groups survived out to three years, compared with 82% of patients of the transplant tourists.

In a separate study also presented at the World Transplant Congress here, Muna T. Canales, M.D., and colleagues, of the University of Minnesota and Hennepin County Medical Center in Minneapolis reported on the outcomes of 10 U.S. residents who decided to try their luck with foreign renal transplants.

Eight of the 10 patients had been on the center's waiting lists for deceased donor transplants, and the remaining two were still undergoing evaluation when they decided to take matters into their own hands. Nine of the patients were on dialysis prior to transplant, with a mean duration of 20+13 months.

Eight of the patients, all originally from Somalia, were transplanted in Pakistan. One, originally from China, went back there for surgery, and one went back to his/her native Iran for surgery. All but one of the patients received organs from living unrelated donors.

The investigators found that complications occurred in six of the 10 patients, including cyclosporine A-related seizures, severe wound infection, aspergillus infection of the central nervous system, post-transplant non-insulin-dependent diabetes, urosepsis, and CMV infection requiring hospitalization. At last follow-up, mean creatinine was 1.2+0.3 mg/dL, acute rejection occurred in two of the 10 patients, resulting in one graft failure, and all 10 patients were still alive.

The authors concluded that while "kidney function and graft survival were generally good after surreptitious overseas kidney transplantation?major problems included incomplete peri-operative information communicated to the post-transplant care facility and a high incidence of major post-transplant complications. Longer follow-up and detailed cost analyses are needed to better understand the implications of the growing phenomenon of transplant tourism."