Outcome of overseas commercial kidney transplantation: an Australian perspective

Kidney transplantation is accepted as a better treatment for patients with endstage kidney disease (ESKD) than long-term dialysis. Mortality, morbidity and cost comparisons are significantly better than dialysis regimens.1-3 The major factor limiting transplantation rates is availability of donor kidneys. About 520 kidney transplants are performed each year in Australia,4 and this number has remained relatively stable over recent years, despite a steady increase in the number of patients receiving dialysis treatment. There are about 2000 Australians awaiting kidney transplantation.

The deceased donor (DD) rate has diminished over the past 10 years, but there has been a corresponding increase in living donor (LD) transplants. In Australia, these now contribute 35%–40% of kidney transplants. LD kidneys have traditionally been from related donors (usually parents or siblings), but there has been a recent rise in the number of living unrelated donors (LURD).4 LURD kidneys are from spouses (69%), with other “emotionally related” donors making up most of the remainder. A small number of kidneys are transplanted from donors who have no direct genetic or emotional relationship with the recipient, and increasing the frequency of this type of donation is seen as a potential way of reducing the waiting list for transplantation. Most Australian states have enacted laws that forbid payment for organs and tissues for transplantation. Protocols enabling altruistic donor procedures are currently under consideration by health authorities.

The lack of transplantable organs is a universal problem in developed countries, and has led to the growth of commercial programs or renal transplantation in which donors are financially compensated. The main centres for these practices were initially in India; although the practices are now illegal in India, an estimated 60% of kidney donations are still paid donations.5 More recently, programs have developed in Iraq, Iran, Eastern Europe, South America, South Africa and the Philippines.6 Large commercial transplantation programs have also been established in China, attracting recipients from around the world. The source of these commercially acquired kidneys is not always apparent; some reports claim that up to 90% of transplanted kidneys in China are retrieved from executed prisoners.7 South Korea is notable for having developed an organ donation registry supporting both altruistic LURD and “paired-exchange” donations.8 A paired exchange occurs when two patients have incompatible potential donors and kidneys are exchanged. Paired exchanges are presently illegal in Australia.

A small percentage of Australian patients with ESKD have availed themselves of overseas commercial kidney transplantation. We reviewed the literature about outcome of overseas commercial kidney transplantation and report the experience of four Australian centres.

We reviewed the literature using the MEDLINE database 1966 to June 2003. Primary search terms were “kidney transplantation” and “commerce”, followed by a second search using “kidney transplantation” and “living donors” and “unrelated”. The phrase “commercial transplantation” was used as a separate keyword. The abstracts of retrieved articles were reviewed, and those that focused on outcome of commercial transplantation were obtained in full, and their reference lists were searched for further articles. Four articles, each reviewing the outcome of more than 100 cases of commercial transplantation (1301 cases in total), were published between 1990 and 2001 (Box 1). These are discussed below.

Salahudeen et al reported the outcome of 131 transplants in patients from the United Arab Emirates and Oman who received commercial transplants in India.9 All patients had arranged their own transplants in Bombay through brokers and without reference to their treating nephrologists. Eight patients died during the perioperative period, a further eight within the first 3 months and another eight before 12 months (patient survival rate, 81.5% at 1 year). Infections were the major cause of death (56%). One patient developed AIDS and died within 3 months of transplantation; HIV infection in the recipient had been suspected pre-transplantation. A further four patients became HIV-positive. Other fatal infections included pneumonia, septicaemia, tuberculosis, viral hepatitis and fungaemia. Most patients returned from India without adequate documentation (50 had no record or knowledge of their antirejection regimen) and many were sick or undergoing rejection on arrival home.

The pooled experience of several Saudi Arabian centres was reported in 1997.10 The outcomes of 540 patients who had received commercial transplants in India between 1978 and 1993 were compared with patients transplanted at their own centres with LD kidneys. After adjusting for several variables, the 1-year, 3-year, and 5-year patient survival rates in the Indian group were similar to those of the locally transplanted group (95%, 91%, 91% and 97%, 94%, 92%, respectively; P = 0.4921), as were the graft survival rates. There was a higher incidence of HIV infection (4.6% v 0), and hepatitis B virus infection (8.1% v 1.4%) in the cohort transplanted in India.

Sever et al reported the experience of 115 Turkish patients who were transplanted in India (106 patients), Iraq (7) and Iran (2) between 1992 and 1999.11 There was a high incidence of early surgical complications, as well as three cases of primary non-functioning grafts. The non-surgical infectious complications included 10 patients who developed malaria, 8 who developed serious fungal infection (5 fatal) and six cases of atypical pneumonia. Six patients became positive for hepatitis B. The patient survival rates at 2 years (90%), 5 years (80%) and 7 years (74%) were not significantly different from LD transplants performed in Istanbul (90%, 85% and 80%, repectively; P = 0.53). Graft survival rates for commercial transplants were 84%, 66% and 53% v 86%, 78% and 73% for Turkish LD transplants (P = 0.036) at these endpoints.

A comparison of 515 Malaysian patients who had received overseas commercial kidneys with 258 patients who had received LD kidneys in Malaysia showed that patient and graft survival, as well as infectious complications, were comparable between all groups.12 The analysis did not include all patients who went overseas for commercial transplants — only those who returned.

Other, smaller reviews have also been published, with similar high rates of infectious complications (see Box 1).13,14

We surveyed four renal units in the East Coast Renal Services of New South Wales and identified 16 patients who had travelled overseas for commercial kidney transplantation. Patient details and outcomes are shown in Box 2. Three patients who travelled overseas did not receive a kidney graft, but received haemodialysis therapy while abroad. Two have subsequently died. Patient 15 travelled to China twice for transplantation. During his first visit urological surgery was performed in preparation for transplantation, but on his return visit he was considered too unwell for further surgery and has subsequently died. Patient 16 contracted hepatitis B virus while undergoing dialysis in India and died of liver failure.

Kidney transplantation has significant survival advantages over dialysis therapy,1 and the quality of life of kidney transplant recipients is significantly better than that of similar patients maintained on dialysis.15 It is therefore not surprising that some dialysis patients are prepared to seek alternatives to the uncertain waiting period associated with a DD transplant. Similarly, patients who, for reasons of comorbid disease or advanced age, are not offered the option of DD transplantation may seek transplant donors from other sources.

Our case series highlights some areas of concern about overseas commercial kidney transplantation. As illustrated in previously published series, the early postoperative mortality rate was high. The 1-year patient survival rate of overseas commercial transplants may be between 80% and 96%, compared with greater than 95% for Australian LD transplants.4 Although the early survival rate was good in our relatively small series, two patients died 1 year after transplant and the 5-year patient survival rate was 60%. This is a marked survival disadvantage compared with the Australian DD kidney transplant recipients’ 5-year survival rate of 82% or greater.4 Survival rates for Australian dialysis patients placed on the transplant waiting list in Australia at 1 year (from time of joining the list) are also above 95%.1 The 3-year survival rate for all dialysis patients in Australia is greater than 60%.

Our series covers a period of 14 years. The three patients who died were transplanted in the early 1990s. More recent overseas transplants appear to have better outcomes, but even in this small group there has been a high incidence of serious infection. It is also important to note that we (as in previously published series) reported only the outcomes of patients who have returned from overseas, which means early mortality and complications may be under-reported.

Infectious complications were notable. Cytomegalovirus infection is a common occurrence in the first 6 months after transplant, and, to reduce the risk of CMV disease, most Australian centres have instituted routine use of prophylactic therapy. Details of CMV screening of overseas donors were scarce. HIV and viral hepatitis could both be contracted during the transplant period, either from an infected donor organ or blood products. Prospective Australian organ donors and blood donors are screened for CMV, HIV, HBV and hepatitis C virus. The screening procedures of commercial transplant programs are not evident, despite a generally high incidence of these infections in the populations of the countries performing commercial transplantation.

An area of concern identified in our patients is the lack of communication between the transplantation team and the unit caring for the patient in Australia. Our experience is similar to that reported by others. An obstacle in at least one instance was reluctance on behalf of the patient to disclose information.