The outcomes and controversies of transplant tourism—Lessons of an 11-year retrospective cohort study from Taiwan

Abstract

BackgroundTransplant tourism has increased rapidly in the past two decades, accounting for about 10% of world organ transplants. However it is ethically controversial and discouraged by professional guidelines. We conducted this study to investigate the outcomes and trends of overseas kidney and liver transplantation in Taiwan to provide a sound basis for ethical reflection.Methods and findingsThe Taiwanese National Health Insurance Research Database was used to identify 2381 domestic and 2518 overseas kidney transplant (KT) recipients from 1998 to 2009 and 1758 domestic and 540 overseas liver transplantation (LT) recipients from 1999 to 2009. Cox proportional hazards models were used to assess the risks of mortality and graft failure. The numbers of overseas transplantation increased after 2000, reached a peak in 2005 and decreased after 2007. Compared to their domestic counterparts, the overseas KT recipients were older, male predominant, with shorter pre-op dialysis period and more comorbidities. Similarly, the overseas LT recipients were older, male predominant and had more hepatocellular carcinoma cases. The 1-, 5-, and 10-year patient survival rates were 96.9%, 91.7% and 83.0% respectively for domestic KT and 95.8%, 87.8% and 73.1% for overseas KT (p<0.001). The 1-, 5-, and 10-year patient survival rates were 89.2%, 79.5%, 75.2% for domestic LT and 79.8%, 54.7%, 49.9% for overseas LT (p<0.001).ConclusionThe poorer outcomes of the overseas groups may be due to more older patients, more comorbidities (KT), or more hepatocellular carcinoma recurrences (LT). After domestic reform and international ethical challenges, the numbers of organ tourism decreased but the practice still persisted surreptitiously. Compulsory registration policies for overseas transplantation with international conventions to sanction organ trafficking and transplant tourism should be considered to stop these controversial practices.

Kidney transplantation waiting times and risk of cardiovascular events and mortality: a retrospective observational cohort study in Taiwan

“…This finding may be explained by the fact that delayed KT requires longer pre-KT dialysis duration; that is, the prolonged duration of dialysis while awaiting KT may worsen the prognosis. Consistent results obtained from several studies have exhibited that pre-KT and post-KT dialysis duration is reversely associated with the survival outcome 21–25. Furthermore, an 11-year retrospective cohort study on KT recipients (n=4654) revealed a marginal increase in mortality in patients with a delay of >1 year, as well as bridge pre-KT HD treatments, compared with patients without delay (HR: 1.36; 95% CI: 1.01 to 1.81; p=0.04) 25.…”

“…Consistent results obtained from several studies have exhibited that pre-KT and post-KT dialysis duration is reversely associated with the survival outcome 21–25. Furthermore, an 11-year retrospective cohort study on KT recipients (n=4654) revealed a marginal increase in mortality in patients with a delay of >1 year, as well as bridge pre-KT HD treatments, compared with patients without delay (HR: 1.36; 95% CI: 1.01 to 1.81; p=0.04) 25. Moreover, the documented pre-emptive KT was associated with a 45% reduction in the hazard of the dialysis or pre-KT (HR: 0.55; 95% CI: 0.47 to 0.64; p<0.001), and a 40% reduction in the hazard of death with a functioning graft (HR: 0.60; 95% CI: 0.50 to 0.71; p<0.001) 27.…”

“…Late KT with longer pre-KT dialysis duration may worsen the clinical and survival outcomes, thus increasing the risks of infections and malignancies. Compatible results from relevant studies have depicted that late KTs with longer pre-KT dialysis duration may lead to a relatively poorer survival 21–25. By contrast, early KT with shorter pre-KT dialysis duration may yield more favourable outcomes.…”

“…Thus, by early 2017, the KT waitlist in Taiwan exceeded 6000 patients; nevertheless, only 230–325 patients received KTs per year (between 2005 and 2016) 20. While evidence regarding the effect of KT timings on clinical outcomes is very limited,9 a few national reports have shown that longer pre-KT dialysis duration is associated with a higher risk of all-cause mortality 21–25. We hypothesised that longer KT waiting times were associated with poorer clinical and survival outcomes in a selected group of Taiwanese patients with ESRD receiving uncomplicated KT, and vice versa.…”

Liver Transplant Tourism

“…In 2005, the government of Taiwan acknowledged ethical issues involved in TT and imposed disciplinary actions on acts relating to TT. This, along with the call to improve national sufficiency in transplantation, resulted in a decrease in overseas LTs …”