Transplantation in foreign nationals: Lower rates of waitlist mortality and higher rates of lost to follow-up posttransplant

Abstract

A controversial issue in the transplant community is whether or not to provide deceased donor liver transplantation (DDLT) to noncitizen/nonresidents (NCNRs) who travel for liver transplantation (LT). The expectation is that transplantation of NCNRs will not compromise access for US citizens/residents (USCRs), and that NCNRs would have similar post-LT follow-up. This has never been formally assessed. The United Network for Organ Sharing (UNOS) data from February 27, 2002 to December 31, 2016 were used to identify NCNRs and compare to USCRs, excluding Status 1 adults. Multivariable logistic regression was used to analyze waitlist outcomes, and competing risk analysis was used to assess rates of lost to follow-up post-LT. From February 27, 2002 to December 31, 2016, 1260 NCNRs were listed for LT (0.86% of listings). Adjusted probability of DDLT was not significantly different for NCNRs and USCRs (P > .5), but NCNRs were significantly less likely to be removed from the waitlist for death or clinical deterioration (aOR: 0.80, 95% CI: 0.69-0.93, P = .003). In multivariable competing risk models, NCNRs had an 11-fold higher risk of being lost to follow-up after accounting for the competing risk of death (SHR: 11.44, 95% CI: 8.72-15.01, P < .001), as well as lower rates of posttransplant mortality (SHR: 0.67, 95% CI: 0.49-0.91, P = .012). Our findings speak to the need to standardize practices for NCNRs and set expectations for post-LT care.

Liver Transplantation in Unauthorized Immigrants in the United States

“…Indeed, without distinguishing transplant tourists from unauthorized immigrants, the non-US citizens/ non-US resident group in LT has been described as predominantly of high socioeconomic class, from Gulf countries (e.g., Saudi Arabia, United Arab Emirates, Kuwait, and so on), and with worse post-LT survival. (6,7) With our exclusion criteria to identify presumed unauthorized immigrants, we found that non-US citizen/non-US resident LT recipients in our study reflect the general US unauthorized immigrant population and are predominantly from Latin America. More importantly, contrary to a study examining non-US citizens/non-US residents that included transplant tourists, (6) our study found that patient survival was similar between non-US citizens/non-US residents and residents when excluding transplant tourists.…”

“…(6,7) With our exclusion criteria to identify presumed unauthorized immigrants, we found that non-US citizen/non-US resident LT recipients in our study reflect the general US unauthorized immigrant population and are predominantly from Latin America. More importantly, contrary to a study examining non-US citizens/non-US residents that included transplant tourists, (6) our study found that patient survival was similar between non-US citizens/non-US residents and residents when excluding transplant tourists. Although we found a higher likelihood of being lost to follow-up among presumed unauthorized immigrants, this finding should be interpreted with caution, as it was based on only seven events.…”

“…Our study differs from studies (6,7) that have examined non-US citizens/non-US residents as a composite group: non-US citizens/non-US residents who traveled to the United States for the purpose of LT (i.e., transplant tourists) and non-US citizens/ non-US residents who are unauthorized immigrants. The distinction is critical because unauthorized immigrants pay social security tax and contribute to organ donation, estimated at 3% of the total donated US organs, (9,10) whereas transplant tourists do not.…”

“…Recently, there has been federal and state legislation introduced that proposes to specifically intervene on access to organ transplantation for unauthorized immigrants. (4,5) This may in part have been prompted by a recent study (6) suggesting that non-US citizens/ non-US residents (vs. US residents) who received LT have poor post-LT survival and higher probability of being lost to follow-up.…”

“…US residents) who received LT have poor post-LT survival and higher probability of being lost to follow-up. However, this study and others (6,7) focused on LT for non-US citizens/non-US residents and included patients traveling to the United States specifically for LT (i.e., transplant tourism). To inform policy regarding LT for unauthorized immigrants who are not transplant tourists, the purpose of this study was to assess the national landscape of LT for unauthorized immigrants and to examine patient and graft survival post-LT by residency status.…”