Outcome of overseas commercial kidney transplantation: an Australian perspective

224 MJA • Volume 182 Number 5 • 7 March 2005
H E A LT H C A R E
The Medical Journal of Australia ISSN: 0025-
729X 7 March 2005 182 5 224-227
©The Medical Journal of Australia 2005
www.mja.com.au
Healthcare
idney 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 altruis-
tic 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 support-
ing 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 transplanta-
tion. We reviewed the literature about outcome of overseas
commercial kidney transplantation and report the experience of
four Australian centres.
Literature review
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.
Outcome of overseas commercial kidney transplantation:
an Australian perspective
Sean E Kennedy, Yvonne Shen, John A Charlesworth, James D Mackie, John D Mahony, John J P Kelly and Bruce A Pussell
ABSTRACT
• Lack of donors has led to a worldwide increase in commercial
kidney transplantation programs where recipients acquire
kidneys either from executed prisoners or live non-related
donors.
• Commercial transplantation is prohibited by legislation in
Australia.
• Our centres have had 16 patients who have travelled overseas
to receive a commercial kidney transplant; five have
subsequently died.
• As has been found previously, patients who received
commercial transplants were more likely to develop infections
such as HIV, hepatitis B virus, cytomegalovirus and fungal
infections.
• Previous reports have found that patient and graft survival
were comparable to local results, whereas we found that
patient and graft survival were worse than transplantation
within Australia.
• Patients considering the option of overseas commercial
donation should be advised that heightened risks to life and
MJA 2005; 182: 224–227
graft survival exist.
FOR EDITORIAL COMMENT, SEE PAGE 204
East Coast Renal Services, Prince of Wales Hospital, Royal North
Shore Hospital, St George Hospital, Sydney, NSW, and Illawarra
Regional Hospital, Wollongong, NSW.
Sean E Kennedy, FRACP, Renal Registrar, Prince of Wales Hospital;
Yvonne Shen, FRACP, Renal Registrar, Prince of Wales Hospital;
John A Charlesworth, MD, FRACP, Professor of Renal Medicine,
Prince of Wales Hospital; James D Mackie, FRACP, Renal Physician,
Prince of Wales Hospital and Illawarra Regional Hospital;
John D Mahony, FRACP, Renal Physician, Royal North Shore Hospital;
John J P Kelly, MD, FRACP, Renal Physician, St George Hospital;
Bruce A Pussell, PhD, FRACP, Professor of Medicine,
Prince of Wales Hospital.
Reprints will not be available from the authors.
Correspondence: Professor Bruce A Pussell, Department of Nephrology,
Prince of Wales Hospital, Sydney NSW 2031. [e-mail]
K

MJA • Volume 182 Number 5 • 7 March 2005 225
H E A LT H C A R E
Renal outcomes
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 antirejec-
tion 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,
2 Pretransplant and transplant details and outcomes for the 16 patients seen in our Australian centres
Patient
No. Age Sex Primary disease
Time on
dialysis
Previous
transplant
Year and country
of transplant
Rejection
episodes Graft survival Outcome
1 53 M Glomerulonephritis 2 years No 1990, India 0 13 years† Well with good function
2 75 M Interstitial nephritis 5 months No 1993, China 1 12 months
(death with
functioning
graft)
CMV disease at 3 months;
HBV hepatitis at 9 months;
death at 12 months with
fulminant hepatitis
3 43 M Diabetic nephropathy 12 months No 1994, India 1 12 months
(renal infarction)
Death after 13 months;
ischaemic infarct
4 54 M Hypertension 12 months No 1994, India 1 1 month
(acute rejection)
Death after 4.5 years;
sepsis
5 56 M Glomerulonephritis 4 years No 1998, Iraq 0 4 years † Well with good function
6 31 M Glomerulonephritis 2 years No 1999, China 0 5 years † Well with good function
7 65 M Diabetic nephropathy 2 years No 1999, Philippines 0 5 years † Well with good function
8 66 F Glomerulonephritis 2 years Yes 2000, ? Eastern
Europe
0 3 years † Systemic CMV infection
on return
9 52 M Glomerulonephritis 12 months No 2000, China 1 3 years † Well with good function
10 55 F Glomerulonephritis 10 months No 2002, China 0 2 years † Well with good function
11 43 M Glomerulonephritis 12 months No 2002, China 0 2 years † Disseminated herpes zoster
12 49 F Reflux nephropathy 0 No 2002, Lebanon Multiple 1 month
(aspergillosis)
Aspergillosis; septicaemia;
dialysis required
13 41 M Glomerulonephritis 10 months No 2004, China 0 4 months † CMV pneumonitis
14 54 M Glomerulonephritis 6 weeks No Nil,* Lebanon na na Dialysis
15 70 M Diabetic nephropathy 5 years No Nil,* China na na Death
16 52 M Glomerulonephritis 3 years No Nil,* India na na HBV; ‡ death
HBV = hepatitis B virus; CMV = cytomegalovirus; na = not applicable.
* Travelled overseas for transplant but not transplanted. † Ongoing graft function. ‡ Acquired hepatitis (positive for HBV e antigen) while on dialysis awaiting transplant.
1 Summary of commercial transplantation case reports
First author
Country of origin
of patients
Country of
transplant Years No.
Patient survival
at 1 year
New
HIV infection
New
HBV infection
Salahudeen9 UAE and Oman India 1984–1988 131 81.5% 3.8% 2.3%
Living Non-
Related Renal
Transplant Study
Group 10
Saudi Arabia India 1978–1993 540 96% 4.6% 8.1%
Sever 11 Turkey India, Iraq, Iran 1992–1999 115 90% (2 years) nr 6%
Morad12 Malaysia nr 1990–1996 515 92% nr 12%
Onwubalili13 Saudi Arabia India 1985–1991 16 nr 6.25% 6.25%
Ivanovski14 Macedonia India 1993–1997 14 78% nr nr
UAE = United Arab Emirates; HIV = human immunodeficiency virus; HBV = hepatitis B virus; nr = not reported