Journal Club – Ethical Issues in Renal Medicine: ‘Transplant Tourism’

Journal Club – Ethical Issues in Renal Medicine: ‘Transplant Tourism’

Transplant Tourism in the United States: A single-centre experience. Gill J, Bhaskara R et al cJASN 3: 1820-1828. 2008

Matthew Graham-BrownLGH August 2013

Introduction - Ethics• ‘Ethos’ – meaning character• Ethics is the philosophy of morality that involves

systematizing, defending and recommending concepts of right and wrong

• The study of moral behaviour in humans and how one should act

• Ethics seeks to resolve questions dealing with human morality—concepts such as good and evil, right and wrong, virtue and vice, justice and crime

Introduction – Morals (Morality)• Moralitas, meaning manner, character, proper

behaviour• Morality is what ‘you’ believe to be right or

wrong – informed by ethics, (religious) beliefs, experiences and observations.

• ‘What is believed to be right or good’• Immorality: active opposition to morality• Amorality is an unawareness of, indifference

towards, or disbelief in any set of moral standards or principles

Ethical Theories• Utilitarianism – greatest good for the greatest

numberVS• Immanuel Kant – ‘categorical imperative’ - reason

is the source of morality, ‘universal right and wrong’, ‘cannot use a person as a means to an end – they must be an end in themselves’

VS• Situation ethics – what is the most loving thing to

do in any given situation

Medical Ethics - Historical

• Formula Comitis Archiatrorum – (Early 5th century) It demands from physicians that they widen and deepen their knowledge and enacts the consultation with other physicians

• Hypocratic Oath – Honesty (Physicians only!)

• Declaration of Geneva (1948, 1968, 1983, 1994, 2005 and 2006) – Post Nazi Germany. Modernised Hypocrates

Medical Ethics Key Tennants

• Autonomy• Beneficence• Non-maleficence• Justice

Relevance Today

So… This Study (!)

• Transplant tourism – ‘The practice of travelling outside the country of residence to obtain organ transplantation’

• Implications of this are largely unknown

• This study described the characteristics and post-transplantation outcomes of patients who sought transplant abroad and returned to be followed up at UCLA

Study Design & Methods 1

• Single Centre (UCLA)• Retrospective, observational, comparison study,

including a comparison against a ‘matched’ cohort • Included - All living and deceased-donor kidney

transplant recipients followed up at UCLA who underwent transplantation outside the US as of April 2007 – Total number 33 patients

• Excluded – patients who had moved to US after transplant and all non-kidney patients (1 kidney pancreas transplant was included)

Study Design & Methods 2• Looked at:– Demographic recipient data– Donor data (where available)– Transplant data (where available)– Clinical events– Graft survival– Patient death– Acute rejection– Serum creatinine after transplant– Infectious events

• Data verified with transplant staff + physicians, NOT patients (attempting to negate recall bias)

Study Design & Methods 3

• Compared ‘tourist’ demographics, transplant characteristics and outcomes with:1. ALL adult patients who had transplant at UCLA during

the study period (graft survival, patient survival, incidence rejection at 1 year, serum Cr at 1 yr)

2. A matched (Age, race (Asian vs non-Asian), transplant year, previous transplantation, dialysis time, donor type) cohort of 66 adult patients who had transplant at UCLA (graft survival, patient survival, incidence rejection at 1 year, renal function and infectious events)

Results – Tourism over time

Results – Demographic Details

Results – Country of Transplantation

Results – Countries of origin (data incomplete)

Worrying group…

Hospital stay and D/C Meds

• Average length of stay was 15 days (info unavailable for 47%)

• All D/C’d on CNI• 90% D/C’d on Pred + Mycophenolate• Only 24% received induction immunosup (info

unavailable in 39%) vs 60% of UCLA patients• Only 12 patients received co-trimoxazole and

no patients received CMV prophylaxis

Results – Arrival post transplant

• Median time to initial visit to UCLA post Tx was 35 days (13 2796 days)

• 4 patients needed immediate admission, 2 lost grafts, 1 recovered function after prolonged period of Gram –ve sepsis and 1 died of fulminant hepatic failure on ITU (presumed Hep B contracted from unscreened donor)

Results – Graft &Patient Outcomes

Results - Infections

• Overall no difference in infection rates 52% vs 48%• But….• Marked difference in severity• 27% tourist group required hospital admission, vs 9% of

matched cohort• More than twice as many CMV positive patients (30% vs

12.1%) with one CMV pneumonia in tourist group• ??Increased incidence of bacterial infections in matched

cohort group ??Incomplete records of infections from transplant centres

Results - Infections

Discussion – General Points

• Supply and demand an underlying problem• More and more common• Predominantly American-Asian patients

sought transplants abroad – Cultural aspects poorly understood…..

• Reasons for travelling abroad not sought, not clear and certainly multifactorial

• Why go abroad for live related… ?cost in US

Discussion – A fair bit lacking

• Live donors most common – lack of documentation on where kidney comes from – vendor-driven, executed prisoners, open market….

• Lack of information from transplant centers– Health, age, viral status of donor– Cold/warm ischaemic time– HLA matching– Post-op issues– Drug levels

Discussion - Reasonable outcomes, Not without risk

• No statistical significance between one year graft and patient survival, even in matched group, but low patient and event numbers limit power (NB only patients that return included…)

• Discursive results section wanting to demonstrate experience that when things went wrong they went very wrong!

• Inferior graft function and patient survival described elsewhere in literature (refs 5,7,9,14,15)

• Higher episodes of acute rejection• Generally higher rates of (severe) infections and less

prophylaxis. CMV a particular problem

Discussion - A public Health Issue?

• Potential infectious diseases• Unclear donor selection• Further work required

Dicsussion - Trust

• Of the 29 ‘transplant tourists’ evaluated at UCLA prior to Tx ‘few’ discussed plans to go abroad

• Can you council patients on transplant tourism? Can you give information on risks? Should you mention it’s an option? Should you ask if they’re thinking about it?

• Does it damage the Dr/patient relationship when patients return with grafts

More ethical stuff to think about• Right or wrong?• Incredibly complex mixture of social, political, economic,

cultural factors underpinning decisions of people willing to sell organs and those willing to buy them. Desperation on both sides

• Are we supporting this practice by looking after patients when they return? We can’t not look after them!

• Can we affect practices happening in a far away land??• Way forward? – continue striving to improve transplant

services here (including numbers of organs) so people don’t ‘need’ to go abroad…

Limitations• Small study, low power• Retrospective and observational (selection bias)• Only returning tourist included – no evidence

about peri-operative deaths/deaths from complications in those not returning

• ‘Matched’ group contained no matching for nature of underlying renal disease or co-morbid illness

• Lots of incomplete data from transplant centres

Thankyou!