The perils of transplant tourism

The perils of transplant tourism
Shortages are leading patients to travel abroad for new kidneys, but studies show the practice is risky for recipients and donors

CELIA MILNE

From Tuesday's Globe and Mail

January 6, 2009 at 10:44 AM EST

George Archer, at the age of 78, travelled to Lahore, Pakistan, in May, 2006, for a kidney transplant. Three weeks later he came home to Montreal, jubilant, with the kidney of a 22-year-old man. But jubilation would soon turn to pain and regret.

Mr. Archer had been desperate for a new kidney. Since his kidneys had failed in the spring of 2004, his life depended on dialysis.

"He felt stuck. There was that desperation," said his daughter, Ann Archer.

Ms. Archer saw pictures of the hospital in Lahore where her father's operation took place.

"It looked okay but not what we are used to," she said.

A few weeks after Mr. Archer returned from Pakistan, his transplant incision, which had been leaking slightly, split open. While treating him, doctors in Montreal discovered other health problems: respiratory distress, heart beat irregularity and atherosclerosis.

Ms. Archer travelled to Montreal from her Ottawa home in June to see her father and was shocked to find him bedridden, with laboured breathing and little muscle mass. He died two days later.

"I wasn't expecting that," she said.

Along with grief, Ms. Archer is feeling discomfort over the fact that her father bought a kidney in a foreign country.

"The donor was a young man who is down to one kidney. It upsets me. It's disturbing, the harvesting of organs."

Mr. Archer, fighting for his life, was part of a worldwide trend dubbed "transplant tourism." Studies have emerged that show this practice is often unethical and risky for both recipients and donors. Still, Canadians unwilling or unable to wait for a transplant at home are part of the transplant tourism trade.

Canadian doctor Jagbir Gill, while working as a postdoctoral research scholar at the University of California at Los Angeles, was involved in a study comparing outcomes of kidney transplant recipients who travelled overseas with those who stayed at UCLA. After one year, the rate of kidney rejection was 30 per cent in transplant tourists and 12 per cent in those operated on at home.

"In some cases, patients returned in good health and excellent kidney function," said Dr. Gill, who is back in Canada and working as a transplant nephrologist at St. Paul's Hospital in Vancouver.

"On the other extreme," he said, "patients presented directly from the airport to the emergency room requiring urgent admission to hospital with severe infections or kidney failure."

Dr. Gill described the worst-case scenario encountered in the study: One patient who contracted hepatitis from an organ donor returned to the United States to discover she required a repeat kidney transplant as well as a liver transplant.

"Both of these transplants failed and she died within two years of obtaining her transplant and after having spent over 20 months in hospital." The study is published in the November, 2008, issue of the Clinical Journal of the American Society of Nephrology.

The Canadian experience is similar. Two years ago, Jeffrey Zaltzman and colleagues at the renal transplant clinic at St. Michael's Hospital in Toronto studied Canadians who had travelled overseas for an organ transplant and returned to the hospital. That study revealed greater risk of infection and higher rates of rejection and death.

"They sometimes get off the plane very sick and go straight to [emergency]," Dr. Zaltzman said. "They bring back infections that are endemic to the area where the transplant was done. These can be resistant to many of the drugs here."

While going overseas for a transplant can be risky, it also raises the question: Who is providing the body parts? It has been widely reported that in China, after execution, political prisoners' organs were harvested. But Dr. Zaltzman believes this practice was curtailed before the Olympics because of worldwide pressure.

Another source is impoverished people in underprivileged countries who sell kidneys through an underground broker. Monir Moniruzzaman, a PhD candidate in anthropology at the University of Toronto, has studied this phenomenon. Originally from Bangladesh, he managed to track down and interview - at great personal risk - 33 kidney sellers in his home country.

Of those, all were living in poverty and most were illiterate. All but two saw no improvement in their way of life after the removal of a kidney. Many lost their jobs after returning home because they could no longer lift heavy objects, such as a rickshaw.

"We are living cadavers," one told Mr. Moniruzzaman. "My body is lighter, but my chest is heavier than ever."

The surgical scars from kidney removal are dramatic.

"They generally end up with scars of 15 to 20 inches, even though it is possible to do it laparoscopically in four inches," Mr. Moniruzzaman said. Of the sellers he interviewed, a kidney from one was transplanted into a Canadian.

The World Health Organization, the Transplantation Society and other international transplantation groups condemn this practice. They recently published a consensus statement called the Declaration of Istanbul, opposing organ trafficking and transplant tourism.

Although it is difficult to say how many North American patients travel abroad for organs, a recent U.S. study found 373 patients who travelled for an organ between 2001 and 2006.

"The numbers appear to be increasing dramatically in the last few years," Dr. Gill said.

Why the upward trend? As the success rate of transplantation rises so does demand, which is further boosted by the aging of the population and higher rates of kidney failure. There is no corresponding rise on the supply side. "Organ donation rates can't keep up," Dr. Zaltzman said.

Canada ranks poorly in organ donation compared with the rest of the world. A country's track record is measured by "organ donors per million population." Canada's rate is about 13, which is low compared with France (22), the United States (21) and Spain (35).

In Canada, latest figures show almost 3,000 patients are waiting for a kidney transplant. How fast they get to the top of the list depends on where they live.

There is no uniformity between provinces, or even cities and towns. In large, multiethnic cities, cadaveric donation rates are very low, perhaps because of a mistrust of the medical system, Dr. Zaltzman suggests. "In Toronto and Vancouver, the wait times are over 10 years.

"There is a lot of room to grow in terms of deceased donors. We know we can do better," he added.

One way to increase domestic organ donation rates is to encourage live donations. There are improvements coming to this system. As of this year, Canadian Blood Services has expanded its mandate to include organ and tissue donation and transplantation. The first priority is establishing organ patient registries such as the Live Donor Paired Exchange, which will match living donors across the country.

Efforts to boost domestic transplants are critical: When Canadians such as George Archer, driven by desperation, engage in transplant tourism, chances are good there will be two victims.

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