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

1. 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-Brown LGH August 2013

2. Introduction - Ethics • ‘Ethos’ – meaning character • Ethicsis 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

3. 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

4. Ethical Theories • Utilitarianism – greatest good for the greatest number VS • 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

5. Medical Ethics - Historical • Formula ComitisArchiatrorum – (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. ModernisedHypocrates

6. Medical Ethics Key Tennants • Autonomy • Beneficence • Non-maleficence • Justice

7. Relevance Today

8. 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

9. Study Design & Methods 1 • Single Centre (UCLA) • Retrospective, observational, comparison study, including a comparison against a ‘matched’ cohort • Included - Allliving 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)

10. 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)

11. Study Design & Methods 3 • Compared ‘tourist’ demographics, transplant characteristics and outcomes with: • 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) • 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)

12. Results– Tourism over time

13. Results– Demographic Details

14. Results – Country of Transplantation

15. Results – Countries of origin (data incomplete) Worrying group…

16. 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

17. 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)

18. Results – Graft &Patient Outcomes

19. 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

20. Results - Infections

21. 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

22. 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

23. 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

24. Discussion - A public Health Issue? • Potential infectious diseases • Unclear donor selection • Further work required

25. 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

26. 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…

27. 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

28. Thankyou!