Transplantation Tourism Mohammed Alsaghier, MBBS MultiOrgan Transplant Surgeon King Fahed Specialist Hospital Damamm , Saudi Arabia
Outline of Presentation Background Challenges for transplant on Saudi Arabia Transplant Tourism China Conclusions
Issues with Transplant Tourism Clinical / Medical Financial Ethical Legal
Transplant global history Research for transplant: one hundred years ago Alexis Carrel (Nobel Prize 1912) WW II, kidney transplants between identical twins immunosuppression living donors First heart transplant (1967) “Definition” of brain death Growing no organs from deceaseddonors (DD) Supply never meets the need (waiting lists) Transplantation becomes global practice 1980s:organ traffickingand Tourism.
Deceased donors Donor has been declared dead by two physicians independent of the transplant team Usually occurs only in cases of neurologically determined death Live donors to donate one or part of an organ to someone on a transplant waiting list. DONATION
Yearly Number of kidney transplant per million population per year - USA - 52 Predominantly Deceased Donors Europe - 27 Predominantly Deceased Donors Asia - 3 Predominantly Living Donors WORLD STATUS OF RENAL TRANSPLANTS
The deceased donors per million population per year USA - 20.7 Europe - 15.9 Asia - 1.1 South America - 2.6 DECEASED DONOR RATES
Incidence of End Stage Organ failure Community and professional Mind-set to Brain Death and Donation Legal aspect Trained Donor Coordinators COMMON PROBLEMS IN DD TRANSPLANT
Public awarness Reporting of Brain Death Hospitals Donation system . Religion , Society and Organ Donation COMMON PROBLEMS IN DD
System Funding for Donor program Hospitals work to identify & maintain “Brain Dead” donors Community Awareness of “Brain- Death” Concept PROBLEMS WITH DD Transplant For cadaveric donation, ‘ Society acceptance remains a crucial in a transplant program’
Hospitals Donation System Trained transplant Co-coordinators Adequate No. of Intensivists in ICUs Well qualified Surgeons to undertake Retrieval & TX Support Organization to SCOT Transport of organs –between cities HLA Tissue typing and Cross-match
... و مَنَ اَحياها فَكَاَ نما اَحيَا الناسَ جميعاً ... And he who saves a man’s life shall be considered as one who has saved the life of mankind as a whole
Issues Living donors Autonomy vs. nonmaleficence Risks to Donor ( “benefit”) Deceased donors Brain death (accuracy; conflict of interests) Consent? Waiting lists Allocation (medical vs. social) “Shortage” Commercialism Autonomy vs. desperate “donors” ) Transplant tourism ( “ deal” including donor, at “bargain” )
Japan - 12,974 Taiwan - 7000 Saudi Arabia - 4248 Korea - 4000 Pakistan - 1650 Hong Kong - 1018 Singapore - 666 Bangladesh - 125 Waiting Time Taiwan – 1.9 yrs Korea – 2.2 yrs Hong Kong – 4.3 yrs Singapore – 5.8 yrs No Waiting list in Iran for Kidney Tx. KIDNEY TX WAITING LIST IN ASIA (2002)
Five organ trafficking hotpots identified by the WHO CHINA PAKISTAN EGYPT COLOMBIA PHILIPPINES 2007 Sources: Reuters, World Health Organization
Clinical Outcomes for Saudi Patients Receiving Deceased Donor Liver Transplantation in China 2King Faisal Specialist Hospital & Research Center – Saudi Arabia
consequent increase in the number of patients seeking transplant abroad especially in China. Attracting factors in China: easy accessibility. relatively low cost, relatively short waiting time. laxtransplantation indications.
Despite these attractive factors, the main growing concern with this choice is the uncertaintyregarding the outcome ……
Seventy-four adult patients (60 males & 14 females). Mean age: 54.7 years. Nationality: Forty-six Saudi nationals; 28 Egyptians. Average MELD score: 17. In 5 patients (6.8%) MELD score > 25. Indications for liver transplantation: hepatitis C related decompensated cirrhosis (n=29). hepatocellular carcinoma (n=24). hepatitis B (n=14). cryptogenic cirrhosis (n=6). primary biliary cirrhosis (n=1). Median period between contacting centre & travel: 4 weeks (2-16w). RESULTS
41 patients (55%) had been deniedlive transplantation in KSA or in Egypt. Reasons for rejection of transplantation: unsuitable medical condition due to multiple co-morbidities (n=23), age >65 (n=13), advanced hepatocellular carcinoma (n=5). three patients: tumor size > Milan and UCSF criteria; one: invasion of the right branch of the portal vein; one: invasion of the main portal vein.
Reports from China In-China waiting period: 5-20 days (median14 days). Donors’ data: Only the age of the donor (range 20-35 years, median 25 years) & the cause of death (severe brain injury in all cases) were provided. Operative details: missing or incomplete. Early post-operative morbidity: Complications were rarely described in detail. Mortality: Two patients died in China, due to unknown cause.
Follow up care for a median of 13 months (2-60 months). Follow up after return from China
Diffuse biliary stricture: 14 (18.9%) Six died. The rest required repeated interventions (ERCP, PTC). Two required surgery and one required retransplantation. Anastomotic stricture: 6 (8.1%) Bileleakage:4 (5.4%) Biliary Complications
Mortality Two patients died in China very early after surgery. Sixteen died during follow up: biliary complications resulting in either sepsis or poor graft function (10 patients). recurrent metastatic HCC (3 patients). poor graft function due to portal vein thrombosis (1 patient). GVHD (1 patient). fibrosingcholestatic hepatitis (1 patient).
Outcome of patients rejected for Tx in KSA • Age above sixty-five: revise • Eight died in the first year post-transplant, • Two had portal vein thrombosis, one had biliary stricture, five required repeated admissions to the hospital during the first year, and three suffered from severe infections. • Rejected due to advanced HCC • Four died in the 1st year post transplant, three of whom suffered from brain or lung metastasis. • One died after two months of severe pneumonia and sepsis.
Patient Survival rate Survival Functions 1.0 0.8 0.6 0.4 0.2 0.0 Country Saudi Arabia China 1.00 - Censored Cum Survival 2.00 - Censored 0 500 1000 1500 2000 Survival ( Days )
Graft Survival rate Survival Functions 1.0 0.8 0.6 0.4 0.2 0.0 Country 1 2 1 - Censored 2 - Censored Cum Survival 0 500 1000 1500 2000 0 500 1000 1500 2000 Survival ( Days )
Medical Care Postoperative interventions. Frequent hospital admissions. Frequent Visits to day medical unit. Frequent Visits to the ER. Frequent Laboratory investigations. Burden on the Hospital resources.
The results in this study may not represent the actual survival data of the Chinese centers. Indeed, the presented data from China are only of the patients who are followed up in our center, and do not include those who may have had early death or complications, those who are followed elsewhere, and all other non-Saudi & non-Egyptian patients not known to us.
Renal Transplant – Favorable Outcomes Sever MS et al 1997 540 Saudi patients transplanted in India 96% graft survival 89% patient survival Similar results to those transplanted in Saudi Arabia Pediatr Nephrol. 2006 Morad et al 2000 515 Malaysian patients transplanted in China or India >90% graft and patient survival Transplant Proc. 2000 Nov
Renal Transplant - Inferior Outcomes Kennedy et al 2005 16 Australian patients 66% graft survival 85% patient survival Sever et al 2001 Turkish patients 84% graft survival patient survival similar to locally transplanted patients