Kidney Transplant Outcomes Good in Undocumented Immigrants

Nancy A. Melville

July 30, 2021

Undocumented immigrants with end-stage renal disease who underwent kidney transplantation had outcomes that were as good as, if not better than, those in the general population of transplant patients at one US center.

"The highly encouraging outcomes — using standard selection and post-transplant care protocols — in this challenged recipient population strongly suggest that undocumented immigrant patients with end-stage kidney disease should not be precluded from consideration for kidney transplant based on immigration status alone," write Marie Siobhan Luce, MD, and colleagues in a research letter published online in JAMA Surgery.

"I was pleasantly surprised to find that our undocumented transplant recipients had better graft survival than expected, and higher graft survival rates when compared to our institution's overall cohort," Luce of the Department of Surgery, UC Davis School of Medicine, Sacramento, California, told Medscape Medical News.

"Given the retrospective nature of our study, it's difficult to know why this is, however, I speculate that a strong family support system may play a part," she ventured.

An Alternative to Emergency-Only Dialysis?

As a result of their lack of citizenship, many undocumented immigrants with end-stage kidney disease are unable to receive kidney transplants — due to limited or nonexistent financial coverage — and they may instead be offered dialysis on an emergency-only basis, which can ultimately increase the costs to society.

Under California's Medi-Cal healthcare system, many can receive health coverage regardless of their immigration status, and private insurance may be an option for some undocumented immigrants as well, Luce and coauthors explain.

They evaluated data from 75 patients with undocumented status who received kidney transplants at the UC Davis center between 2003 and 2019.

The patients were from Mexico, Central America, or South America, and most (68) received kidneys from a deceased donor. Two recipients who did not achieve graft function — one with thrombosis and one with primary nonfunction — were excluded from the study cohort.

Of the remaining 73 patients — 68 adults and five adolescents — 59% were male and their median age was 38.2 years, which was significantly lower than the mean age of 50.3 years among the center's overall transplant cohort.

All transplant patients at the center receive the standard follow-up algorithm of care, regardless of documentation status, including weekly visits to the transplant center for the first several weeks postoperatively, followed by individualized care based on specific needs.

Seven of the undocumented recipients (10%) were lost to follow-up, all of whom had good graft function as of the last known contact. This figure is higher than is generally lost to follow-up, at around 5%, and indicates "that specialized protocols and/or additional follow-up may be needed for this unique population," Luce said.

85% of Transplanted Kidneys Still Functioning After 8 Years

Among the remaining patients, with a median follow-up of 5.5 years, there were seven graft losses (10%), none of which appeared to be related to the patients' documentation status or insurance coverage, the authors note.

The rate of graft survival at 8 years for deceased donor recipients (n = 65) was 85.9%, and this figure was 100% for recipients of live donor organs (n = 8).

The 3-year graft survival was 95.1% for the undocumented patients receiving deceased donor organs, which compared favorably with 88.2% for the center's overall adult patient cohort.

The UC Davis center does not have a documentation policy for kidney transplant screening. However, for patients to be eligible — whether undocumented or not — they must have financial coverage as well as a designated support system involved in pre- and postoperative care.

In identifying a total of 173 undocumented patients at the center over a 16-year period as part of the study data collection, Luce found only 22 of the patients were denied due to financial concerns.

"We found that undocumented patients had excellent results after kidney transplantation with many utilizing financial coverage provided by public insurance," she noted.

"Given the long-term socioeconomic burden of dialysis compared to kidney transplantation and the burden to the individual patient, I would...argue that improving access to health insurance and kidney transplantation country-wide would benefit undocumented patients individually and the healthcare system," she observed. 

"We are hopeful that our work will stimulate further research in undocumented persons and eventually influence policy to improve access to transplantation for this population," she concluded. 

JAMA Surg. Published July 28, 2021. Abstract

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