However, the practices and the outcomes of international organ tourism have not been well understood. Nationally-integrated and comprehensive medical and social research concerning transplant tourism is still scant.
A total of 68 transplants were excluded because of a second KT or with a simultaneous LT. To make domestic and overseas KT comparable, we further excluded 63 subjects who died or resumed dialysis within 1 month after the domestic KT operation, because only the successful overseas transplantation patients who returned to Taiwan and received anti-rejection therapies could be included in our study.
Therefore, the remaining domestic KT recipients were selected for further analysis. The overseas KT recipients were validated with the NHI-based registry of catastrophic illness to exempt co-payment, and transplantation, cancer and dialysis were all included in the designated categories of catastrophic illness. The transplant-related immunosuppressive drugs recognized in this study include cyclosporine, tacrolimus, mycophenolate mofetil, sirolimus, rapamune, and cytotect.
Among the overseas KT identified between January and June , transplants were excluded because of a second KT or with a simultaneous LT. The remaining overseas KT recipients were selected for further analysis. By applying similar criteria in selecting domestic and overseas LT recipients from the NHIRD, we identified domestic LT recipients excluding 84 patients who died within one month after LT and 16 secondary LT and overseas LT recipients for further analysis between January and December We further contacted the TORSC to get the number of overseas and domestic including deceased and living transplants beyond the study period.
The trends of overseas and domestic transplants were compared using Cochran-Armitage trend test. Multivariable Cox proportional hazards models were further conducted to estimate their adjusted associations.
The proportional hazards assumption was evaluated by plotting Kaplan—Meier survival curves for investigated covariates against follow-up time. Study entry was defined as the date of transplantation. For overseas KT and LT recipients, the date of transplantation was defined as 14 days and 35 days, respectively, prior to the date the patients took the first prescription of post-transplant immunosuppressant drugs, because the average postoperative hospital stays for overseas KT and LT were 14 days and 35 days, respectively, according to a previous questionnaire survey 8.
As determined by database availability, the KT and LT cohorts were followed up through the ends of and , respectively. In the models estimating the hazard ratio HR of mortality, observations were censored on December 31, , for kidney transplants and December 31, , for liver transplants, or on the date that the patients died, whichever occurred first.
In the models estimating the hazard ratio of kidney graft failure, observations were censored on December 31, , on the date that the patients died, or the date on which the subjects resumed persistent dialysis, whichever came first.
The pre-transplant characteristics adjusted in the multivariable Cox proportional hazards models for KT recipients included gender, age at KT, CCI score, and time interval between initiation of dialysis and KT. To assess mortality risk for LT recipients, age, gender, CCI score, and hepatocellular carcinoma, were adjusted in the multivariable models.
Analyses were performed using SAS software, version 9. The steady decrease of overseas LT after coincided with an increase of domestic LT, which was mainly from related living donations S1 Table. The numbers in would be incomplete since some recipient data were not available until in NHIRD. Table 1 shows that, compared to the domestic KT recipients, the overseas KT recipients were older As shown in Table 2 , overseas LT recipients were older In addition, more of them had hepatocellular carcinoma compared to their domestic counterparts Overseas LT recipients with prior hepatocellular carcinoma had the lowest survival rate Fig 2.
We further identified that post-KT malignancy and liver disease were the two main causes of death for overseas KT recipients compared to those for the domestic KT recipients. On the other hand, hepatocellular carcinoma was the major cause of death for overseas LT recipients Our results showed that the overseas transplant group had the following characteristics: male predominant, older, having more comorbidities, having a shorter pre-operative dialysis time in kidney transplant, and more hepatocellular carcinoma cases in liver transplant.
The outcomes of overseas transplant were inferior to domestic transplants in crude rate. After adjusting for covariates, no difference was noted in overseas and domestic kidney transplant. However, overseas liver transplant is much worse than domestic liver transplant in the hepatocellular carcinoma group. There were several reasons that created the different characteristics between domestic and overseas transplant. Taiwan is still a relatively paternalistic society, and males commonly play a dominant role in family finance and income disposition.
Older people generally have greater financial and social resources; yet they might have more health problems and comorbidities, which put them at a disadvantage in rank on the transplant-waiting lists and may even lead to them being excluded for surgery. Hence, they are more likely to grasp an opportunity for overseas transplantation. The pre-transplantation dialysis period is shorter in the overseas group, which indicates a shorter waiting period and the commercial nature of overseas transplantation.
The same reason applies to overseas liver transplants, with more recipients being older and male. In our study, the crude patient survival rate was better for domestic KT recipients, but there was no difference in graft survival. The higher mortality rate in overseas KT recipients might have been reduced by a low kidney graft failure rate overseas vs. However, after adjusting for covariates, the mortality rate was similar between domestic and overseas KT patients.
The poor survival rate in overseas patients is attributed to the characteristics of overseas patients old age, more comorbidity, and male. We found that the main causes of death for KT, especially in overseas transplants, were malignancy and liver disease. The most common malignancies in overseas KT recipients were genitourinary malignancy kidney or bladder cancer and hepatocellular carcinoma.
Tsai et al. The year cumulative cancer incidence of the tourism group In Turkey, advertisements targeted refugees to consider being donors. Chin-Hong said many organs used in transplants in China might have been acquired from prisoners. They noted that 19 studies involving 2, transplants took place before , when there was no volunteer donor program in the country.
Rogers called for the retraction of these studies pending investigation of individual papers. Chin-Hong noted that patients who engage in transplant tourism face numerous infectious disease risks, including a risk for wound infections. Performing surgeries in a nonsterile environment can result in surgical site infections, including those caused by multidrug-resistant organisms.
Other potential infectious complications include UTIs with multidrug-resistant organisms as a result of kidney transplants — the most common transplants sought abroad. Although the U. Because of this, in commercial transplantation, HIV, HBV and cytomegalovirus CMV are estimated to be transferred at higher rates than in traditional transplantation, with 7. The risk for fungal infections also can be attributed to nonsterile operating environments, Chin-Hong said.
They can also suffer infections and surgical complications, and in the long term they're at risk of deteriorating function in the remaining kidney. Both he and Cohen encouraged kidney disease patients to stick with legal care in their home country. But the reality, he added, is that a transplant is not a good option for some patients -- such as those who are in poor health because of co-existing medical conditions.
The data and conclusions of research presented at medical meetings should be viewed as preliminary until published in a peer-reviewed journal. Please enter email address to continue. Please enter valid email address to continue. Chrome Safari Continue. Be the first to know. Retrieved November 10, from www. Although acute transplant rejection responds relatively well to steroids, chronic rejection which is mainly mediated by antibodies And 64 percent of them are currently on a waiting list — to which roughly 1 person is Print Email Share.
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