Transplantation Tourism

1
Transplantation Tourism

• Mohammed Alsaghier, MBBS
• MultiOrgan Transplant Surgeon
• King Fahed Specialist Hospital
• Damamm , Saudi Arabia

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Outline of Presentation

• Background
• Challenges for transplant on Saudi Arabia
• Transplant Tourism
• China
• Conclusions

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Issues with Transplant Tourism

• Clinical / Medical
• Financial
• Ethical
• Legal

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Introduction
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No of Dialysis units on Saudi Arabia1971-2007
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1993-2007 No of Patients
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2007Age distribution by
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The future patients1995-2015?
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No of new patient per Million
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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 deceased donors (DD)
• Supply never meets the need (waiting lists)
• Transplantation becomes global practice
• 1980s organ trafficking and Tourism.

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• DECEASED DONATION

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DONATION

• 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.

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WORLD STATUS OF RENAL TRANSPLANTS

• 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

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DECEASED DONOR RATES

• The deceased donors per million population per
  year
• USA - 20.7
• Europe - 15.9
• Asia - 1.1
• South America - 2.6

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1986-2007
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1986-2007
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The successful Donation from DD1986-2007
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DD Reported 2008
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Reason for Donation Rejection1986-2007?
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COMMON PROBLEMS IN DD TRANSPLANT

• Incidence of End Stage Organ failure
• Community and professional Mind-set to Brain
  Death and Donation
• Legal aspect
• Trained Donor Coordinators

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COMMON PROBLEMS IN DD

• Public awarness
• Reporting of Brain Death
• Hospitals Donation system .
• Religion , Society and Organ Donation

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PROBLEMS WITH DD Transplant

• System Funding for Donor program
• Hospitals work to identify
  maintain Brain Dead donors
• Community Awareness of Brain-
  Death Concept

For cadaveric donation, Society acceptance
remains a crucial in a transplant program
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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
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• ... ? ???? ??????? ?????? ??? ?????? ??????
  ?????? ...
• And he who saves a mans life shall be considered
  as one who has saved the life of mankind as a
  whole

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Transplantation Tourism
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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 )

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KIDNEY TX WAITING LIST IN ASIA (2002)

• 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.

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KIDNEY TX WAITING LIST IN THE WORLD (2002)
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Five organ trafficking hotpots identified by the
WHO

• CHINA
• PAKISTAN
• EGYPT
• COLOMBIA
• PHILIPPINES

2007 Sources Reuters, World Health Organization
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Clinical Outcomes for Saudi Patients Receiving
Deceased Donor Liver Transplantation in China
2King Faisal Specialist Hospital Research
Center Saudi Arabia
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• 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.
• lax transplantation indications.

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• Despite these attractive factors, the main
  growing concern with this choice is the
  uncertainty regarding the outcome

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RESULTS

• 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 gt 25.
• Indications for liver transplantation
• hepatitis C related decompensated cirrhosis
  (n29).
• hepatocellular carcinoma (n24).
• hepatitis B (n14).
• cryptogenic cirrhosis (n6).
• primary biliary cirrhosis (n1).
• Median period between contacting centre
  travel
• 4 weeks (2-16w).

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• 41 patients (55) had been denied live
  transplantation in KSA or in Egypt.
• Reasons for rejection of transplantation
• unsuitable medical condition due to multiple
  co-morbidities (n23),
• age gt65 (n13),
• advanced hepatocellular carcinoma (n5).
• three patients tumor size gt Milan and UCSF
  criteria
• one invasion of the right branch of the portal
  vein
• one invasion of the main portal vein.

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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.

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Follow up after return from China

• Follow up care for a median of 13 months (2-60
  months).

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Complications
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Biliary complications
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Biliary Complications

• 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)
• Bile leakage 4 (5.4)

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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).
• fibrosing cholestatic hepatitis (1 patient).

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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.

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Comparison of Outcome with patients at KFSH
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Patient Survival rate
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Graft Survival rate
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Incidence of Complications
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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.
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• 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.

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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
• gt90 graft and patient survival
• 
  Transplant Proc. 2000 Nov

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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

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Compared to Canadian Transplants.

• Inferior graft survival at 3 years
• 98 biologically related donors
• 86 emotionally related donors
• 62 transplanted abroad
• Patient survival at 3 years
• 100 for those transplanted in Canada
• 82 for transplant tourists

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Iran facts

• One, and five survival rate is reported to be
  92.8, 83.7 respectively.
• Iran is the only country with no waiting list for
  kidney transplant and patients can receive the
  necessary organ in less than 2 months.

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Transplant outcomes

• Outcomes of United States Residents who Undergo
  Kidney Transplantation Overseas Canales et al,
  Transplant Tourism
• 10 kidney transplant patients (Sept 02 July
  06)
• Transplanted in Pakistan (8), China (1), Iran (1)
• Mean age 36.8 years
• Follow-up period 0.4-3.7 years (mean 2.0)
• 6 serious post op (in 3 months) infections in 4
  patients
• 1 death
• 1 graft failure due to acute rejection
• Graft survival and function generally good
• High incidence of post transplant infection
• Inadequate communication of information
  immunosuppressive regimens and perioperative
  information

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Kidney Transplants - India

• 150,000 Indians need transplants annually
• Only 3,500 actually performed
• Sale of organs illegal -
• Criminal act for foreigners to go to India to
  obtain transplants

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Stem Cell Transplants - China

• Parkinsons
• Human retinal epithelial cells from adults
• No immunosuppression required
• Cells injected stereotactically into putamen
• Daily cocktail of drugs to fertilize the area
• Stem cell activation and proliferation treatment
  (to enhance the bodys own neural stem cells)
• 20 patients treated
• No published RCTs

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Stem Cell Transplants - China

• Stroke
• self stem cell activation and proliferation
• 50 patients treated
• Minor to significant improvements
• Cerebral plasy, Degenerative neurologic
  disorders, Epilepsy, Brain infections
• Neural (fetal) stem cells
• Bone marrow stem cells (autologous)
• Both types of cells delivered by lumbar puncture
  cells are said to flow through the CSF into the
  brain

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Ethical issues transplant tourism

• Source of transplanted organs
• Potential for coerced organ donation
• Involuntary donations executed prisoners,
  kidnapping ??
• Transplant flow.
• South to north
• Female to male
• Inter ethnic
• Poor to financially secure
• Association with organized crime
• India, Brazil and other areas

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WHO

• World Health Organization
• 1987 concern over commercial trade (WHA)
• reports about brokers
• Benefits???
• 1989 Initiative for standards needed (WHA)
• International interest
• 1991 WHO Principles (WHA)
• 2004 Assemble more data (WHA)
• 2003 worldwide discussion on transplantation
  (Madrid)
• 2004-2006 meetings on cells, tissues, organs
• 2006 comprehensive awareness on Transplantation
• 2007 overall Observations (Spanish Ministry of
  Health)
• 2007 Second worldwide conference (Geneva)

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WHO

• 1991 Principles
• International standards
• Deceased donors preferred
• Related donors preferred
• No commercial transactions in human body
  ,prohibition on advertising.
• Fair access to donated organs ( economic)
• 2008 In revising Principles?
• Preference for deceased tempered by practice
  changes
• wider door for unrelated
• Commercial ban maintained,
• incentives acceptable? (real vs. subtle)
• Actions translucent scrutinize confidentiality
  secured.
• Quality for donors Tx recipient.

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Policies

• 50 countries adopted laws giving effect to norms
  in 1991 Guiding Principles
• China law adopted in 2006 sets standards
• license of transplant facilities (many closed)
• Bans profitable dealings.
• Establish criterions for deceased donor and
  allocation of organs
• End using organs from executed prisoners
• Pakistan law adopted in 2007 ban transplant
  tourism

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Cadaver Transplant - Conclusion

• Organ Shortage is a Crisis
• In the gulf we need to Network and start thinking
  of sharing resources, expertise and organs
• Set up Collaborative project
• Use Media for advertising
• Get Islamic scholars to contribute on Organ
  promotion.
• Set up regional Transplant coordinators Forums

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CHINA CONCLUSION

• Our data clearly show that Saudi patients who
  received transplants in China exhibited high
  mortality and morbidity rates.
• This result could be attributed to poor selection
  criteria, long warm ischemia time, and a question
  of suboptimal post-transplant care.
• Patients and clinicians need be aware of the
  outcome and its implications.
• Furthermore, patients should be enlightened about
  these risks as well.

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DD Transplant - Conclusion
In Gulf countries we need successful donor
programs that look at all the options On a
straightforward steps and changes we can make all
the distinction for our patients
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Bottom line

• Transplant tourism is a reality and a growth is
  expected
• Both risks and benefits exist
• Difficult to determine the extent of risks
• Quality of care is variable
• Gulf countries be aware
• Many ethical issues

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• THANK YOU