Undocumented immigrants' transplant survival rates on par with US citizens'

Unauthorized immigrants who receive liver transplants in the United States have comparable three-year survival rates to U.S. citizens, according to a study by researchers at UC San Francisco. Yet access to life-saving organs for this population varies widely by state, in part due to a medical misperception that undocumented migrants face a higher risk of transplant failure.

The findings appeared online Sept. 20, 2019, in Hepatology.

"Our results bring much-needed scientific evidence to a politically and medically divisive issue and shed light on disparities due to policy and provider attitudes," said corresponding author Brian P. Lee, MD, MPH, a gastroenterology and hepatology fellow at UCSF. "This could have considerable implications for the estimated 6,500 unauthorized immigrants in the United States who have end-stage renal disease and also may be relevant for other organ-transplant patients. We hope this will prompt appropriate action on national transplant policy."

An estimated 11 million foreign-born, non-citizens reside illegally in the United States and generally pay Social Security taxes. They account for about 3 percent of all deceased organ donors, but less than 0.5 percent of the recipients.

The United Network of Organ Sharing (UNOS) has no guidelines regarding liver transplant access for unauthorized immigrants, leaving transplant centers to establish their own policies. In 2012, UNOS began requiring liver transplant centers to record patients' citizen and residency status to better understand transplant tourism. Federal and state legislation also has been introduced that proposes specifically limiting organ transplant access for unauthorized immigrants. However, studies of this population group are sparse, partly due to difficulties identifying patients in medical registries.

In the Hepatology study, Lee and Norah Terrault, MD, MPH, a former UCSF professor of medicine who is now at the University of Southern California (USC), reviewed UNOS records of all U.S. liver transplant recipients between March 2012 and December 2018. They used Pew Research Center data to estimate the population of unauthorized immigrants in each state and by country of origin.

Of 43,192 recipients, 99.6 percent (43,026) were U.S. citizens and 0.4 percent (166) were unauthorized immigrants. The most common countries of origin were Mexico (52 percent), Guatemala (7 percent), China (6 percent), El Salvador (5 percent) and India (5 percent), rates similar to that of the overall U.S. immigrant population.

Compared to U.S residents, unauthorized immigrants were younger (49 years old vs. 58 years old), more frequently Hispanic (59 percent vs. 14 percent) and Asian (16 percent vs. 4 percent), had high school or below as the highest level of education (62 percent vs. 45 percent), and were covered by Medicaid (51 percent vs. 14 percent). They also were sicker, with a higher transplant score, and more likely to be on dialysis (31 percent vs. 15 percent), which suggests access to transplant late into their disease, Lee said.

Most transplants for these patients occurred in California (78 patients, 47 percent) and New York (30 patients, 18 percent), roughly twice their representation in the local populations (27 percent in California, 7 percent in New York), and almost a quarter of them occurred at USC (31) and UCSF (10). By contrast, the proportion of liver transplants for unauthorized immigrants was lower than their relative populations in Texas and Florida, highlighting a disparity in access across the country, Lee said. These differences corresponded to states favoring or resisting Medicaid expansion for transplant coverage.

A risk analysis found similar graft and patient survival rates for unauthorized immigrants as U.S. citizens, with one- and three-year survival rates of 95 percent and 88 percent, respectively, in unauthorized immigrants and 92 percent and 85 percent among residents.

"Given these findings of acceptable survival outcomes among unauthorized immigrants, concern for worse survival should not be used as a reason to deny access to liver transplant," Lee said. "Continued financial support after transplant also can be a barrier in this group, but those means are confirmed beforehand and also not a reason for denial."