Caring for Undocumented Immigrants With Kidney Disease

Rajeev Raghavan


Am J Kidney Dis. 2018;71(4):488-494. 

In This Article

Abstract and Introduction


The care of dialysis-dependent undocumented immigrants exemplifies a problem at the crux of 2 US national agendas: immigration and health care reform. Undocumented immigrants represent 3% of the US population and 27% of the uninsured, and an estimated 6,500 individuals are dialysis dependent. With no uniform national policy, an estimated 30% to 50% of these individuals receive treatment only in life-threatening situations (emergent dialysis). Since 2005, about 400 undocumented immigrants have received a kidney transplant (>70% living). Although the Affordable Care Act specifically excluded noncitizens, its policies have indirectly allowed more than 200 individuals to purchase insurance from a health insurance exchange and transition from emergent to thrice-weekly hemodialysis. Under the Trump administration, uncertainties with health care plans, threats of deportation, and rescinding of policies such as sanctuary city status are bound to result in unforeseen challenges for this vulnerable population. Global variation in the care accessible to migrants, refugees, undocumented immigrants, and asylum seekers argues for the need for a framework to transform advocacy into public policy to improve the lives of patients with kidney disease worldwide. Access to nonemergent dialysis is humane and cost-effective; it deserves to be espoused and advocated by leading medical organizations.


Undocumented immigrants constitute 3% of the US population and are the largest group (27%) among the uninsured, despite passage of the Affordable Care Act (ACA) and expansion of state-based insurance coverage.[1] Worldwide, globalization and mass migration of refugees have forced host countries to reexamine their health care policies for noncitizens with chronic illnesses, including those with chronic kidney disease (CKD). The fundamental question for policy makers is whether to provide equal access to health care for all individuals within their national border, regardless of legal immigration status.

There is a lack of uniform policy for provision of care for undocumented immigrants with kidney failure, with variability within and among states in the United States and also among countries worldwide.[2,3] The result of these inconsistent approaches is increased costs for hospital systems, reduced quality of life for patients, and daily ethical dilemmas for providers forced to determine "who deserves hemodialysis today?"[4–7]

Two comprehensive reviews on the care of dialysis-dependent undocumented immigrants have been published.[2,8] This AJKD Policy Forum article provides an update, considers looming US policy changes, examines how noncitizens receive kidney care globally, and proposes an approach to document and advocate solutions that can improve the care of this population. The purpose of this Perspective is to stimulate research and public discussion of the issues to create cost-effective and humane solutions for the care of undocumented immigrants with kidney failure.