Should Kidney Transplants Be Offered to Undocumented Immigrants?

Nancy A. Melville

February 15, 2023

Undocumented immigrants who receive kidney transplants show no significant differences in key outcomes of all-cause graft loss or risk of rejection, compared with US residents, a new study shows.

This suggests that the denial of access to patients based on immigration status alone is not warranted, say the authors, led by Natsuki Eguchi, BSc, of the Department of Surgery, University of California, Irvine, and colleagues.

"Across the US, [undocumented immigrants] have consistently had unequal access to transplantation," they note in their article published online February 13 in JAMA Network Open. "These findings suggest that extending kidney transplants to undocumented immigrants is safe and does not portend worse outcomes."

Coverage Is Key and Is Provided in California

Undocumented immigrants are often perceived as having a higher risk of transplant failure due to language barriers as well as a lack of access to immunosuppressive medication and healthcare, say the authors.

Maintenance dialysis and kidney transplant, known to be significantly more cost-effective options for patients with end-stage kidney disease (ESKD) compared with emergency-only dialysis, are covered by Medicare for US residents, but not for undocumented immigrants.

However, California is one of the few states that provides undocumented immigrants with state-funded coverage for transplantation and post-transplant immunosuppression, as well as maintenance dialysis, under the California medical assistance program (Medi-Cal), say Eguchi and colleagues.

The new study therefore underscores the success of California's Medi-Cal policy for all patients with ESKD, regardless of residency status, as noted in an accompanying editorial.

In addition, the study "exemplified the tangible outcomes an individual kidney transplant center can produce when it is committed to providing equitable access to transplantation for undocumented immigrants," write Aaron M. Delman, MD, and colleagues at the University of Cincinnati College of Medicine, Ohio, in their editorial.

Study Details

To analyze kidney transplant outcomes among undocumented immigrants versus US residents in a setting where they have equal access to kidney healthcare services, Eguchi and colleagues conducted a retrospective cohort study at their center.

The study included 446 consecutive kidney transplant recipients treated at UC Irvine between 2012 and 2019, among whom 114 (26%) were undocumented immigrants.

Patients, who were a mean age of 47 and 59% were male, had a median follow-up of 3.4 years. During that time, all-cause graft loss occurred among 6 (5.3%) undocumented immigrants and 48 (14.5%) US residents.

After adjusting for age and ethnicity, there was no significant difference in rate of kidney allograft rejection between US residents (3.5 per 100 person-years) versus undocumented immigrants (2.4 per 100 person-years; rate ratio, 1.45; P = .08).

However, before adjustment, there was a significantly higher rate of kidney graft loss and all-cause mortality among US residents compared with the undocumented immigrant group.

This suggests that undocumented immigrant patients receiving kidney transplantation are generally younger and healthier, and this may have been the primary driver of the reduced mortality observed, consistent with another nationwide study, say the authors.

"Granting maintenance dialysis and kidney transplantation access to all ESKD patients is not only essential to provide ESKD patients with better outcomes, but to also reduce the cost of ESKD treatment," they say.

"All in all, [recent] studies, along with ours, call into question the long-held belief that undocumented immigrants have worse transplant outcomes," they conclude.

The study authors and editorialists had no relevant disclosures.

JAMA Netw Open. Published online February 13, 2023. Full text, Editorial

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