BTS 2013 Report – Transplant tourism – a single centre experience
by Maria Dalby reporting on the presentation by Philip J Whatling, Royal Free Hospital, London. Patients who go abroad to have transplantations and return to the NHS for aftercare and follow-up may pose a significant threat to UK transplant centres in terms of multi-resistant infections.
Philip Whatling and colleagues at Royal Free Hospital in London have collated data from the last six years and presented their findings in a session entitled ‘Controversies in transplantation’. Philip Whatling described the figures as ‘disconcerting’.
The Declaration of Istanbul defines transplant tourism as patients who travel abroad to have transplantations, where organ trafficking or commercialisation is involved. The team at Royal Free reviewed all patients that had gone abroad for transplantation and returned to the centre during 2006 – 2012, thus using a wider definition of the term for a phenomenon that the NHS knows very little about, and on which no guidance is provided.
The retrospective analysis comprised a total of 22 patients who were identified as transplant tourists during the 6-year study period. The first surprising finding of the analysis was that more than half of the transplant tourists were under 50 years of age – not older patients who would, perhaps, not be considered for transplantation in the UK, as Philip Whatling and the team had anticipated. The predominant destinations were India (six patients) and Pakistan (nine patients); the other destinations were Iran, Brazil, Libya, Germany, Colombia, Cyprus and Israel (one patient each). Most of the procedures involved liver transplantations, and with the exceptions of the transplantations performed in Colombia and Cyprus, all organs were obtained from living donors (half from unrelated donors). No information was available regarding the two cadaveric donors – Philip Whatling described the circumstances surrounding these two operations as ‘unclear’ and pointed out that the patients had not been forthcoming with information. Lack of documentation was indeed a defining characteristic of this patient group – records and referral letters were non-existent or rudimentary in most cases.
Patients in the transplant tourist population at the Royal Free centre showed a mean eGFR of 53.5mls/min/1.73m2 at one year post-transplant, which is comparable to that seen amongst patients transplanted locally. The same proved true for the rate of surgical and medical complications – wound complications were reported for nine patients; the rate of acute rejection was around 18% which is similar to the UK median of 17%.
However, when the team looked specifically at infectious complications, a different picture emerged. Of the 22 patients transplanted abroad, four were diagnosed with hepatitis C within six weeks of re-presenting to the NHS, and one patient is currently awaiting a liver transplant. Even more seriously, in the same six-month period post-transplant, eight patients were found to be infected with a total of 19 multi-drug resistant pathogens, suggesting that transplant tourists may be a pool for these infections in the NHS. One patient was found to be infected with a strain carrying the very serious New Delhi metallo-beta-lactamase 1 gene which confers resistance to carbapenem antibiotics. The most common pathogens found were E coli and K pneumoniae, and one patient developed a Pseudomonas transplant abscess. Philip Whatling concluded that despite the small sample size and the similarity in non-infectious outcomes between transplant tourists and patients transplanted in the UK, this data suggests that the former may be at significant risk of developing severe infections and bringing multi-resistant strains into UK centres. Whilst the practice of transplant tourism cannot be condoned, it is happening and there is a need for consensus guidelines on the screening and management of these patients as they re-present to the NHS.