Deceased Donor Kidney and Liver Transplantation to Nonresident Aliens in the United States

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Abstract
Policies governing the allocation of deceased donor organs to nonresident aliens (NRAs) have existed from the early days of transplantation. However, there is a paucity of research describing this population. The aim of the present study is to examine characteristics and allocation patterns for NRAs compared to U.S. citizens in the context of the two most common forms of solid organ transplantation. The study included kidney and liver transplant candidates and deceased donor transplant recipients from 1988-2005 in the United States. We describe demographic characteristics, insurance coverage, geographic variability, and donor relationship based on citizenship and residency status. We additionally examined the association of citizenship with time to transplantation utilizing survival models. From 1988-2005, there were 2724 solitary kidney and 2072 liver NRA candidate listings with United Network for Organ Sharing. NRA recipients had more self-pay (liver 36% and kidney 22%) and foreign sources (liver 26% and kidney 13%) of insurance coverage. Transplants to NRAs were more frequent than deceased donations deriving from NRAs for both organs. Adjusted models indicated that NRA kidney candidates received transplants at the same rate as U.S. citizens while liver NRA candidates received transplants more rapidly during the pre-Model for End-Stage Liver Disease (MELD; adjusted hazard ratio [AHR] 1.2, confidence interval [CI] 1.2-1.3) and post-MELD (AHR 1.5, CI 1.3-1.7) eras. NRAs are demographically and socioeconomically diverse and have historically had a more rapid progression on the waiting list to receive a liver transplant. Further discussion and investigation concerning the ethical, economic, and public health ramifications of transplantation to NRA patients are warranted.