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Ethical Aspects of Kidney Donation and Transplantation for Migrants

      Summary: Migrants represent a large and diverse population globally that includes international refugees, stateless persons, expatriate workers, and more. Many migrants face significant barriers in accessing health care, especially scarce and costly resources such as dialysis and kidney transplantation. Improving equity of access to these kidney replacement therapies for migrant populations may present a range of complex ethical dilemmas, particularly in the setting of crises and when considering the use of residency status and citizenship as eligibility criteria for access to treatment. In this article, we discuss ethical obligations to provide kidney care for migrants, the implications of the self-sufficiency concept with regard to access to deceased donation and transplantation, factors that may influence evaluation of the risks and benefits of transplantation for migrants with insecure access to care, and the vulnerability of migrants to organ trafficking. We also present a set of general recommendations to assist in preventing and managing ethical dilemmas when making decisions about policy or practice regarding kidney care for migrants.

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      REFERENCES

        • Gostin LO
        • Abubakar I
        • Guerra R
        • Rashid SF
        • Friedman EA
        • Jakab Z.
        WHO takes action to promote the health of refugees and migrants.
        Lancet. 2019; 393: 2016-2018https://doi.org/10.1016/S0140-6736(19)31051-7
        • Langlois EV
        • Haines A
        • Tomson G
        • Ghaffar A.
        Refugees: towards better access to health-care services Europe PMC Funders Group.
        Lancet. 2016; 387: 319-321https://doi.org/10.1016/S0140-6736(16)00101-X.Refugees
        • El-Dassouki N
        • Wong D
        • Toews DM
        • et al.
        Barriers to accessing kidney transplantation among populations marginalized by race and ethnicity in Canada: a scoping review part 1—indigenous communities in Canada.
        Can J Kidney Health Dis. 2021; 82054358121996835https://doi.org/10.1177/2054358121996835
        • Aoun M
        • Koubar SH.
        Impact of forced human migration on management of end-stage kidney disease in host countries.
        Semin Nephrol. 2020; 40: 363-374https://doi.org/10.1016/j.semnephrol.2020.06.004
        • Van Biesen W
        • Vanholder R
        • Vanderhaegen B
        • et al.
        Renal replacement therapy for refugees with end-stage kidney disease: an international survey of the nephrological community.
        Kidney Int Suppl. 2016; 6: 35-41https://doi.org/10.1016/j.kisu.2016.09.001
        • Raghavan R.
        Caring for undocumented immigrants with kidney disease.
        Am J Kidney Dis. 2018; 71: 488-494https://doi.org/10.1053/j.ajkd.2017.09.011
        • OIM
        Glossary on Migration No. 34.
        2019 (Accessed March 11, 2022.)
        • McAuliffe M
        • Khadria B.
        1 Report Overview: Providing Perspective on Migration and Mobility in Increasingly Uncertain Times.
        International Organization for Migration, 2020
      1. UNHCR. Global Trends: Forced Displacement in 2020. 2021. Accessed March 11, 2022. https://www.unhcr.org/60b638e37/unhcr-global-trends-2020.

        • Crawley H
        • Skleparis D.
        Refugees, migrants, neither, both: categorical fetishism and the politics of bounding in Europe's ‘migration crisis.
        J Ethn Migr Stud. 2018; 44: 48-64https://doi.org/10.1080/1369183X.2017.1348224
        • Arici M.
        Refugees with kidney disease: an increasing global challenge.
        Nat Rev Nephrol. 2021; 17: 366-367https://doi.org/10.1038/s41581-020-00377-0
        • Lemke J
        • Schild R
        • Konrad M
        • et al.
        Distribution and management of the pediatric refugee population with renal replacement: a German pediatric cohort.
        Pediatr Nephrol. 2021; 36: 271-277https://doi.org/10.1007/s00467-019-04374-9
        • Uberoi D
        • Forman L.
        What role can the right to health play in advancing equity in kidney care?.
        Semin Nephrol. 2021; 41: 220-229https://doi.org/10.1016/j.semnephrol.2021.05.003
        • Onarheim KH
        • Melberg A
        • Meier BM
        • Miljeteig I.
        Towards universal health coverage: including undocumented migrants.
        BMJ Glob Health. 2018; 3e001031https://doi.org/10.1136/bmjgh-2018-001031
        • Bello AK
        • Alrukhaimi M
        • Ashuntantang GE
        • et al.
        Global overview of health systems oversight and financing for kidney care.
        Kidney Int Suppl. 2018; 8: 41-51https://doi.org/10.1016/j.kisu.2017.10.008
        • Luyckx VA
        • Moosa MR.
        Priority setting as an ethical imperative in managing global dialysis access and improving kidney care.
        Semin Nephrol. 2021; 41: 230-241https://doi.org/10.1016/j.semnephrol.2021.05.004
        • Ruger JP.
        Ethics and governance of global health inequalities.
        J Epidemiol Community Health. 2006; 60: 998-1003https://doi.org/10.1136/jech.2005.041947
        • Isreb MA
        • Kaysi S
        • Rifai AO
        • et al.
        the effect of war on Syrian refugees with end-stage renal disease.
        Kidney Int Reports. 2017; 2: 960-963https://doi.org/10.1016/j.ekir.2017.05.009
        • Rulli T
        • Millum J.
        Rescuing the duty to rescue.
        J Med Ethics. 2016; 42: 260-264https://doi.org/10.1136/medethics-2013-101643
        • Chiarenza A
        • Dauvrin M
        • Chiesa V
        • Baatout S
        • Verrept H.
        Supporting access to healthcare for refugees and migrants in European countries under particular migratory pressure.
        BMC Health Serv Res. 2019; 19: 1-14https://doi.org/10.1186/s12913-019-4353-1
        • Isreb MA
        • Oussama Rifai A
        • Murad LB
        • Al-Makki A
        • Al-Saghir F
        • Sekkarie MA
        Care and outcomes of end-stage kidney disease patients in times of armed conflict: recommendations for action.
        Clin Nephrol. 2016; 85: 281-288https://doi.org/10.5414/CN108795
        • Sekkarie MA
        • Abdel-Rahma EM
        Cultural challenges in the care of refugees with end-stage renal disease: what Western nephrologists should know.
        Nephron. 2017; 137: 85-90https://doi.org/10.1159/000477362
        • Sekkarie M
        • Murad L
        • Al-Makki A
        • Al-Saghir F
        • Rifai O
        • Isreb M.
        End-stage kidney disease in areas of armed conflicts: challenges and solutions.
        Semin Nephrol. 2020; 40: 354-362https://doi.org/10.1016/j.semnephrol.2020.06.003
        • Pérache AH
        • van Leeuwen C
        • Fall C.
        The politics of exclusion: fighting for patients with kidney failure in Yemen's war.
        J Public Health (Bangkok). 2020; 42: E311-E315https://doi.org/10.1093/pubmed/fdz133
        • Davies M
        • Cassimjee Z.
        Provision of long-term renal replacement therapy to non-national patients in South Africa.
        S Afr Med J. 2021; 111: 615-619https://doi.org/10.7196/SAMJ.2021.v111i7.15395
        • Delmonico FL
        • Domínguez-Gil B
        • Matesanz R
        • Noel L.
        A call for government accountability to achieve national self-sufficiency in organ donation and transplantation.
        Lancet. 2011; 378: 1414-1418https://doi.org/10.1016/S0140-6736(11)61486-4
        • Martin DE
        • Van Assche K
        • Domínguez-Gil B
        • et al.
        Strengthening global efforts to combat organ trafficking and transplant tourism: implications of the 2018 edition of the Declaration of Istanbul.
        Transplant Direct. 2019; 5: 1-13https://doi.org/10.1097/TXD.0000000000000872
        • Pérez-Blanco A
        • López-Fraga M
        • Forsythe J
        • et al.
        Access of non-residents to transplantation of deceased donor organs: practices and strategies in the European setting.
        Transpl Int. 2021; 34: 2112-2121https://doi.org/10.1111/tri.14113
        • Fortin MC
        • Williams-Jones B.
        Should we perform kidney transplants on foreign nationals?.
        J Med Ethics. 2014; 40: 821-826https://doi.org/10.1136/medethics-2013-101534
        • Martin DE
        • Fadhil RAS.
        The Doha model of organ donation and transplantation: thinking beyond citizenship.
        Griffith J Law Hum Dign. 2014; 2: 293
        • Fortin MC
        • Greenberg R.
        Should transplantation be offered to pediatric foreign nationals?.
        in: Greenberg R Goldberg A Rodríguez-Arias D Ethical Issues in Pediatric Organ Transplantation. Springer, 2016: 237-257https://doi.org/10.1007/978-3-319-29185-7_13
        • Rizzolo K
        • Cervantes L.
        Barriers and solutions to kidney transplantation for the undocumented Latinx community with kidney failure.
        Clin J Am Soc Nephrol. 2021; 16: 1587-1589https://doi.org/10.2215/CJN.03900321
        • de Castro LD.
        The Declaration of Istanbul in the Philippines: success with foreigners but a continuing challenge for local transplant tourism.
        Med Health Care Philos. 2013; 16: 929-932https://doi.org/10.1007/s11019-013-9474-4
        • Martin DE
        • Delmonico FL.
        Ethical issues and transplant tourism.
        in: Weir MR Lerma E V Kidney Transplantation. 1st ed. Springer Science, 2014: 69-74https://doi.org/10.1007/978-1-4939-0342-9_7
        • Al Attar B.
        Deceased donation after brain death (DBD).
        Saudi J Kidney Dis Transplant. 2021; 32: 597-612
        • Jamal M
        • Almahmeed H
        • Alghanem M
        • et al.
        Organ transplantation in Kuwait and the recent initiation of a liver program.
        Transplantation. 2021; 105: 2125-2127https://doi.org/10.1097/TP.0000000000003537
        • AlSahow A
        • AlYousef A.
        Global dialysis perspective: Kuwait.
        Kidney360. 2021; 2: 1015-1020https://doi.org/10.34067/kid.0000392021
        • Charnaya O
        • Verghese P
        • Goldberg A
        • Ladin K
        • Porteny T
        • Lantos JD.
        Access to transplantation for undocumented pediatric patients.
        Pediatrics. 2020; 146: 1-6https://doi.org/10.1542/peds.2019-3692
        • Shen JI
        • Hercz D
        • Barba LM
        • et al.
        Association of citizenship status with kidney transplantation in Medicaid patients.
        Am J Kidney Dis. 2018; 71: 182-190https://doi.org/10.1053/j.ajkd.2017.08.014
        • Yu E
        • Wightman A.
        Pediatric kidney transplant in undocumented immigrants: an American perspective.
        Pediatr Transplant. 2021; 25: 1-8https://doi.org/10.1111/petr.13788
        • Greenberg R
        • Ballesteros-Gallego F
        • Allard J
        • Fortin MC.
        Organ transplantation for foreign nationals in Canada: a survey of transplant professionals.
        Can J Kidney Health Dis. 2019; 62054358119859530https://doi.org/10.1177/2054358119859530
        • Luyckx VA
        • Al-Aly Z
        • Bello AK
        • et al.
        Sustainable development goals relevant to kidney health: an update on progress.
        Nat Rev Nephrol. 2021; 17: 15-32https://doi.org/10.1038/s41581-020-00363-6
        • Nguyen OK
        • Vazquez MA
        • Charles L
        • et al.
        Association of scheduled vs emergency-only dialysis with health outcomes and costs in undocumented immigrants with end-stage renal disease.
        JAMA Intern Med. 2019; 179: 175-183https://doi.org/10.1001/jamainternmed.2018.5866
        • Suphanchaimat R
        • Kantamaturapoj K
        • Putthasri W
        • Prakongsai P.
        Challenges in the provision of healthcare services for migrants: a systematic review through providers’ lens.
        BMC Health Serv Res. 2015; 15: 1-14https://doi.org/10.1186/s12913-015-1065-z
        • Doreille A
        • Godefroy R
        • Martzloff J
        • et al.
        French nationwide survey of undocumented end-stage renal disease migrant patient access to scheduled haemodialysis and kidney transplantation.
        Nephrol Dial Transplant. 2021; 37: 393-395https://doi.org/10.1093/ndt/gfab275
        • Shukhman E
        • Hunt J
        • LaPointe-Rudow D
        • et al.
        Evaluation and care of international living kidney donor candidates: strategies for addressing common considerations and challenges.
        Clin Transplant. 2020; 34: 1-11https://doi.org/10.1111/ctr.13792
        • Hartsock JA
        • Helft PR.
        International travel for living donor kidney donation: a proposal for focused screening of vulnerable groups.
        Transplantation. 2019; 103: 2576-2581https://doi.org/10.1097/TP.0000000000002875
        • Alasfar S
        • Isreb M
        • Kaysi S
        • Hatahet K.
        Renal transplantation in areas of armed conflict.
        Semin Nephrol. 2020; 40: 386-392https://doi.org/10.1016/j.semnephrol.2020.06.006
        • Poulakou G
        • Len O
        • Akova M.
        Immigrants as donors and transplant recipients: specific considerations.
        Intensive Care Med. 2019; 45: 401-403https://doi.org/10.1007/s00134-019-05534-z
        • Van Biesen W
        • Vanholder R
        • Ernandez T
        • Drewniak D
        • Luyckx V.
        Caring for migrants and refugees with end-stage kidney disease in Europe.
        Am J Kidney Dis. 2018; 71: 701-709https://doi.org/10.1053/j.ajkd.2017.10.015
        • Gursu M
        • Arici M
        • Ates K
        • et al.
        Hemodialysis experience of a large group of Syrian refugees in Turkey: all patients deserve effective treatment.
        Kidney Blood Press Res. 2019; 44: 43-51https://doi.org/10.1159/000498832
        • Oztek FZ
        • Tekin P
        • Herle M
        • Mueller T
        • Arbeiter K
        • Aufricht C.
        Does immigration background influence outcomes after renal transplantation?.
        Pediatr Nephrol. 2011; 26: 309-315https://doi.org/10.1007/s00467-010-1685-9
        • Council of Europe
        Resolution CM /Res (2017)1 on principles for the selection, evaluation, donation and follow-up of the non-resident living organ donors.
        2017 (Accessed March 11, 2022.)
        • Martin DE
        • Muller E.
        In defense of patient autonomy in kidney failure care when treatment choices are limited.
        Semin Nephrol. 2021; 41: 242-252https://doi.org/10.1016/j.semnephrol.2021.05.005
        • Thiessen C
        • Gordon EJ
        • Reese PP
        • Kulkarni S.
        Development of a donor-centered approach to risk assessment: rebalancing nonmaleficence and autonomy.
        Am J Transplant. 2015; 15: 2314-2323https://doi.org/10.1111/ajt.13272
        • Reese PP
        • Boudville N
        • Garg AX.
        Living kidney donation: outcomes, ethics, and uncertainty.
        Lancet. 2015; 385: 2003-2013https://doi.org/10.1016/S0140-6736(14)62484-3
        • Columb S.
        Excavating the organ trade: an empirical study of organ trading networks in Cairo, Egypt.
        Br J Criminol. 2017; 57: 1301-1321https://doi.org/10.1093/bjc/azw068
        • Lundin S.
        Organ economy: organ trafficking in Moldova and Israel.
        Public Underst Sci. 2012; 21: 226-241https://doi.org/10.1177/0963662510372735
        • Gill J
        • Diec O
        • Landsberg DN
        • et al.
        Opportunities to deter transplant tourism exist before referral for transplantation and during the workup and management of transplant candidates.
        Kidney Int. 2011; 79: 1026-1031https://doi.org/10.1038/ki.2010.540
        • Noel A.
        Les migrants, cibles du trafic d'organes.
        Le Monde, 2017 (September 4. Accessed March 11, 2022.)
      2. Nossiter A, Rahim N. Afghanistan, a booming kidney trade preys on the poor. New York Times. February 6, 2021. Accessed March 11, 2022. https://www.nytimes.com/2021/02/06/world/asia/selling-buying-kidneys-afghanistan.html

        • Capatides C
        • Williams H.
        Desperate Syrian refugees are resorting to selling their organs on the black market just to pay rent.
        CBS News, 2020 (May 19. Accessed March 11, 2022.)
        • Sahuquillo MR
        • Duva J.
        Five arrested in Spain's first case of human organ trafficking.
        El Pais, 2014 (March 12)
        • Berglund S
        • Lundin S.
        I had to leave.
        in: Gunnarson M Svenaeus F The Body as Gift, Resource, and Commodity. 1st ed. 2011: 321-342 (Sodertorns Hogskola)
        • Cohen L.
        Connecticut family begs government to approve visa so father can get kidney transplant.
        CBS News, 2019 (November 26. Accessed March 11, 2022)
        • Baylon J.
        As U.S. patients await organ transplants, potential donors struggle for visas.
        New York Times, 2011 (January 21. Accessed March 11, 2022)
        • Lentine KL
        • Motter JD
        • Henderson ML
        • et al.
        Care of international living kidney donor candidates in the United States: a survey of contemporary experience, practice, and challenges.
        Clin Transplant. 2020; 34: e14064https://doi.org/10.1111/ctr.14064
      3. Australian Government. Australian involvement in organ trafficking and transplant tourism 3.1. 2018. Accessed March 11, 2022.https://www.aph.gov.au/-/media/02_Parliamentary_Business/24_Committees/244_Joint_Committees/JFADT/Foreign_Affairs_Defence_and_Trade/Organ_Harvesting_Inquiry/Chapter_3.pdf.

        • Vanholder R
        • Gallego D
        • Sever MS.
        Wars and kidney patients: a statement by the European Kidney Health Alliance related to the Russian-Ukrainian conflict.
        J Nephrol. 2022; 35: 377-380https://doi.org/10.1007/s40620-022-01301-4
        • American Society of Nephrology, European Renal Association, International Society of Nephrology
        Joint statement from ASN, ERA, and ISN: global kidney organizations appeal for kidney health for all war victims.
        2022 (2022. Accessed March 11)
        • Sekkarie MA
        • Zanabli AR
        • Rifai AO
        • Murad LB
        • Al-Makki AA
        The Syrian conflict: assessment of the ESRD system and response to hemodialysis needs during a humanitarian and medical crisis.
        Kidney Int. 2015; 87: 262-265https://doi.org/10.1038/ki.2014.336
        • Vanholder R
        • Sever MS
        • Lameire N.
        The role of the Renal Disaster Relief Task Force.
        Nat Clin Pract Nephrol. 2008; 4: 347https://doi.org/10.1038/ncpneph0862
        • European Society for Pediatric Nephrology
        The ESPN Ukraine taskforce.
        2022 (2022. Accessed April 8)
        • Handtke Id O
        • Schilgen B
        • Mö M
        Culturally competent healthcare – a scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision.
        PLoS One. 2019; 14e0219971https://doi.org/10.1371/journal.pone.0219971
        • Balat A
        • Kilic BD
        • Aksu B
        • et al.
        Kidney disease profile and encountered problems during follow-up in Syrian refugee children: a multicenter retrospective study.
        Pediatr Nephrol. 2022; 37: 393-402https://doi.org/10.1007/s00467-021-05046-3
        • Olmeda Barrientos R
        • Valbuena VSM
        • Jacobson CE
        • et al.
        Non-English language resources and readability of kidney transplant center websites in the United States.
        JAMA Netw Open. 2021; 4: 2-5https://doi.org/10.1001/jamanetworkopen.2021.34236
        • Maneze D
        • Ramjan L
        • Rowhani-Farid N
        • et al.
        Attitude and Information from health professionals were associated with decision to donate organs among Arabic-speaking refugees: exploring opportunities for intervention.
        J Refug Stud. 2021; 34: 2478-2491https://doi.org/10.1093/jrs/feaa063
        • Tonelli M
        • Nkunu V
        • Varghese C
        • et al.
        Framework for establishing integrated kidney care programs in low- and middle-income countries.
        Kidney Int Suppl. 2020; 10: e19-e23https://doi.org/10.1016/j.kisu.2019.11.002
        • Otoukesh S
        • Mojtahedzadeh M
        • Cooper CJ
        • et al.
        Lessons from the profile of kidney diseases among Afghan refugees.
        Med Sci Monit. 2014; 20: 1621-1627https://doi.org/10.12659/MSM.890958