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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 7-11

Kidney transplant-related medical tourism in patients with end-stage renal disease: A report from a renal center in a developing nation


Department of Medicine, Renal Centre, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Submission19-Mar-2019
Date of Decision06-May-2019
Date of Acceptance18-Oct-2019
Date of Web Publication18-Mar-2020

Correspondence Address:
Dr. Hamidu Muhammad Liman
Department of Medicine, Renal Centre, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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DOI: 10.4103/smj.smj_17_19

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  Abstract 


Background: Kidney transplant-related medical tourism is still prevalent in developing countries for patients with end stage renal disease. Objectives: We set out to review our single centre experience with kidney transplant-related medical tourism. Materials and Methods: We reviewed the demographic and clinical characteristics of our endstage renal disease patients who opted for kidney transplant over an 11 year period. Endpoint was kidney transplantation. Data was analysed with SPSS Statistical software Version 20. Results: A total of 27 patients were referred for kidney transplant evaluation, out of which 12(44.4%) were transplanted. All the 15 patients who were not transplanted died within one year of returning to our centre. The finding of co-morbidity during pre-transplant evaluation and lack of a suitable donor were the major reasons for our patients returning without a transplant. Of those who were transplanted, 5(41.7%) patients died from various complications. Conclusion: Kidney transplant-related medical tourism is still prevalent in Nigeria. Comorbidity and lack of suitable donor remain important impediments to kidney transplantation even when finance is available. Local Kidney transplant needs to be encouraged in Nigeria.

Keywords: End-stage renal disease, kidney transplant, medical tourism


How to cite this article:
Liman HM, Makusidi MA, Sakajiki AM. Kidney transplant-related medical tourism in patients with end-stage renal disease: A report from a renal center in a developing nation. Sahel Med J 2020;23:7-11

How to cite this URL:
Liman HM, Makusidi MA, Sakajiki AM. Kidney transplant-related medical tourism in patients with end-stage renal disease: A report from a renal center in a developing nation. Sahel Med J [serial online] 2020 [cited 2020 Mar 28];23:7-11. Available from: http://www.smjonline.org/text.asp?2020/23/1/7/280938




  Introduction Top


Kidney transplantation is the preferred form of treatment for patients with end-stage renal disease (ESRD), as it offers a better quality of life[1],[2] and is also cheaper than chronic maintenance dialysis in the long term.[3],[4] Kidney transplantation has become a routine surgical procedure in many hospitals in developed countries.[5],[6] This procedure is still uncommon in developing countries such as Nigeria. Impediments to successful adoption of kidney transplantation in Nigeria include the lack of political will from the Government to fund the program, inadequately trained workforce, lack of appropriate diagnostic facilities, reliance on imported medical products and drugs, lack of health insurance coverage for ESRD patients, poverty and shortage of voluntary organ donors.[7]

Kidney transplant tourism involves the movement of the recipient, donor, or medical personnel to health facilities from one country to another, for kidney transplantation.

The first kidney transplantation in Nigeria was done in the year 2000 at St. Nicholas Hospital, Lagos.[7],[8] As of November 2016, 13 other public and private health facilities in Nigeria have conducted at least one kidney transplant.[9] However, with a population of about 180 million Nigerians, these transplant centers are still inadequate to meet the needs of ESRD patients requiring kidney transplants.

Studies have described favorite destinations for kidney transplant tourism for Nigerian patients, with the most favorite being India.[7],[8] This is mainly due to its relatively cheaper cost of care, and perhaps easy access to commercial donors before the abolishment of commercial kidney donation in 1994.[10]

This study describes the characteristics and outcomes of patients from a renal center in North-Western Nigeria, who were exposed to kidney transplant tourism.


  Materials and Methods Top


Study area

This study was conducted at the Renal Centre of Usmanu Danfodiyo University Teaching Hospital, Sokoto. The hospital is an 800-bedded multi-specialty facility serving four Nigerian States (Sokoto, Kebbi, Zamfara, and Niger) with a combined population of about 15 million. The Renal Centre offers outpatient and inpatient care for renal patients, including pre- and post-transplant care. It is, however yet to start kidney transplantation. The center conducts about 100 dialysis sessions monthly, and most of the patients are unable to sustain chronic dialysis.[11]

Study design and population

This is a retrospective study of ESRD patients seen from July 1, 2007 to June 30, 2018 (11 years). Ethical approval (UDUTH/HRE/2019/no 883) was obtained from the ethical committee of the hospital on 5th July 2019. The study complied with guideline in 2013 Helsinki's declaration.

Inclusion criteria

Patients with chronic kidney disease referred to foreign countries for treatment.

Exclusion criteria

Patients who were transplanted in center within Nigeria were excluded from the study.

Data collection and analysis

Recipient pre-transplant tourism information collected included bio-data, cause of ESRD, and duration on hemodialysis, hepatitis status, and source of funding. Transplant information collected included donor source, country visited, duration of stay at transplant center, and outcome of kidney transplant tourism. Post transplant data collected included post transplant complications and survival as at the last follow-up. For deceased patients, causes of death were retrieved from the medical records. All data were collected using a structured open questionnaire. Outcome variables included transplant procedure and survival after returning to our center. Data were analyzed using the Statistical Package for the Social Sciences Version 20 (IBM New York, USA). Categorical data are expressed as frequencies and percentages, whereas continuous data are expressed as median, means, and standard deviation.


  Results Top


A total of 1017 ESRD patients were enrolled in our hemodialysis program during the study period. Of these, only 27 (2.7%) patients, comprising 15 (55.6%) males, were referred for kidney transplant following their expression of interest. The patients' age ranged from 15 to 75 (mean 41.2 ± 15.6) years old. The causes of ESRD are shown in [Table 1]. Chronic glomerulonephritis was the most frequent cause of ESRD (n = 12, 44.4%). The median duration on dialysis before referral was 18.7 (range, 1–276) weeks. The median number of hemodialysis sessions was 26 (range, 3–102). Only 2 (7.4%) patients were seropositive to Hepatitis B Virus. Male donors were more readily available as only 2 (7.4%) female donors donated their kidneys for their recipients (both donors were mothers to the recipients). Funding for the transplant evaluation was provided by personal and family sources in 15 (55.6%) patients. Government funded 5 (18.5%) patients. Five (18.5%) patients were supported by combined Government and family funding; 1 (3.7%) patient was fully supported by a philanthropist and 1 (3.7%) patient was supported by a private company. Health insurance did not support any patient. A total of 19 (70.4%), 7 (25.9%) and 1 (3.7%) patients were referred to India, Egypt, and the United Arab Emirates, respectively, for transplant evaluation. Patients who traveled to India stayed the longest at the transplant center with a median duration of 12.4 (range, 3–26) weeks. Of the 27 patients referred for transplant evaluation, only 12 (44.4%) patients were transplanted. Of these, 5 (41.7%) were males. The mean age of the transplanted patients was 36 ± 14.6 (range, 15–56) years. The reasons for returning without a transplant were due to the finding of significant pretransplant comorbidity in 8 (53.3%) patients and issues with donor availability [Table 2]. Of the 12 transplanted patients, 7 (58.3%) are currently alive, with the oldest graft being 8 years old. One and 5 years graft survival rates were 41.7% and 33.3%, respectively. Of the 12 transplanted patients, 2 (7.4%) died of chronic allograft rejection and 1 (3.7%) each from acute allograft dysfunction, stroke, and massive upper gastrointestinal bleeding. All the 15 patients who were not transplanted died within 6 months of returning to our center.
Table 1: Characteristics of the study population (n=27)

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Table 2: Reasons for returning to Nigeria without transplant (n=15)

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  Discussion Top


Medical tourism for the purpose of kidney transplantation is still prevalent in Nigerian patients. The overall transplant referral rate from our center is quite low compared to other renal centers in developed countries where transplant rates ranging between 12.5% and 23% were reported.[5],[12],[13],[14] Most of our patients were young and in their reproductive age group. This is a common feature in patients with ESRD in developing countries.[15],[16] However, this is in sharp contrast with patients from advanced countries where the elderly are more predominant.[17],[18] There is a slight male preponderance in our patients, a finding similar to reports from other developing countries.[19],[20]

In our study population, the three leading causes of ESRD are chronic glomerulonephritis, hypertension, and diabetes mellitus, a finding similar to published studies in ESRD patients in developing countries.[21],[22],[23] The diagnosis of multiple myeloma was missed in two of the patients. This was confirmed at the referral center necessitating their rejection as potential kidney transplant recipients. This highlights the need for more extensive evaluation of all potential kidney transplant recipients. Among the two patients with Hepatitis B infection, one was rejected because of confirmed liver cirrhosis, whereas the second patient could not secure an anticipated commercial donor.

Majority of our patients opted for India as their transplant destination, a finding similar to the findings of other studies from Nigeria.[6],[24],[25] Other studies have identified Egypt, Pakistan, China, Philippines, and Mexico as favorite destinations for kidney transplant-related medical tourism.[26],[27] Some studies have identified other factors that determine the choice of transplant destination. These include expertise, cost, donor approval, geographical proximity, advertisement, and ease of obtaining travel documents from the country of destination.[28]

Although some studies have identified the difficulty in obtaining living donors by patients from low-socioeconomic countries,[29],[30] none of our patients benefitted from cadaveric transplant. Most of our donors were genetically related to our patients. This is similar to the findings of a study of Nigerian transplant patients from different transplant centers over a 10-year period where 82.5% of the donors were genetically related.[19] This is, however, in sharp contrast to the findings of a study in eastern Nigeria where 69.8% of the donors were living unrelated.[25] The source of organs for Nigerian patients with ESRD is mainly living donors. Some studies have identified living-related donor source of between 30% and 40%, whereas nonrelated donors (emotional and commercial) ranged between 40% and 60%.[10],[31]

The main source of funding for medical tourism and transplantation for our patients was from personal and family savings. A few patients were supported by the government. No patient was supported by health insurance. This is similar to the findings of other studies in Nigerian patients.[7],[8],[19],[25] This is unlike many developed countries where health insurance supports the transplant of most patients.[5],[6],[14],[32]

Most of our patients were on dialysis for <3 months before they were referred for transplant. There was no preemptive transplant for any of our patients because of late presentation of most of our patients. Patients from low-socioeconomic status settings are generally less likely to receive a transplant before commencing dialysis.[29] Of the 26 patients referred for transplant, 53.9% returned to our facility without a transplant. The main reasons for not being transplanted were due to the presence of comorbidity and failure to secure a suitable donor. Other studies have also identified lack of donor, presence of comorbidities, and sudden shortage of finances as reasons for returning without transplant.[25],[33]

The outcome of kidney transplantation in Nigerian patients has been described as largely successful, with 1 and 3 years graft survival ranging between 80% and 90% and 70% and 75%, respectively. A mortality rate of 27% mortality over a 10-year period has been reported.[19] In our study population however, the 1 year graft survival rate for tourist transplants is quite low compared to 89% reported in the USA[34] and 81% reported in Lagos.[35]

Of the five patients who died after transplant, 2 died of chronic allograft dysfunction caused by poor drug compliance. This emphasizes the need to adequately counsel patients on the need to be adherent to their posttransplant immunosuppression protocol.

Limitations

This study is limited by its small size and lack of control to compare the outcome of transplant. This notwithstanding, it is important to note that only a small proportion of our ESRD patients requiring kidney transplant were able to afford to travel overseas for kidney transplant evaluation, mostly in India.


  Conclusion Top


Kidney transplant-related medical tourism is still prevalent in Nigeria. Comorbidity and lack of suitable donor remain important impediments to kidney transplantation even when finance is available. One-year graft survival is poor. Local Kidney transplant needs to be encouraged in Nigeria. Financial support and sponsorship

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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