Advertisement
American Journal of Kidney Diseases

Kidney Transplantation in Undocumented Immigrants With ESRD: A Policy Whose Time Has Come?

  • Ellena A. Linden
    Affiliations
    Division of Nephrology, Elmhurst Hospital Center, Elmhurst, NY

    Mount Sinai School of Medicine, New York, NY
    Search for articles by this author
  • Author Footnotes
    ⁎ Current affiliation: Department of Medicine, Hospital Metropolitano “Dr. Tito Mattei”, Yauco, Puerto Rico.
    Jeannette Cano
    Footnotes
    ⁎ Current affiliation: Department of Medicine, Hospital Metropolitano “Dr. Tito Mattei”, Yauco, Puerto Rico.
    Affiliations
    Division of Nephrology, Elmhurst Hospital Center, Elmhurst, NY
    Search for articles by this author
  • George N. Coritsidis
    Correspondence
    Address correspondence to George N. Coritsidis, MD, Nephrology, Elmhurst Hospital Center, 79-01 Broadway, B2-01, Elmhurst, NY 11373
    Affiliations
    Division of Nephrology, Elmhurst Hospital Center, Elmhurst, NY

    Medicine and Surgery, Mount Sinai School of Medicine, New York, NY
    Search for articles by this author
  • Author Footnotes
    ⁎ Current affiliation: Department of Medicine, Hospital Metropolitano “Dr. Tito Mattei”, Yauco, Puerto Rico.

      Background

      In most US states, taxpayers are paying, either directly or indirectly, for years of dialysis therapy for undocumented immigrants with end-stage renal disease who lack resources to pay for care themselves. Living donor transplant is a less expensive long-term alternative, but it is unknown what percentage of these patients have potential living donors.

      Methods

      We conducted a cross-sectional survey of undocumented immigrant patients receiving dialysis at our outpatient center between March and May 2010. Forty-five patients completed the survey. The survey focused on the availability of potential living donors, perceived health status of those donors, and potential recipients' outlook on remaining on dialysis therapy versus receiving a kidney transplant. We gathered demographic and health status data for the survey participants and the 82 documented resident patients receiving care in the same dialysis unit.

      Results

      The average age of our undocumented immigrant patients was 44 years. The undocumented patients were healthier than their legal resident counterparts, with a lower incidence of coronary artery disease (7% vs 33%; P < 0.005) and diabetes mellitus (40% vs 68%; P < 0.005). Approximately half the undocumented immigrants were working when they were surveyed. Of the half who had stopped working, 82% said they would seek work if they had a kidney transplant. 60% had at least one potential kidney donor. Most donors were reported to reside in the United States or Canada.

      Conclusions

      Undocumented immigrants treated with dialysis in the United States are relatively young and healthy, and many have at least one potential living kidney donor. Given the societal cost-savings associated with transplant, we suggest that policy makers should consider extending coverage to pay for living donor transplant for undocumented immigrants with end-stage renal disease.

      Index Words

      Editorial, p. 335
      There are approximately 11 million undocumented immigrants in the United States.
      Pew Hispanic Center
      Unauthorized immigrant population: national and state trends, 2010.
      Media reports have been emphasizing the impact of this group on the US health care system
      • Wolf R.
      Rising health care costs put focus on illegal immigrants.
      Fox News
      LA emergency rooms full of illegal immigrants.
      ; however, there is a paucity of data regarding the health of both the undocumented immigrant population in general and the subset with end-stage renal disease (ESRD). Nevertheless, it is apparent that dialysis care for this population is expanding. In a survey of American nephrologists from 44 states, 65% of respondents reported providing care for undocumented immigrants.
      • Hurley L.
      • Kempe L.A.
      • Crane L.A.
      • et al.
      Care of undocumented individuals with ESRD: a national survey of US nephrologists.
      This care is being provided although most states do not have clear financial provisions for such treatment.
      Legislation surrounding undocumented immigrants' access to dialysis care is complex. A federal law passed in 1972 guaranteed access to renal replacement therapy (RRT) to all patients with ESRD in the United States without mention of citizenship status. The 1986 Omnibus Reconciliation Act prohibits the use of federal funds for undocumented immigrants except in emergency situations. Congress simultaneously enacted the Emergency Medical Treatment and Active Labor Act (EMTALA). Thus, hospitals receiving Medicare funding are mandated to provide emergency care, but restricted from providing nonemergency care to undocumented immigrants. In the case of RRT, this means that dialysis must be provided in an emergency situation, but cannot be provided until the situation becomes emergent. The subsequent Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA, also known as the Welfare Reform Act) passed in 1996 further restricts eligibility requirements for federal funding and leaves states to determine independently what public benefits would be offered to undocumented immigrants. Some states, namely Arizona, California, Massachusetts, New York, and North Carolina, have chosen to use state-allocated Medicaid funds to support maintenance dialysis treatment for undocumented immigrant patients with ESRD.
      • Straube B.
      Reform of the US healthcare system: care of undocumented individuals with ESRD.
      However, most states continue to provide dialysis on an emergent basis only, meaning that patients who require long-term dialysis treatment are forced to seek their care in emergency departments and must wait for ESRD complications that are considered to be emergent (such as refractory hyperkalemia, volume overload, or acidosis or complications of uremia) to arise before receiving dialysis.
      • Campbell G.A.
      • Sanoff S.
      • Rosner M.
      Care of the undocumented immigrant in the United States with ESRD.
      • Raghavan R.
      • Nuila R.
      Survivors—dialysis, immigration and U.S. law.
      Queens County, New York, is the most diverse county in the United States, with immigrants making up 47% of the county's residents. The state of New York has the fourth largest undocumented immigrant population after California, Texas, and Florida.
      • Campbell G.A.
      • Sanoff S.
      • Rosner M.
      Care of the undocumented immigrant in the United States with ESRD.
      During the last 20 years, our institution (Elmhurst Hospital Center, a 700-bed public hospital in Queens, NY) has seen the proportion of undocumented immigrant population increase from 11% (1991-1995) to 31% (2001-2005) regarding incident dialysis patients.
      • Shahata H.
      • Hernandez M.
      • Dhayalan M.
      • et al.
      The impact of inadequate pre-dialysis care and undocumented aliens on an urban hospital based dialysis center.
      The outpatient dialysis treatments are paid for by the state's Emergency Medicaid program. Options for ESRD treatment in this population do not include transplant. Emergency Medicaid coverage provides payments for ongoing outpatient dialysis, but not for transplant.
      We hypothesized that undocumented immigrants with ESRD generally are younger and healthier than the overall dialysis population and that they may have available potential living donors, making living donor kidney transplant a viable possibility.

      Methods

      Elmhurst Hospital Center is 1 of 2 municipal Health and Hospital Corporations' hospitals in the borough of Queens. The Health and Hospital Corporations has 11 hospitals in the New York City metropolitan area; of these, Elmhurst has the busiest emergency department. The outpatient hemodialysis unit is physically located within the hospital building, but is privately owned. Most ESRD referrals come from Elmhurst's emergency department and clinics.
      Charts of all outpatient dialysis patients from March until May 2010 were reviewed. Undocumented immigrant patients were identified by social history and lack of a social security number. Patients then were asked to complete an oral questionnaire administered by one of the authors in English or Spanish or in any other language that the patient requested with the use of a telephone translation service. Patients were given a choice to have the questionnaire administered during a dialysis session or in a closed office.
      The questionnaire (Item S1, available as online supplementary material) included demographic questions focusing on the patient's country of origin, reasons for coming to the United States, level of education, and employment status, as well as questions about time elapsed since the patient became aware of having kidney disease and duration of treatment with maintenance dialysis. Patients were asked about their attitude toward transplant and what they thought they would do if they received a transplant. The questionnaire inquired about the availability of, relationship to, and health of potential kidney donors.
      Patients' charts and Centers for Medicare & Medicaid Services 2728 forms (ESRD Medical Evidence Reports) were reviewed for demographic information, such as the patient's age, years on dialysis therapy, cause of ESRD, comorbid conditions, and hospitalizations within the previous year. For comparison, we gathered demographic and health status data from the charts of the 82 legally resident dialysis patients receiving care in our unit. The study was approved by our Institutional Review Board. Upon request of the institutional review board committee, a Certificate of Confidentiality was obtained from the National Institutes of Health. Written informed consent was obtained from all study participants.

      Results

      Of 132 patients receiving RRT at our outpatient dialysis unit, 50 (38%) were identified as undocumented immigrants. One patient was excluded due to prolonged hospitalization for anoxic encephalopathy. The 49 remaining patients were approached by one of the study investigators. Forty-five patients gave consent to participate and completed the oral questionnaire. Four patients chose not to participate in the study; no reason was given for their refusal. One of the 45 participating patients (2%) was undergoing peritoneal dialysis, and the other 44 (98%) were receiving hemodialysis. Study participants were mostly men (71%) and relatively young, with an average age of 43.8 ± 13.9 years. Most were from Mexico and South and Central Americas (87%); the rest were from East and South Asia. Basic demographics and causes of ESRD are listed in Table 1.
      Table 1Characteristics of Survey Respondents
      CharacteristicValue
      Men32 (71)
      Age (y)43.8 ± 13.9
      Geographic origin
       Mexico & Central America26 (58)
       South America13 (29)
       Asia6 (13)
      Cause of ESRD
       Diabetes mellitus16 (36)
       Hypertension13 (29)
       Glomerular disease11 (24)
       Other/unknown5 (11)
      Diabetes mellitus18 (40)
      Coronary artery disease3 (7)
      Annual no. of hospitalizations per patient0.9
      Employed23 (51)
      Note: N = 45. Except as indicated, values are shown as number (percentage) or mean ± standard deviation.
      Abbreviation: ESRD, end-stage renal disease.
      Education level generally was low; 47% received either no formal education or only elementary education, and another 31% had a high school degree (Table 2). Most (71%) came to the United States to work. Most were employed as unskilled laborers (cooks, house cleaners, restaurant workers, and construction workers), and only 4 patients had skilled positions (3 graphic designers and 1 fashion consultant).
      Table 2Social Status of Survey Respondents
      ParameterValue
      Education level
       No formal education4 (9)
       Elementary17 (38)
       High school14 (31)
       College10 (22)
      Time based in US (y)12.2 ± 7.4
      Reason for coming to the US
       To work/make money27 (60)
       To be with family3 (6)
       To work and be with family5 (11)
       Came as a tourist/to visit5 (11)
       Came to seek health care for self4 (9)
       Came to seek health care for family member1 (2)
      Current employment status
       Working full-time19 (42)
       Working part-time4 (9)
       Stopped working21 (47)
       Never worked1 (2)
      Note: Values shown are number (percentage) or mean ± standard deviation.
      Abbreviation: US, United States.
      The average time the survey respondents had been in the United States was 12.2 ± 7.4 years. On average, these patients had known that they had kidney disease for 4.5 ± 4.8 years and had been receiving dialysis for 2.9 ± 2.4 years. Study participants had been in the United States for an average of 7.7 years before learning that they had kidney disease and an average of 9.3 years before starting dialysis therapy. Four (9%) patients stated that kidney disease was diagnosed prior to coming to United States and indicated that they are in the United States because they need RRT (Table 2).
      Fifty-one percent of undocumented immigrants were still working despite the need for dialysis, and 83% of those working were doing so full time. One person (2%) had never worked in the United States. Of those who had stopped working, 52% did so due to kidney disease and dialysis schedule (Table 2). Of those who were still working, all except one stated that they would continue working if they remained on dialysis therapy (96%) and all would continue working if they received a transplant (100%). Of those not working, 18 (82%) stated that they would seek work if they had a kidney transplant versus 11 (50%) if they stayed on dialysis therapy (P < 0.05). For comparison, only 6% of our legally resident patients were employed.
      Seven (16%) undocumented immigrants stated that they would return to their home country after a kidney transplant, whereas 36 (84%) would remain in the United States. If nothing changed, 5 (11%) patients planned on going back to their home countries, whereas 40 (89%) patients planned to continue living in the United States. The reasons for continuing to live in the United States were given as health care/kidney disease treatment in 34 (85%), family residing in the United States in 4 (10%), and “other” in the remaining 2 patients (5%).
      Forty-three (96%) patients said that if eligible, they would like to get a kidney transplant. Thirty-two (71%) described kidney transplant as being viewed positively in their culture, 7 (16%) were not sure how kidney transplant would be perceived, and the rest gave varied answers. When asked how much they would be able or willing to pay for kidney transplant surgery, 16 (36%) could not provide a figure. The other 29 patients gave an average of $18,775.
      Of the 45 patients surveyed, 27 (60%) said they had at least one potential kidney donor. Of patients with donors, the average number of donors was 1.9 (range, 1-4). The average age of the potential donor was 33 years. Forty-four percent of potential donors were patient's siblings; parents and other relatives accounted for another 38%. A known medical problem was reported in only one potential donor (diabetes mellitus), and the other 51 (98%) donors were reportedly healthy. Most donors (64%) already resided in the United States or Canada, another 6% were in the Dominican Republic, and the rest were scattered around the world, reflecting patients' countries of origin (Table 3). Of the 27 patients from Mexico and Central and South Americas, 25 (93%) had potential living donors.
      Table 3Potential Kidney Donors of Survey Respondents
      VariableValue
      No. of potential donors per patient1.9 ± 1.0
      Age of potential donor (y)33.3 ± 11.1
      Relationship of donor to patient
       Sibling23 (44)
       Child9 (17)
       Parent4 (8)
       Other relative7 (13)
       Spouse2 (4)
       Friend5 (10)
       Girlfriend/boyfriend2 (4)
      Health problems in donor
       None51 (98)
       Diabetes1 (2)
      Donor's place of residence
       US and Canada32 (64)
       Dominican Republic3 (6)
       Mexico & Central America8 (16)
       South America3 (6)
       South East Asia3 (6)
       Middle East1 (2)
       No answer given2 (4)
      Note: Values expressed as number (percentage) or mean ± standard deviation.
      Abbreviation: US, United States.
      Compared with the legally resident population, the undocumented immigrant group was younger and healthier. The prevalence of diabetes mellitus was 40% in the undocumented immigrant group versus 68% in the comparison group (P < 0.005). In 7% of undocumented immigrant patients, coronary artery disease had been diagnosed versus 33% of legally resident patients (P < 0.005).
      Hospitalization rates were not different between our undocumented immigrant and legally resident groups. In terms of reasons for admissions, 6 patients had been admitted during the previous year for cardiac reasons (namely, angina and myocardial infarction); all were in the legally resident group. Overall, reasons for hospitalizations varied widely in both groups.

      Discussion

      Consistent with our hypothesis, undocumented immigrant dialysis patients in our study were younger and healthier than their legally resident counterparts. Table 4 shows comparisons of patients in our unit with the US Renal Data System population, as well as with patients who are actively listed and those who have received living donor transplants.
      Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR)
      OPTN/SRTR 2010 Annual Data Report Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation.
      US Renal Data System
      USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.
      Similar to our previous data,
      • Coritsidis G.N.
      • Khamash H.
      • Ahmed S.I.
      • et al.
      The initiation of dialysis in undocumented aliens: the impact on a public hospital system.
      our present study found that undocumented immigrants on dialysis therapy were significantly younger than the general dialysis population. The average age of our legally resident dialysis patients was 60 years, which is consistent with national data
      • Kutner N.G.
      • Johansen K.L.
      • Kaysen G.A.
      • et al.
      The Comprehensive Dialysis Study: a USRDS special study.
      (Table 4). By contrast, the mean age of our survey respondents was 44 years, which is similar to the average age of 46 years reported for living donor transplant recipients in the Scientific Registry of Transplant Recipients
      • Schweitzer E.J.
      • Wiland A.
      • Evans D.
      • et al.
      The shrinking renal replacement therapy “break-even” point.
      (Table 4). Moreover, the undocumented immigrant patients in our study had significantly fewer comorbid conditions than the comparison groups. Only 40% of the study participants had diabetes mellitus and only 7% had known coronary artery disease, substantially lower proportions than in our unit's legally resident patients (68% and 33%, respectively) and the general US dialysis population (55% and 70%, respectively).
      Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR)
      OPTN/SRTR 2010 Annual Data Report Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation.
      This difference likely has much to do with the age disparity, but also may reflect different causes of underlying kidney disease.
      Table 4Comparison of Study Participants With Other ESRD Groups
      Present StudySRTR
      Undocumented Immigrant (n = 45)Legal Resident (n = 82)USRDS (n = 389,674)Active Waiting List (n = 52,516)Recipients of LD Transplants (n = 6388)
      Male32 (71)45 (55)215,071 (55)31,125 (59)3,892 (61)
      Age (y)43.8 ± 13.960 ± 1161.151.6 ± 13.446 ± 16.1
      Race/ethnicity
       Hispanic39 (87)32 (39)58,818 (15)9,875 (19)938 (15)
       African American0 (0)16 (20)146,315 (38)17,734 (34)875 (14)
       Asian6 (13)25 (30)18,960 (5)4,432 (8)278 (4)
       White0 (0)9 (11)218,691 (56)19,802 (38)4,237 (66)
       Other0 (0)0 (0)5708 (1)673 (1)60 (1)
      Cause of ESRD
       Diabetes mellitus16 (36)47 (57)170,798 (44)14,965 (29)1,341 (21)
       Hypertension13 (29)19 (23)111,543 (29)12,105 (23)1,069 (17)
       Glomerular disease11 (24)6 (7)39,016 (10)10,835 (21)1,901 (30)
       Other/unknown5 (11)10 (12)68,317 (18)14,611 (28)2,077 (33)
      Note: Values shown are number (percentage) or mean ± standard deviation.
      Abbreviations: ESRD, end-stage renal disease; LD, living donor; SRTR, Scientific Registry of Transplant Recipients; USRDS, US Renal Data System.
      Despite the difference in health status between the 2 groups in our unit, their overall hospitalization rates were not different. Several factors may contribute to this finding. Emergency Medicaid in New York covers only procedures performed while the patient is hospitalized, thus necessitating hospitalization for procedures that typically are considered outpatient and possibly raising the rate of hospitalizations in the undocumented immigrant group. Also, many of our undocumented immigrant patients do not have primary care physicians and use the emergency department for reasons that often can be addressed in an outpatient setting. In addition, we previously have shown
      • Coritsidis G.N.
      • Khamash H.
      • Ahmed S.I.
      • et al.
      The initiation of dialysis in undocumented aliens: the impact on a public hospital system.
      that the undocumented immigrant patients with ESRD are more likely to be hospitalized with longer lengths of stay in the first year of dialysis, largely owing to lack of predialysis care.
      Caring for undocumented immigrant dialysis patients is a national problem. Although it is very difficult to estimate the numbers of undocumented immigrants in the United States in general, let alone those with ESRD, some have estimated that there are approximately 6,000 such patients.
      • Campbell G.A.
      • Sanoff S.
      • Rosner M.
      Care of the undocumented immigrant in the United States with ESRD.
      Most nephrologists report providing dialysis care for undocumented immigrants.
      • Hurley L.
      • Kempe L.A.
      • Crane L.A.
      • et al.
      Care of undocumented individuals with ESRD: a national survey of US nephrologists.
      In our unit, 38% of patients are undocumented immigrants, a proportion that has continued to increase since 2005.
      The options for undocumented immigrant patients with ESRD are limited to dialysis, and in most states, dialysis can be administered on an emergency basis only, which leads to much more costly and fragmented care.
      Fox News
      LA emergency rooms full of illegal immigrants.
      • Raghavan R.
      • Nuila R.
      Survivors—dialysis, immigration and U.S. law.
      • Sheik-Hamad D.
      • Paiuk E.
      • Wright A.
      • et al.
      Care for immigrants with end-stage renal disease in Houston: a comparison of two practices.
      • Goldberg M.J.
      • Simmerling M.
      • Frader J.E.
      Why nondocumented residents should have access to kidney transplantation: arguments for lifting the federal ban on reimbursement.
      The well-publicized closure of Atlanta's Grady Hospital outpatient dialysis unit, which provided care to more than 50 undocumented immigrant hemodialysis patients, brought the issue of caring for this population to public attention. Grady Hospital cited significant monetary losses in maintaining the dialysis unit and was forced to close the unit.
      • Sack K.
      Hospital falters as refuge for illegal immigrants.
      Budgetary reasons are at least partially responsible for the outsourcing of 4 of 7 dialysis units functioning in the Health and Hospital Corporations' hospital system. In our survey, most undocumented immigrant dialysis patients reported that they planned to remain in the United States. Thus, providing long-term dialysis for this group of patients will remain an ongoing social and financial issue.
      It has been well established that kidney transplant is superior to dialysis in terms of morbidity, mortality, quality of life, and cost.
      • Wolfe R.A.
      • Ashby V.B.
      • Milford E.L.
      • et al.
      Comparison of mortality in all patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.
      Receiving an organ from a living donor results in significantly greater transplant and patient survival at all stages of follow-up.
      Health Resources and Services Administration
      Organ Procurement and Transplantation Network (OPTN). OPTN annual report. Survival rate data.
      The younger age of undocumented immigrants and their fewer comorbid conditions would make them ideal patients for successful transplant. Given their relative youth and their desire to work, they would be likely to continue to work or re-enter the work force, as our data show.
      The Organ Procurement and Transplantation Network of the US Department of Health and Human Services has specific policies pertaining to transplant of nonresident aliens, that is, individuals granted permission by the US Government to enter the United States temporarily.
      Organ Procurement and Transplantation Network (OPTN)
      Department of Health and Human Services, Health Resources and Services Administration Transplantation of non-resident aliens.
      There is no written policy regarding transplant of individuals who entered the United States illegally; the decisions regarding whether they are eligible for listing and transplant is left to individual transplant centers. As discussed, lack of insurance that usually would cover transplant costs effectively excludes undocumented immigrants from transplant.
      Based on our survey, 96% of undocumented immigrants said that they would like to get a kidney transplant, and on average, they were willing to pay $18,775. This is significantly lower than $262,900, the average charges per kidney transplant billed by transplant centers in the United States in 2011.
      Bentley TS, Hanson SG. Milliman 2011 US Organ and Tissue Transplant cost estimates and discussion
      Although the initial costs of transplant and immediate posttransplant care are greater than those of dialysis; over time, transplant becomes the cost-saving option. In an analysis from 1998,
      • Schweitzer E.J.
      • Wiland A.
      • Evans D.
      • et al.
      The shrinking renal replacement therapy “break-even” point.
      the average “break-even” point for recouped costs was 2.7 years; 3.7 years in the most expensive and 1.7 years in the least expensive groups. Based on more recent estimates, which calculate yearly hemodialysis costs at >$77,000 per patient,
      US Renal Data System
      USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End Stage Renal Disease in the United States.
      the $110,000 that Medicare spends on average for a transplant and the first year of follow-up would be recovered in less than 1.5 years. After the first year, Medicare spends $27,000 annually on a transplant recipient compared with $77,000 for someone who remains on dialysis therapy. Taking a conservative estimate of 8 years of life expectancy for the average undocumented immigrant patient, paying for transplant would translate into savings of $321,000 per patient in New York. If we extrapolate these calculations to the 27 of our undocumented immigrant patients who have potential living donors, it would mean a savings of >$8 million for one dialysis unit over 8 years.
      Given the shortage of deceased donor organs and the current kidney transplant waiting list of almost 90,000 Americans, adding undocumented immigrants to that list would be a politically challenging endeavor. However, given the cost of dialysis and the superior health status of the undocumented immigrant population (implying less likelihood of a requirement for rehabilitation and greater potential to return to the work force), mechanisms to provide for living donor transplant for those in this group who have available donors could be pursued. In our population of undocumented immigrant patients, 60% reported having at least one potential living donor, and on average, there were 1.9 potential donors per patient. Of the 27 patients from Mexico and Central and South Americas, 93% reported that they had potential living donors. The donors were young (with the average age of 33 years), tended to be close relatives of the patient, and were reportedly healthy. Most donors already resided in the United States, Canada, or Puerto Rico.
      There are several important limitations of this study. It derives from a single dialysis unit, which may have a skewed patient population. Additionally, the numbers of potential donors and their health were reported by patients. Some potential donors identified by the patients may choose not to donate, and those perceived to be healthy by the patient may turn out not to be. Also, although the potential recipients appear to be excellent candidates for transplant, some may have as yet unknown contraindications to transplant that would be revealed during the extensive evaluation that typically is performed prior to transplant.
      In conclusion, we found that undocumented immigrants with ESRD who were treated with dialysis were relatively young and healthy, and most reported having potential living kidney donors. Many were employed and of those who were not employed, many reported that they would work after kidney transplant. Taken in sum, our findings suggest that policy makers should consider covering the costs of living donor transplant for undocumented immigrants.

      Acknowledgements

      Support: None.
      Financial Disclosure: Dr Coritsidis has received consulting fees from Amgen and Genzyme. The other authors declare that they have no relevant financial interests.

      Supplementary Material

      References

        • Pew Hispanic Center
        Unauthorized immigrant population: national and state trends, 2010.
        http://pewhispanic.org/reports
        Date: February 1, 2011
        (Accessed September 12, 2011)
        • Wolf R.
        Rising health care costs put focus on illegal immigrants.
        USA Today. January 22, 2008; (Accessed December 15, 2011)
        • Fox News
        LA emergency rooms full of illegal immigrants.
        www.foxnews.com
        Date: March 18, 2008
        (Accessed September 12, 2011)
        • Hurley L.
        • Kempe L.A.
        • Crane L.A.
        • et al.
        Care of undocumented individuals with ESRD: a national survey of US nephrologists.
        Am J Kidney Dis. 2009; 53: 940-949
        • Straube B.
        Reform of the US healthcare system: care of undocumented individuals with ESRD.
        Am J Kidney Dis. 2009; 53: 921-924
        • Campbell G.A.
        • Sanoff S.
        • Rosner M.
        Care of the undocumented immigrant in the United States with ESRD.
        Am J Kidney Dis. 2010; 55: 181-191
        • Raghavan R.
        • Nuila R.
        Survivors—dialysis, immigration and U.S. law.
        N Engl J Med. 2011; 364: 2183-2185
        • US Census Bureau
        Quick facts.
        (Queens, New York) (Accessed September 12, 2011)
        • Shahata H.
        • Hernandez M.
        • Dhayalan M.
        • et al.
        The impact of inadequate pre-dialysis care and undocumented aliens on an urban hospital based dialysis center.
        J Am Soc Nephrol. 2008; 19 ([abstract]): 503a
        • Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR)
        OPTN/SRTR 2010 Annual Data Report.
        (Accessed 12/29/2011)
        • US Renal Data System
        USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.
        Am J Kidney Dis. 2012; 59: e1-e420
        • Coritsidis G.N.
        • Khamash H.
        • Ahmed S.I.
        • et al.
        The initiation of dialysis in undocumented aliens: the impact on a public hospital system.
        Am J Kidney Dis. 2004; 43: 424-432
        • Kutner N.G.
        • Johansen K.L.
        • Kaysen G.A.
        • et al.
        The Comprehensive Dialysis Study: a USRDS special study.
        Clin J Am Soc Nephrol. 2009; 4: 645-650
        • Schweitzer E.J.
        • Wiland A.
        • Evans D.
        • et al.
        The shrinking renal replacement therapy “break-even” point.
        Transplantation. 1998; 6: 1702-1708
        • Sheik-Hamad D.
        • Paiuk E.
        • Wright A.
        • et al.
        Care for immigrants with end-stage renal disease in Houston: a comparison of two practices.
        Texas Med. 2007; 103: 53-58
        • Goldberg M.J.
        • Simmerling M.
        • Frader J.E.
        Why nondocumented residents should have access to kidney transplantation: arguments for lifting the federal ban on reimbursement.
        Transplantation. 2007; 83: 17-20
        • Sack K.
        Hospital falters as refuge for illegal immigrants.
        The New York Times. September 2009; (Vol 159 #54866) (Accessed September 12, 2011)
        • Wolfe R.A.
        • Ashby V.B.
        • Milford E.L.
        • et al.
        Comparison of mortality in all patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.
        N Engl J Med. 1999; 341: 1725-1730
        • Health Resources and Services Administration
        Organ Procurement and Transplantation Network (OPTN). OPTN annual report. Survival rate data.
        (Accessed September 12, 2011)
        • Organ Procurement and Transplantation Network (OPTN)
        Department of Health and Human Services, Health Resources and Services Administration.
        (Accessed September 12, 2011)
        • Bentley TS, Hanson SG. Milliman 2011 US Organ and Tissue Transplant cost estimates and discussion
        (Accessed September 12, 2011)
        • US Renal Data System
        USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End Stage Renal Disease in the United States.
        Am J Kidney Dis. 2011; 57: e1-e526