Transplantation Abroad: Closing Gaps in Data and Practice

There are currently >100 000 people in the United States waiting for an organ transplant.1 Given the shortage of available organs and long wait times, it is not surprising that some patients look abroad for other options. Transplant tourism—the practice of traveling to another country for transplant—is estimated to account for 10% of all transplants globally.2 To combat organ trafficking and reduce the risk of exploitation, the Declaration of Istanbul reaffirmed ethical principles for international transplantation in 2018.3 Although prior studies examined this practice among US patients before 2006,4 there remains a paucity of contemporary data on prevalence, destinations, and outcomes. In this study, Terlizzi et al5 analyzed trends in international transplantation among US waitlist candidates, focusing on temporal patterns, geographic destinations, and patient characteristics associated with waitlist removal because of transplant abroad. Although the study provides valuable insights into who is traveling and where they are going, it also underscores persistent gaps in our understanding of the ethical, clinical, and policy dimensions—and raises more questions than it answers. Using Scientific Registry of Transplant Recipients data from 2010 to 2023, the authors found that US patients who received transplants abroad were more likely to be male and Asian, with India and the Philippines emerging as the most common destinations. These findings echo a prior Scientific Registry of Transplant Recipients–based study (1987–2006),4 although at that time China was the top destination. Although the study cannot definitively explain why patients choose particular countries, the patterns suggest cultural or ethnicities: most Asian patients received transplants in Asia, and most Hispanic patients in Mexico. Although the number of cases remains low—<60 per year—the trend peaked in 2017 and has risen again since 2021. Given the persistent organ shortage, interest in transplantation abroad will likely continue to grow. A recent Canadian study found that 59% of candidates expressed interest in traveling abroad for transplantation, although willingness declined when patients were informed of potential medical risks.6 These trends, although informative, also raise important unanswered questions about outcomes, ethics, and the responsibilities of transplant systems. The analysis by Terlizzi et al5 is unfortunately unable to provide detail on patient motivations, donor types, and posttransplant outcomes. This highlights the need for more systematic data collection and follow-up. In the United States, expanding Organ Procurement and Transplantation Network reporting to include donor type, transplant modality, and patients’ ties to the transplant country (eg, citizenship or family) would provide important context. Globally, there is a strong case for an international registry: in a survey of transplant providers across 68 countries, most providers caring for such patients were willing to contribute to a global registry.8 Such a system could track outcomes, immunosuppression, infections, and donor-recipient characteristics—while protecting privacy and supporting follow-up care. The most urgent gap remains outcomes, as the only data come from small, single-center studies that suggest higher risks of infection and rejection abroad.7-9 In the United States, the Organ Procurement and Transplantation Network could take a first step by requesting follow-up data on patients delisted because of transplant abroad. In parallel, transplant centers need clearer protocols for managing patients who return after receiving transplants abroad. As Terlizzi et al5 noted, these individuals often lack medical records, complicating immunosuppression, infection screening, and graft monitoring. Documentation gaps, uncertain donor history, and fragmented care pose serious risks. Insurance coverage and programmatic responsibility for these patients are often ambiguous. More data from centers currently providing care to these individuals are needed to inform evidence-based clinical guidance and policy development. Although this study does not include direct outreach to such centers, it offers a starting point for deeper examination. Overall, the practice of traveling abroad for transplantation is likely to persist. To protect the safety and well-being of these patients, a system for monitoring and assessing outcomes globally is urgently needed. Continued efforts to document this practice within the United States—and to better understand why patients pursue transplant outside national borders—are critical first steps toward a more meaningful, grounded evaluation of international transplantation.

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