International Travel for Liver Transplantation: A Comprehensive Assessment of the Impact on the United States Transplant System.

BACKGROUND International travel for transplantation remains a global issue as countries continue to struggle in establishing self-sufficiency. In the United States (US), the United Network for Organ Sharing (UNOS) requires citizenship classification at time of waitlisting to remain transparent and understand to whom our organs are allocated. This study provides an assessment of patients who travel internationally for liver transplantation, and their outcomes, using the current citizenship classification employed by UNOS. METHODS Adult liver UNOS data from 2003-2019 was utilized. Patients were identified as citizens, noncitizen, nonresidents (NCNR), or noncitizen residents (NC-R) according to citizenship status. Descriptive statistics compared demographics among the waitlisted patients and demographics and donor characteristics among transplant recipients. A competing risks model was used to examine waitlist outcomes. The Kaplan-Meier method and Cox proportional hazards were used for posttransplant outcomes. RESULTS There were significant demographic differences according to citizenship group among waitlisted (n=125 652) and transplanted (n=71 536) patients. Compared with US citizens, NCNR was associated with a 9% increase in transplant (Subdistribution Hazard Ration (SHR) 1.09, 95% CI 1.00-1.18, p=0.04), and NC-R was associated with a 24% decrease transplant (SHR 0.76, 95% CI 0.72-0.79, p<0.0001) and 23% increase in death or removal for too sick (SHR 1.23, 95% CI 1.14-1.33, p<0.0001). US citizens had significantly inferior graft and patient survival (p-values <0.001). CONCLUSIONS Though the purpose of the citizenship classification system is transparency, the results of this study highlight significant disparities in access to, and outcomes following, liver transplantation according to citizenship status.