I was keenly interested in a recent study: BP Lee, NA. Terrault. Liver Transplantation in Unauthorized Immigrants in the United States. Hepatology 2020; 71: 1802-12.  Given the potential for causing a political firestorm, I was surprised it was published.

Definitions: “Unauthorized immigrants, also termed illegal aliens in US federal statures are…all foreign-born non-citizens who are not legal residents.”  Since March 2012, UNOS has required transplant centers to record citizenship…”primarily to better understand transplant tourism.” The authors excluded international transplant tourists in their cohort.

Key findings: 

• 116 of 43,192 (0.4%) liver transplant (LT) recipients were unauthorized immigrants
• The majority were from Mexico (52%).  Others came from Guatemala (7%), China (6%), El Salvador (5%) and India (5%).
• Unauthorized immigrant recipients had a similar risk of graft failure (sHR 0.74) and death (sHR 0.68), though at time of LT, there was higher disease severity (higher MELD scores and increased need for renal replacement therapy).
• Most LTs for unauthorized immigrants took place in California (47%) and New York (18%).  Texas (3%) and Florida (4%) had a lower proportion of LTs for unauthorized immigrants based on population distribution.
• The authors note that unauthorized immigrants are different that transplant tourists  –they pay social security tax/other taxes and contribute to organ donation (~3% of donated organs) whereas transplant tourists do not.
• The authors note that unauthorized immigrant LTs were less than half the number of transplant tourist LTs; the later LT recipients are commonly individuals from Persian Gulf countries.
• Current federal law mandates that LT be distributed based on “established medical criteria” which does not suggest a “tiered allocation system by citizenship.”  Almost half of the unauthorized immigrant LTs were covered by Medicaid.

My take: Unauthorized immigrants are underrepresented as LT recipients compared to their total population distribution in the U.S.  This likely is due to a number of barriers.  Interestingly, this population is not underrepresented when it comes to organ donation.