Citizenship Status and Outcomes after Kidney Transplantation

There are approximately 6000 undocumented immigrants in the United States with end-stage renal disease (ESRD), based on data from 2014. All US citizens with end-stage kidney disease are eligible for maintenance dialysis; however, care for undocumented immigrants is fragmented. Some states extend the eligibility for scheduled maintenance dialysis to that patient population; others provide dialysis only when the patient’s condition is life-threatening. In that scenario, federal funds may be used to cover costs.

In spite of the fact that transplantation is a more cost-effective form of renal replacement therapy and provides improved outcomes for patients with ESRD, there is no federal mandate in place to subsidize the costs of kidney transplantation for undocumented immigrants, making access to transplant even more limited than dialysis. Charitable donations or private insurance account for the majority of funding for transplantation in this patient population.

There are few data available on the outcomes of undocumented immigrants who are recipients of kidney transplants. There are concerns that because these patients are subject to deportation, they may not continue to experience the social and financial stability needed to sustain post-transplantation healthcare.

To test the hypothesis that post-transplantation outcomes among undocumented immigrants would be similar to those of US citizens, Jenny I. Shen, MD, MS, and colleagues recently conducted an analysis of patients with Medicaid who received their first kidney transplant from 1990 through 2011. The researchers compared outcomes of presumed undocumented immigrants with those of US citizens. Results of the analysis were reported online in the American Journal of Kidney Diseases [doi:10.105.3/j.ajkd.2017.08.014].

The researchers utilized data from the US Renal Data System, a database that includes virtually every patient with ESRD, to identify all patients ≥18 years of age who underwent first kidney transplantation from January 1, 1990, through December 31, 2011. Patients who underwent transplantation after 2011 were excluded because the categories for recording citizenship were changed in 2012 to a combination of US citizen/non–US citizen and US resident/non–US resident; both permanent residents and undocumented immigrants would be identified as non–US citizen/US resident. The cohort was restricted to patients with Medicaid as their primary payer to reduce the likelihood of including patients who traveled to the United States for the purpose of transplantation.

The primary exposure of interest was recipient citizenship status, which was self-reported on the Transplant Candidate Registration form as US citizen, resident alien, or nonresident alien. The primary outcome was all-cause transplant failure.

A total of 278,779 adult patients received their first kidney transplant from 1990 to 2011. Of those, Medicaid was the primary payer for 10,495. Among patients with Medicaid, 82.4% (n=8660) were US citizens, 14.2% (n=1489) were permanent residents, and 3.3% (n=346) were nonresident aliens. Compared with patients in the US citizen and permanent resident groups, those in the nonresident alien group were younger and more likely to be male and Hispanic. Nonresident aliens generally had better functional status and were less likely to have comorbid conditions, despite having spent more time on maintenance dialysis prior to transplantation.

There were no significant differences in the panel-reactive antibody profiles of nonresident aliens compared with US citizens; nonresidents were more likely to have blood type O and to have received an HLA antigen-mismatched kidney. Nonresident aliens spent more time prior to being waitlisted and before undergoing transplantation. A higher percentage underwent transplantation in more recent years; 61% (n=210) of nonresident aliens underwent transplantation after 2005, compared with only 36% (n=3704) of permanent residents and US citizens.

Patients in the nonresident alien group were also more likely to have received a kidney from a living donor (40% vs 32% of US citizens and 27% of permanent residents). Donors for nonresident aliens tended to be younger, Hispanic, and nonresident aliens themselves. Transplantations were performed on nonresident aliens in 20 states; 71% of nonresident aliens undergoing transplantation were in California, the state with the highest percentage of Medicaid-funded transplants for nonresident aliens.

Over 37,000 person-years of follow-up, there were 2741 transplant losses, for a rate of 7.3 all-cause transplant losses per 100 person-years. In unadjusted analysis, nonresident aliens had a >45% lower risk for all-cause transplant loss, death-censored transplant loss, and death compared with US citizens (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.35-0.65). Following adjustment for demographics, dialysis factors, transplant factors, and comorbid condition count, the results were attenuated but remained significant [HR, 0.7; 95% CI, 0.46-0.94]; there was no significant difference in mortality when adjusted for transplant factors or in death-censored transplant loss or death in the fully adjusted model.

Limitations to the study cited by the authors included self-reporting of citizenship status and the inability to include outcomes data on nonresident aliens who leave the United States and do not return. There was also no way to adjust for potential confounders such as employment status and immunosuppressive regimen. Finally, the results may not be generalizable to wealthier patients who do not qualify for Medicaid or who live outside of California.

“In conclusion, we found that only a small percentage of patients with Medicaid who received transplants in the United States were nonresident aliens. The transplantations occurred mostly in California and have increased in recent years, and our study suggests that these nonresident aliens do no worse than US citizens after transplantation. Policymakers should consider expanding coverage for kidney transplantation in nonresident aliens, including undocumented immigrants, because it is associated with high-quality outcomes,” the researchers said.

Takeaway Points

  1. Researchers conducted an analysis to examine whether nonresident aliens, including undocumented immigrants, undergoing kidney transplantation have outcomes similar to those of US citizens.
  2. All adult Medicaid patients in the US Renal Data System who received their first kidney transplant from 1990 to 2011 were included in the analysis.
  3. Study results suggest that nonresident aliens who undergo transplantation funded by Medicaid do “just as well as US citizens with Medicaid.”


“Kidney transplantation offers patients with end-stage kidney disease a longer and better quality of life at a lower cost than dialysis, which is the other form of treatment for these patients. US citizens can receive subsidized care for kidney transplantation, but most states do not provide this service for undocumented immigrants. For those that do support long-term dialysis for undocumented immigrants, policymakers should consider expanding coverage for kidney transplantation in undocumented immigrants because it is linked to high-quality outcomes.”

                                                                                                                                                Jenny Shen, MD