In the United States, chronic kidney disease is prevalent among incarcerated individuals,1 although the exact estimates are unknown. Notably, there is no government mandate for transplant referral for prisoners with end-stage renal disease. Additionally, prisoners have poor access to transplantation and according to a recent report, only 19% of kidney transplant programs have included prisoners on their waitlists.2 Most inmates routinely receive chronic hemodialysis (HD) as opposed to transplantation, resulting in inferior survival and a significant financial burden to the state.3 Programs that have included prisoners have shown survival and cost benefits.4
ETHICS AND PRACTICAL CONSIDERATIONS IN TRANSPLANTING PRISONERS
The US Constitution guarantees adequate medical care to all convicts,5 however, transplantation is considered ethically contentious.4 The determination to authorize transplantation for an inmate is often made by the prison administration on a case-by-case basis. Nevertheless, the Organ Procurement and Transplantation Network’s ethics committee advises that “one’s status as a prisoner should not preclude them from consideration for a transplant.”6 However, Organ Procurement and Transplantation Network acknowledges that other nonmedical factors may influence patient’s candidacy for transplant and delegates the listing decisions to the individual transplant programs.6 Consequently, programs make listing decisions in the absence of uniform criteria and hesitate to evaluate and waitlist prisoners.2 The possible reasons are logistic challenges in clinical care, security concerns, uncertainty regarding medication adherence and concern of loss of follow-up. Overcoming these challenges requires program’s personnel to be highly motivated to accept convicts for transplantation.
For the past 15 y, at the Erie County Medical Center, Buffalo, NY, we have successfully sustained a renal transplant program for a male prison facility in collaboration with the prison administration. At our center, transplant referral was made only after an inmate demonstrated good behavior, in addition to adherence to HD and medications over a 6-mo period. Based on those criteria, prison administration authorized transplantation on a case-by-case decision and we performed the pretransplant medical evaluation. If found medically suitable, prisoners were listed with the United Network for Organ Sharing kidney waitlist. Posttransplant care at our transplant center was provided in coordination with prison medical providers. To streamline this process, all prisoners were preferably assigned to a single posttransplant coordinator.
After obtaining institutional review board approval, we performed a descriptive analysis of demographics and clinical outcomes of all referred or transplanted prisoners between March 2003 and July 2018. In case of release of the prisoner or transfer to another prison, every attempt was made to maintain follow-up by calling other prisons, providers, or reaching out to the patients themselves.
Forty-five referrals for prisoners with chronic kidney disease were made for cadaveric renal transplantation and 27 were waitlisted between March 2003 and July 2018. Twenty transplants were performed on 18 prisoners (referral to transplant rate of 44% and listing to transplant rate of 75%) with follow-up period ranging from 11 mo to 15 y. Table 1 provides the demographic details, referral and patient outcomes. The mean patient age was 45 y and 44% were African Americans, which reflects general trends in the US prison population.7
TABLE 1. -
Demographics, referral, and transplantation outcomes for prisoners with chronic kidney disease
|No. of referrals
|Prisoners transferred or released without getting transplanted
||10 (6 during evaluation phase, 4 after waitlisting)
| No. of transplants performed
||20 (18 patients, 2 retransplantations)
| Mean age
||9 African Americans, 8 Hispanic, 2 Caucasian, 1 other
| Median wait time
| Graft survival at 1 y
||94% (1 of 17 had graft failure)
| Death at 1 y
| Graft survival at 3 y
||72% (3 graft failures, 3 unknown)
| Death at 3 y
||None (2 patients lost to follow-up)
We experienced a continuous trend of loss of patient follow-up due to prisoner’s release or transfer. Because of this, 4 waitlisted patients could not be transplanted and 3 transplant recipients lost follow-up with our program within the first 3 y. The median waitlisted time for prisoners was similar to all waitlisted nonincarcerated patients at our center in 20188 (960 versus 1095 d), except for 5 hepatitis C seropositive patients who accepted kidneys from antibody-positive nucleic acid test negative donors (349 d). One-year graft and patient survivals were 94% and 100%, respectively. Since 2003, 9 of 18 transplanted patients do not have a verifiable status because of transfer or release. Of the patients who continued to maintain follow-up with our program, 3-y graft and patient survivals are 72% and 100%.
PROJECTED FINANCIAL BENEFIT WITH TRANSPLANTATION
The estimated cost of continuing HD versus transplantation was calculated using the United States Renal Data Systems data.3 The national per person per year spending on HD was $84 092 in 2011 for patients between ages 45 and 64 y. The estimated 3-y costs for a patient continuing HD are $252 276 versus $171 335 after transplantation. Thus, each transplant provided estimated savings of $80 941 within the first 3 y and subsequently $60 749 annually.
THE WAY FORWARD
Transplant programs need to individualize their approaches to waitlisting prisoners: carefully weighing benefits with the possible challenges they may face. Our biggest challenge was loss of follow-up because of inmate’s release or transfer. We were unsuccessful in establishing a verifiable current status for 50% of prisoners we transplanted over 15 y. It is likely that few of those might have had graft loss with medication nonadherence, especially upon their release. In many situations, such loss of follow-up is not always anticipated by individual transplant programs while evaluating a prisoner. On the other hand, ethics of denying transplantation to otherwise medically fit prisoners who may be released or transferred to another prison are controversial. It is important that valuable resources like deceased kidneys are allocated without compromising the principles of medical necessity, equity, and social justice. Thus, it is necessary that transplant programs and multistate prison authorities coordinate efficiently to provide a reliable mechanism which ensures posttransplant follow-up in the community or with the transplanting program.
It is crucial that prisoners with end-stage renal disease have improved access to transplantation to lower mortality and save costs. This requires the transplant community to advocate for transplantation for prisoners and develop uniform listing guidelines. Another potential way to improve access is by offering kidneys from hepatitis C positive donors. Very low transmission rates and good posttransplant outcomes have been demonstrated with the newer antiviral drugs against hepatitis C.9 However, this strategy should be adopted once long-term follow-up is ensured.
Despite the challenges, a renal transplant program for prisoners can be successfully sustained resulting in better clinical outcomes10 and cost benefit when compared to HD. Mechanisms to ensure long-term follow-up, however, are necessary.
We acknowledge Dr Rocco C. Venuto, MD (October 15, 1941–July 11, 2019), who was the principal architect of the program for his guidance in article writing.
1. Bai JR, Befus M, Mukherjee DV, et al. Prevalence and predictors of chronic health conditions of inmates newly admitted to maximum security prisons. j Correct Health Care. 2015; 21:255–264doi:10.1177/1078345815587510
2. Qazi Y, Mahajan A, Bahl D, et al. A multinational study of kidney transplantation in inmates. 2019American Transplant Congress; D232Available at https://atcmeetingabstracts.com/abstract/a-multi-national-study-ofkidney-transplantation-in-inmates/
3. United States Renal Data System. Chapter 9: Healthcare expenditure in persons with ESRD. 2018United States Renal Data System website; Available at https://www.usrds.org/2018/view/v2_09.aspx
4. Panesar M, Bhutani H, Blizniak N, et al. Evaluation of a renal transplant program for incarcerated ESRD patients. j Correct Health Care. 2014; 20:220–227doi:10.1177/1078345814531726
6. Organ Procurement and Transplantation Network (OPTN). Reviewed in 2015: Ethics Committee Position Statement. 2015U.S. Department of Health & Human Services website; Available at https://optn.transplant.hrsa.gov/resources/ethics/convicted-criminals-and-transplant-evaluation/
7. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. Prisoners in 2017. Bureau of Justice Statistics website.2019Available at https://www.bjs.gov/content/pub/pdf/p17.pdf
8. Scientific Registry of Transplant Recipients. Erie County Medical Center (NYEC): Program Summary.2019Scientific Registry of Transplant Recipients website
Available at https://www.srtr.org/transplant-centers/erie-county-medical-center-nyec/?organ=kidney&recipientType=adult&donorType=
. Accessed December 4, 2019
9. Gupta G, Yakubu I, Bhati CS, et al. Ultra-short duration directacting antiviral prophylaxis to prevent virus transmission from hepatitis C viremic donors to hepatitis C negative kidney transplant recipients2020; 20:739–751doi:10.1111/ajt.15664
10. Health Resources and Services Administration. OPTN/SRTR 2017 Annual Data Report. Scientific Registry of Transplant Recipients website.2017Available at https://srtr.transplant.hrsa.gov/annual_reports/2017/Kidney.aspx