Liver Transplantation in Unauthorized Immigrants in the United States

Abstract

Background and aims: Eleven million unauthorized immigrants reside in the United States and may account for 3% of deceased organ donors. Recently introduced federal and state legislation propose to address access to organ transplantation among unauthorized immigrants. The national landscape of liver transplantation (LT) for unauthorized immigrants is unknown.

Approach and results: We included all US LT recipients between March 2012 and December 2018 who were linked to Pew Center of Research data to estimate the population of unauthorized immigrants in each US state and by country of origin, based on US Census data. We categorized patients as unauthorized immigrants versus US citizens/residents. The main outcome measures were (1) the proportion of LTs performed for unauthorized immigrants compared with the proportion of unauthorized immigrants among total population in each US state and (2) graft failure and death post-LT. Of 43,192 LT recipients, 43,026 (99.6%) were US citizens/residents and 166 (0.4%) were unauthorized immigrants. Among unauthorized immigrants, most LTs were performed in California (47%) and New York (18%). The absolute difference in proportion of LTs performed for unauthorized immigrants compared with the proportion of unauthorized immigrants among the total population differed among states, ranging from +20% in California to -12% in Texas. The most common countries of birth among LT recipients who were unauthorized immigrants were Mexico (52%), Guatemala (7%), China (6%), El Salvador (5%), and India (5%). In competing risk analysis, unauthorized immigration status (vs. US citizens/residents) was associated with a similar risk of graft failure (subdistribution hazard ratio [sHR] 0.74; 95% confidence interval [CI], 0.40-1.34; P = 0.38) and death (sHR 0.68; 95% CI, 0.36-1.29; P = 0.23).

Conclusions: LT for unauthorized immigrants is rare, and disparities in access to LT by state are present. Patient and graft survival among unauthorized immigrants is comparable with citizens/residents.

FIG. 1.

Proportion of presumed unauthorized immigrants among the LT and general population by state. Results from six states with highest absolute number of LT recipients for unauthorized immigrants between March 2012 and December 2018. Among presumed unauthorized immigrants who received LT, most LTs were performed in California (n = 78; 47%) and New York (n = 30; 18%). Among the general US population in 2016, California accounted for 27% of the total US unauthorized immigrant population and 7% for New York. The proportion of LTs performed for unauthorized immigrants compared with the total population of unauthorized immigrants differed among states, with the highest differences in proportions in California (+20%) and New York (+11%) and lowest in Texas (−12%) and Florida (−3%). *Between March 2012 and December 2018. **According to Pew Research Center Estimates from US Census Bureau data in 2016.

FIG. 2.

Countries of birth of presumed unauthorized immigrants among the LT and general population by state. Among 115 presumed unauthorized immigrants who received LT between March 2012 and December 2018 with listed countries of birth, the 5 most common countries were Mexico (n = 52; 46%), Guatemala (n = 7; 6%), China (n = 6; 5%), El Salvador (n = 5; 4%), and India (n = 5; 4%). According to the most recent data from the Pew Center of Research, we estimated Mexico, Guatemala, China, El Salvador, and India to account for 51%, 5%, 3%, 7%, and 4% of the unauthorized immigrant population in the United States, respectively. *Between March 2012 and December 2018. **According to Pew Research Center Estimates from US Census Bureau data in 2016. ***Only 115 of 166 had available data for country of birth.

FIG. 3.

(A) Probability of graft survival among presumed unauthorized immigrants versus residents. Cumulative unadjusted probabilities of post-LT graft survival at 1 year and 3 years were 93% (95% CI, 87%−96%) and 86% (95% CI, 77%−92%) among presumed unauthorized immigrants versus 90% (95% CI, 90%−90%) and 83% (95% CI, 83%−83%) among residents (P = 0.36). (B) Probability of patient survival among presumed unauthorized immigrants versus residents. Cumulative unadjusted probabilities of post-LT patient survival at 1 year and 3 years were 95% (95% CI, 89%−98%) and 88% (95% CI, 79%−93%) among presumed unauthorized immigrants versus 92% (95% CI, 92%−92%) and 85% (95% CI, 85%−86%) among residents (P = 0.43).