Contribution and Vulnerabilities of Non-US Citizens as Kidney Donors: Analysis of the UNOS/OPTN Database

Non-US citizens often face financial barriers to receiving organ transplants in the US but less is known about their contributions as donors. We assessed participation of non-US citizens as kidney donors and the vulnerabilities that non-US citizens and their communities accept in order to donate. Using United Network for Organ Sharing and Organ Procurement and Transplant Network data (UNOS/OPTN), we performed cross-sectional analysis of 2,423 kidney living donors (LDs) and 8,965 deceased donors (DDs) in UNOS Region 11 between 2018 and 2022. Non-US citizens comprised 2.4% of LDs. Compared to US citizen LDs, non-US citizen LDs had 13.0 times the odds of lacking health insurance (95% CI 7.5, 22.7). Non-US citizens comprised 1.2% of DDs. Among DDs, 73.6% of non-US citizens lacked written documentation of donor intent, versus 41.2% of US citizens (X² 49.2, p < 0.001). 46% of non-US citizen DDs had not previously expressed donor intent to others, versus 27.1% of US citizen DDs (X² 21.7, p < 0.001). In summary, non-US citizens disproportionately accept donation-related financial burdens and vulnerabilities (i.e., having to make a donation decision while grieving a loved one) and contribute to an organ sharing system that their communities are often unable to access as recipients. This suggests lack of reciprocity that should be further evaluated to promote ethicality within the organ sharing system.