Foreign citizens received a disproportionate number of kidney transplants in the Washington area in 1982, 1983 and 1984, according to federal figures released to The Washington Post under the Freedom of Information Act.
According to a report of End Stage Renal Disease Network of the National Capital Area, 26 percent, or 31 of the 119 local transplant recipients in 1982, were foreign citizens. Nationally, according to the network, 10 percent of all kidney transplants were performed on foreign citizens during that year.
In 1983, 24 percent of the people receiving kidney transplants here were foreign citizens, according to the network. Federal figures for the first half of 1984, the latest available, show a slight decrease, with 22 of 102 kidney transplants in the Washington area -- or 22 percent -- going to foreign citizens.
The network does not have figures for 1983 and 1984, but Dr. Said A. Karmi, director of transplant services at George Washington University Medical Center, estimated that between 4 percent and 6 percent of all kidney transplants nationally are now performed on foreign citizens.
To quell the controversy over foreign citizens receiving scarce organs, local hospitals -- some as recently as last week -- are starting to identify which transplant candidates are foreign citizens in order to give preference to U.S. citizens.
The figures raise new questions about who should be chosen to receive scarce organs, an issue that is becoming more heated as people are urged to donate organs to meet the demand. U.S. Health and Human Services Secretary Margaret Heckler and D.C. Mayor Marion Barry launched campaigns last month to encourage organ donation.
"It's a common-knowledge situation," Jerry Mande, legislative assistant to Sen. Albert Gore Jr. (D-Tenn.), said of the high foreign transplant rate in the Washington area. "It's also true in Pittsburgh, Houston . . . . It has to do with more than money. It's prestige, on building your hospital into a transplant center."
The District has six hospitals performing transplants, and officials at all are eager to perform as many as possible, sometimes using older kidneys that U.S. citizens would find unacceptable. "This is the most competitive transplant area in the country," said Dr. G. Baird Helfrich, director of transplants for Georgetown University Hospital. "We're willing to accept kidneys that would have been sent to a foreign country."
Another factor, transplant surgeons say, is the number of embassies here.
The Washington Hospital Center, which led the city in 1983 in the number of transplants performed on foreign citizens, performed 15 of its 35 kidney transplants that year on patients from Saudi Arabia. The hospital had a "referral arrangement" whereby doctors at the Saudi Arabian health office sent patients to the hospital for transplant surgery, according to Stephanie McNeil, a hospital spokeswoman. She said the arrangement was not a formal contract and no longer exists.
In 1984, the hospital wrote a new policy giving preference to U.S. citizens for transplants. McNeil said foreign citizens received only 7 of the 76 kidney transplants performed that year.
Another local facility, Georgetown University Hospital, had an agreement with the Greek minister of health in the early 1980s to perform transplants on Greek patients, said Dr. George Schreiner, director of the nephrology division at Georgetown University Hospital. He said political difficulties ended the arrangement and that it is being renegotiated.
The Pittsburgh Press recently reported that doctors at Presbyterian-University Hospital in that city gave preference to foreign citizens for kidney transplants. Hospital officials said the exceptions were made for compassionate reasons, but they said they are instituting a policy to give preference to U.S. citizens.
The debate over foreign use of organs in this country has caused some hospitals, such as Rush Presbyterian in Chicago, to refuse any type of transplant to foreign citizens. The hospital "won't do bone marrow, cornea transplants, anything, on foreign nationals because of the problem we had with the kidney program," said Paul Volek, director of organ procurement for the Chicago area. "Americans are dying without organs. How in good conscience can we offer them to others who come to this country?"
Gore, who last year successfully sponsored a bill for a national organ transplant network that would allocate organs based on medical necessity, noted, "Unless this issue is dealt with rationally and candidly, the rate of organ donation will not increase." The network has not been implemented.
The District of Columbia has a particular need for kidneys because the city leads the nation in the rate of kidney disease. "There is a high rate of hypertension among blacks," and the disease can lead to kidney failure, explained Dr. Clive Callen- der, director of Howard University Hospital's transplant center. About 150 D.C. residents, mostly blacks, are waiting for kidneys.
Local doctors say the high rate of foreign citizens receiving transplants in the United States can be explained by several factors. Patients from countries where medical care is less sophisticated than in the United States generally have not received dialysis and their bodies are less sensitive to a new organ, said George Washington University's Karmi. Also, foreign patients generally are less choosy about what type of match they make with a donated kidney, doctors say.
"Yes, they're getting more kidneys, but they're not getting a good quality, a good match," said Dr. Jose Salcedo, chairman of the Washington area network's medical review board. "If we don't use these kidneys in foreigners, these kidneys would probably have to be thrown away. Here you have a way to get rid of these organs that might not be used by District residents."
Although local hospitals are supposed to share organs that they are unable to use, in the past there has not been good cooperation, Salcedo said. A new areawide transplant council was established to help correct the problem, he said.
At least one local hospital is paid more by foreign patients than it receives for kidney transplants to domestic ones. At George Washing- ton, a foreign citizen pays $6,000 for the transplant surgeon's services, according to Karmi. The hospital collects $3,800 from Medicare for the same services on a U.S. citizen.
"The patients are charged the same, but the university definitely gets more money" from foreign citizens, said Karmi. The federal government, through the Medicare program, covers the costs of all kidney transplants of U.S. citizens.
Many doctors are uncomfortable in allocating life-saving operations on the basis of nationality. "We're talking about medicine here, about life," said Karmi.
Foreign patients travel to the United States for transplants because organ donation is not common in many countries. They often must move to the Washington area for months, even years, while waiting for a donor organ, doctors say. "There are a lot of religious taboos overseas that cause people to come here as a medical haven," said one doctor.
Yet, there is considerable discomfort about the bypassing of U.S. transplant candidates.
Ernest Bauer, chairman of the local network's patient action committee, described the large number of foreign citizen kidney transplant cases as "wrong and an affront to U.S. residents."
The American Society of Transplant Surgeons voted last month to give preference to U.S. citizens for transplants and advised the nation's 39 organ networks to revise their computer lists to show which candidates are U.S. citizens. Helfrich, of Georgetown, said some doctors have abused the networks by using false names of candidates to conceal the fact that the patients were foreign citizens.
Those interested in encouraging organ donation are worried that the issue of foreign citizens receiving transplants will hurt their efforts. In California, for example, some organ donors have written "resident only" on their driver's license organ donor cards after news surfaced that some kidneys were being shipped to Japan for transplants there.
The United States ships organs overseas because most foreign doctors are willing to use organs that have aged beyond the 48-hour limit that U.S. surgeons usually require.
Donovan Gay, a hearing examiner in the District of Columbia's Department of Motor Vehicles and a member of the D.C. Organ Donor Project, which promotes organ donation among blacks, said he is drafting a bill for the City Council to restrict foreign citizens from using locally donated organs until all possible U.S. candidates have been eliminated.
"We've not had anyone write across their driver's license 'Americans only,' but we want to nip the problem in the bud," said Gay.