Outcomes of Kidney Transplantation Among Undocumented Immigrants in the United States

Kidney transplantation is the optimal treatment for end-stage kidney disease (ESKD), but undocumented immigrants in the United States are often excluded from health insurance coverage necessary to undergo kidney transplantation. Arguments in favor of such policies are based on concern that undocumented immigrants face increased risk for graft loss, but transplant outcomes in this population are unknown. METHODS: We conducted an analysis of all first single-organ kidney transplant recipients between April 2012 and June 2021 using the UNOS dataset. Recipients were categorized as US citizen/residents or undocumented immigrants. The primary outcome was all-cause graft loss. All-cause mortality and death-censored graft loss were examined as secondary outcomes. Kaplan-Meier curves were constructed to compare the unadjusted graft and patient survival. The unadjusted and adjusted hazard ratios (HRs) for the primary and secondary outcomes were estimated using the Cox proportional hazards models. RESULTS: Of 122,732 kidney transplant recipients, 121,298 (98.8%) were citizen/residents and 1,434 (1.2%) were undocumented immigrants. Undocumented immigrants were younger (39 vs. 54 years) and predominantly Hispanic (78.5 vs. 17.3%) with lower prevalence of diabetic nephropathy (12.6 vs.28.4%). Pre-emptive (5.4 vs 19.2%) and living donor transplants (25.4 vs. 35.5%) were less common among undocumented immigrants. Undocumented immigrants had a lower hazard for all-cause graft loss (HR 0.57; 95% CI 0.48-0.69), all-cause mortality (HR 0.38; 95% CI 0.28-0.50) and death-censored graft loss (HR 0.74: 95% CI 0.59-0.93). These associations remained after adjustment for demographic, dialysis and transplant confounders. CONCLUSIONS: Kidney transplant recipients who are undocumented immigrants have favorable early graft and patient survival compared to US citizen/residents.