Organ transplant service not available in Guam, CNMI and American Samoa despite rise in kidney disease

By Jayvee Vallejera

Compared to the U.S. mainland, American territories in the Pacific have a higher number of people with chronic kidney disease and its advanced stage, end-stage renal disease, yet those numbers have not translated into more organ transplants being made available in these areas, according to a new study.

The study noted the inequities in access to organ transplantation in Guam, American Samoa and the Northern Mariana Islands, mainly because these areas are geographically isolated and medically underserved.

“The challenges are complex and will require significant multidisciplinary effort to address,” states the study.

“The Unmet Need for Solid Organ Transplantation in the U.S. Pacific Islands: A Summary of Current Data and Challenges" is authored Dr. Dylan M. Bush, Dr. Lung-yi Lee, Dr. Paul Muña Aguon, Dr. Jon Yamaguchi and Dr. Dicken S.C. Ko.

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Combing through data from the U.S. Renal Data System and Scientific Registry of Transplant Recipients, the study highlights the unmet need for organ transplants in these U.S. territories and describes the barriers to organ transplants for patients in the region.

The study found that the rate for end-stage renal disease, or ESRD, among residents in Guam, American Samoa and the CNMI is significantly higher compared to the 50 U.S. states.

Chief among the causes of end-stage renal disease is diabetes, followed by hypertension.

The primary method used to treat ESRD in Pacific territories is dialysis.

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The study also looked at the availability of liver transplants in U.S. Pacific territories, and despite sparse data on liver disease in these areas, the authors said prior research suggests a high prevalence of hepatitis B as a risk factor for hepatocellular carcinoma in Pacific Islander populations. 

They also note an “exceptionally high prevalence” of fatty liver disease.

Besides the geographical locations, the authors cited limitations in infrastructure and healthcare services as a barrier to transplantation in the U.S. Pacific territories.

There are no transplant centers in these territories.

Guam maintains an organ donor registry, but there are no organ procurement organizations.

Any resident of Guam, American Samoa or CNMI who needs to undergo an organ transplant will need to move to an area with an active transplant center. The nearest transplant center is in Hawaii.

American Samoa is 2,259 nautical miles away from Hawaii, further than the distance between Los Angeles and New York.

Patients from the CNMI must transit Guam to reach Hawaii.

This means flight times that range from as short as 5.5 hours to a

s much as 28 hours (in the case of the CNMI)

“Additionally, flights connecting these territories to Hawaii occur only a few times per week,” the authors said.

The absence of specialists with transplant practices in the U.S. Pacific territories presents additional challenges.

Since there is no way to quickly transport patients to a transplant center in case of complications, organ donor recipients are forced to live close to the transplant center for at least a year, if not longer, to ensure adequate care, the study said.

Being close to the transplant center may be advantageous to the patient’s health, but it can also be a financial burden, as patients may not have the means to cover the costs of an extended stay in Hawaii. It may also conflict with patients’ desire to return to their communities and families.

The high cost of relocating to an area with a transplant center is often not fully covered by insurance, the authors said.

Since patients will need a family member to go with them to Hawaii, that is an additional cost that is also not covered by insurance.

“As with other populations, family support plays an important role in the well-being and healthcare decisions of Pacific Islanders. This presents a challenge for patients who must relocate for organ transplantation,” the authors said.

The study highlighted that assistance from publicly available insurance programs, such as Medicaid, is limited and subject to statutory caps and fixed matching rates.

“This means that territorial governments contend with less federal monetary support than the states, leading to further restrictions on healthcare coverage for Medicaid beneficiaries in the territories,” they said.

The role poverty plays in this equation cannot be discounted. Poor people tend to have low rates of kidney transplants, the authors said, noting this is “known to be associated with this population.”

The authors stated that creating an effective and sustainable path to transplantation for patients from the region will require a deeper understanding of how socioeconomic status functions as a barrier to transplantation and the development of mechanisms to alleviate the effects of poverty.

Another step that could increase organ transplantation rates is educating the population about living donor transplantation, the study said. This means getting a donated kidney from a parent, sibling, relative, or friend. This will cut through barriers such as limited organ availability, long wait times, and uncertain timing.

The study’s authors believe telemedicine could also play a big role in boosting organ transplantation in U.S. territories in the Pacific.

“By leveraging telemedicine, local specialists could coordinate with transplant centers to conduct initial assessments and manage pretransplant and posttransplant care remotely,” they said.

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