Inequities in Organ Donation and Transplantation Among Immigrant Populations in Italy: A Narrative Review of Evidence, Gaps in Research and Potential Areas for Intervention

Abstract

Immigrants from outside Europe have increased over the past two decades, especially in Southern European countries including Italy. This influx coincided with an increased number of immigrants with end-stage organ diseases. In this narrative review, we reviewed evidence of the gaps between native-born and immigrant populations in the Organ Donation and Transplantation (ODT) process in Italy. Consistent with prior studies, despite the availability of a publicly funded health system with universal healthcare coverage, non-European-born individuals living in Italy are less likely to receive living donor kidney transplantation and more likely to have inferior long-term kidney graft function compared with EU-born and Eastern European-born individuals. While these patients are increasingly represented among transplant recipients (especially kidney and liver transplants), refusal rates for organ donation are higher in some ethnic groups compared with native-born and other foreign-born referents, with the potential downstream effects of prolonged waiting times and inferior transplant outcomes. In the process, we identified gaps in relevant research and biases in existing studies. Given the Italian National Transplant Center’s (CNT) commitment to fighting inequities in ODT, we illustrated actions taken by CNT to tackle inequities in ODT among immigrant communities in Italy.

Systems Connected to Inequities in Access to Kidney Transplantation and the Value of Intersectionality

“…Similar trends are apparent in the UK with an increase in the number of people who identify as Asian or Black [36]. Such changes in demographics are accompanied with a multitude of cultural experiences and practices as well as linguistic diversity which must be considered to practice good science [7,37]. To better support patients, we cannot continue to use color-blind ideological approaches centered on Eurocentric, heteronormative (i.e., perception of heterosexuality as normal and standard), and cisnormative (refer to Table 1) values [37].…”

“…Socioecological models account for the interaction between multiple aspects of the individual, for example, at the intrapersonal, interpersonal, institutional, and societal level to affect health outcomes [15,16]. This model has been used to examine disparities along the steps to kidney transplantation [7,17]. The role of social determinants of health (i.e., non-medical aspects of an individual's life such as where they live, are raised, engage in recreational activities, and their vocation) has been established in the literature.…”

“…Approximately 30,000 people in the UK were reported as receiving dialysis in 2023, with a yearly rate of 3,000 transplant recipients [3]. Inequities in access to renal transplantation, the optimal form of renal replacement therapy, have been documented for decades [4][5][6][7][8]. These imbalances have been associated with sociocultural factors such as gender, race/ethnicity, income status, and immigrant status.…”

“…Hurdles occur along the steps to transplant, such as referral to transplant, pre-transplant evaluation, being waitlisted, and successful receipt of a deceased or live donor transplant [5,14]. Insurance issues, financial constraints, limited health literacy, obesity, lack of referrals, reports of discrimination are examples of typical obstacles faced by patients diagnosed with ESKD who seek a transplant [5,7,13,14]. Many patients encounter multiple barriers that interact with each other to affect their successful access to transplantation.…”

Refusal Rates to Organ Donation in Intensive Care Units Among Immigrant Populations in Italy

“…We contend that it is an ethical duty and responsibility to foster shared decision-making (i.e., “a relational process … allowing decisions to develop over time by jointly respecting clinical indications and individual … subjective considerations, values, needs, preferences, life circumstances and goals”) [ 8 ] to enable free and informed choices surrounding organ donation among these populations. Consideration of the informative, cultural, and psychosocial needs of these communities in relation to deceased organ donation and end-of-life care; understanding of the difficulties and educational gaps among HCPs and of the deficiencies at the organizational level allowing to communicate in a culturally sensitive fashion with bereaved family members in ICUs, and the promotion of an ongoing dialogue among all stakeholders (including representatives from minority, migrant and faith communities) are critical for the subsequent development of interventions directed towards these populations [ 9 , 10 ]. The CNT has recently initiated a project named Fostering And Improving equity, participation and inclusion in Transplantation Healthcare (FAITH) to address the existing gaps in the entire organ donation and transplantation pathway (i.e., promotion of the culture of organ donation and transplantation among the public/communities, relational processes in ICUs, and relational/educational processes at transplant centers with transplant recipients and, when this applies, their potential living donors) to enable the implementation of shared decision-making across the entire process [ 9 ].…”