Has kidney trafficking come to the U.S.?

Federal authorities in July charged a Brooklyn, N.Y., man with conspiracy to violate the federal law banning buying or selling of human organs. If the allegations are true, it would be the first documented case of a black market for organs for transplant operating in the U.S., and experts said it could undermine public confidence in the country's organ system.

A criminal complaint filed in the U.S. District Court of New Jersey alleges that Levy Izhak Rosenbaum asked an undercover FBI agent for $160,000 to line up an unrelated living kidney donor from Israel. The agent pretended to be a longtime secretary of a cooperating witness and in need of a kidney for an uncle waiting on a transplant list in the Philadelphia area.

"This kind of thing happens in Third World countries. There have been suggestions of it happening here, but I just never believed them," said Joren C. Madsen, MD, DPhil, president of the American Society of Transplantation and director of the Massachusetts General Hospital Transplant Center.

If true, the case "would be a big blow" to patients' confidence in the organ system, said Henkie P. Tan, MD, PhD, director of living donor kidney transplantation at the Children's Hospital of Pittsburgh's Starzl Transplantation Institute. "If this is real and ongoing, obviously then the trust of the American public is going to be diminished. We in the transplant field work to uphold the trust of the American public, and if something like this happened, then it's a big concern."

According to the criminal complaint, Rosenbaum said he had brokered "quite a lot" of black-market kidney deals over the last 10 years.

"I am what you call a matchmaker," he allegedly said.

Rosenbaum could not be reached for comment. He was out on bail, which was set at $3 million. If found guilty, he could be fined $50,000 and serve five years in prison.

During discussions with an undercover agent on how to carry out the scheme, Rosenbaum said that during a transplant center's screening process "they're going to investigate" the potential donor. "He's going to speak to a social worker and a psychologist to find out why he is doing it. ... And it is our job to prepare him" with a cover story.

Transplant surgeons said patients who are paid to donate may be able to get past the psychosocial evaluation process if they are properly coached to avoid mentioning money and to remember invented details about their purported relationship with the recipient.

"It's a weak point in the whole system," Dr. Madsen said.

Dr. Tan agreed, saying "it is hard for us to confirm in every single transplant we do that no black market exists."

At the University of Minnesota, numerous professionals extensively interview potential unrelated living donors, said Arthur J. Matas, MD, director of the renal transplant program there.

"If someone has their story perfect, I'm not even sure what extra layer of protection we could have," Dr. Matas said.

Avoiding a black market

The American Society of Transplantation, the American Society of Transplant Surgeons and the United Network for Organ Sharing developed consensus guidelines on screening living unrelated kidney donors, and those guidelines were published in 2007. They label as "risk factors" for poor outcomes for the donor "evidence of, or expectation of, secondary gain (e.g., avoidance of military duty, financial support from recipient," as well as "limited financial capacity to manage donation (lost wages, travel, job concerns)."

Participants at the guideline-making conference "agreed that there remain ongoing concerns about the potential for donors to covertly accept payment for solicited organs," according to a May 2007 report published in the American Journal of Transplantation. The proportion of unrelated living donors, excluding spouses, climbed from 6.5% of all living kidney donations in 1996 to 23% in 2006, the report said.

UNOS has no process in place to allow transplant centers to notify others around the country of potential black-market activities from unrelated donors or so-called brokers, said Joel Newman, the organization's assistant director of communications.

"Given the news of this circumstance, there will probably be more discussion about doing something like that," he said.

For his part, Dr. Matas said the emergence of a black market in the U.S. should have been expected. About 5% of the 93,000 organs transplanted annually around the world are purchased illegally, the World Health Organization estimates.

Dr. Matas supports pilot-testing a system of legal, regulated compensation for living kidney donors in which organs would be allocated according to UNOS criteria.

"There are 80,000 people waiting for kidneys today," he said. "We know that the length of life and the quality of life is far better with a successful transplant than on dialysis. That's the underlying issue that needs to be solved. The fact that this happened is not surprising in many ways. We know it's going on elsewhere. I think the real answer is to change the system rather than have a black market."