Time is quickly running out for Japan’s transplant tourists

Japan’s healthcare system is world-renowned. Offering twice as many hospital beds per capita as the US, the island nation’s system is frequently ranked among the very best by the World Health Organisation. Yet, for all its pioneering use of medical technology and universal health insurance, Japan is still failing many patients.

For Japanese citizens suffering from chronic kidney failure, their diagnosis is akin to a death sentence. According to the Japan Organ Transplant Network, around 300,000 patients rely on near-daily dialysis to keep them alive, while a third of these patients are seeking a kidney transplant. For many, however, the transplant they so desperately need will remain a far-off hope. Last year, just 133 cadaver kidney transplants were performed in Japan, while a record-breaking 2,905 were carried out in Spain, the leading nation for organ transplantation.

These low transplant rates are not just limited to kidney procedures. Demand astronomically outstrips supply across the board in Japan, with as few as 44 life-saving heart transplant surgeries carried out in 2015. Pancreas transplants numbered just four, while not a single intestinal transplant has been carried out since 2013. Compounding all this, the nation’s organ donation rates remain the lowest in the developed world.

For Japanese citizens suffering from chronic kidney failure, their diagnosis is akin to a death sentence

“Organ transplantation is a serious and significant problem in Japan”, said Yasuhiro Kanatani, Director of Health Crisis Management at Japan’s National Institute of Public Health. “Between 2010 and 2015, there were only 14 cases of organ donation from persons under the age of 18.”

Culture shock
In Japan, attitudes towards life and death are largely shaped by a blend of Buddhist and Shinto beliefs, which affirm the body and soul are linked together. As a result, it is held to be important for the body to remain pure and whole after death and through to cremation. The concept of organ donation is seen by many in Japan as incompatible with this practice, and it is far from being readily accepted. However, to entirely attribute the nation’s low rates of organ donation to these unique traditions would be to ignore the complex history of transplantation in Japan.

During the 1950s and 1960s, when the global medical community first began making significant progress with transplant surgery, Japan was leading the way for the pioneering treatment in Asia. Completing its first successful kidney and liver transplants in quick succession in 1964, the country seemed set to become a world leader in the field. However, these impressive advances came to a sudden halt in 1968, after the country’s first heart transplant met with intense public outrage. The surgeon in charge of the operation, Dr Juro Wada, came under intense criticism for personally selecting the organ recipient, and performing the brain death evaluation of the donor alone. As concern over Wada’s evaluation practises mounted, a full criminal investigation into the milestone operation was launched.

While the surgeon’s murder charges were eventually dropped, the controversial incident saw a dramatic reassessment of transplantation surgeries, resulting in a 30-year ban on cadaveric organ donation. The ban was only lifted in 1997, when a new law finally legalised organ transplants from brain-dead donors. While the revised transplant law certainly marked a significant first step in reintroducing the treatment to Japan, its success has been understandably limited. Instances of brain death account for less than one percent of all deaths in Japan, while a lingering deep-rooted distrust of organ transplantation has kept donor registration numbers low. The likelihood of a brain-dead patient having registered as an organ donor, with the required blessing of their family, is therefore minute.

Transplant tourism
For the hundreds of thousands of Japanese patients currently on the organ transplant waiting list, the chances of receiving this life-saving operation seem incredibly slim. Tired of waiting, many prospective transplant recipients are opting to travel abroad to receive the surgery they need. A 2006 survey by the Japanese Health Ministry confirmed at least 522 Japanese patients had received transplants abroad, with the true figure believed to be much higher – in the 10 years since, there has been little to suggest much has changed. Popular destinations for Japanese transplant tourism include the US, Australia and, perhaps most controversially, China.

Since the early 1980s, China’s dominant source of organs has been executed death-row prisoners. Shockingly, the nation’s Deputy Health Minister, Huang Jiefu, acknowledged in 2010 that over 90 percent of organs used in transplants were taken from inmates. While two years have now passed since the nation first pledged to put an end to the controversial practice, an update to the landmark Kilgour-Matas report suggests organ harvesting continues to thrive. According to the update, extracted organs are routinely sold to both native and international patients, with kidneys fetching a price tag around $80,000.

With the additional costs of flights and convalescent accommodation pushing expenses up to hundreds of thousands of dollars, transplant tourism is an option that few can afford. For those Japanese patients lacking the financial means, their best hopes lie in the burgeoning field of regenerative medicine.

Pass the tissues
In recent years, the Japanese Government has been attempting to combat donor shortage through heavy investment in pioneering tissue regeneration projects. Unlike conventional organ transplants, which use tissue taken from donors, regenerative treatments use stem cells taken from patients themselves. These stem cells are then grown into tissue in a lab, before being transplanted back into the patient’s body. Japan Tissue Engineering, a subsidiary of Fujifilm, has been pressing ahead with epidermis culturing, while the University of Tokyo Hospital has been leading the way in bone and cartilage regeneration. Although research such as this has yielded promising results in Japan, perhaps the most significant tissue engineering breakthrough to-date has come courtesy of the Centre for Eye Research Australia (CERA).

Researchers at the Melbourne-based institution have successfully grown cornea cells on a thin layer of synthetic film in a lab, and transplanted them into the eyes of animal test subjects, thus curing them of blindness. This innovative use of a patient’s own cells in transplant operations could not only solve the issue of donor shortage, but may also put an end to another pressing transplantation issue: rejection.

“Rejection is the body’s immune system recognising foreign cells and then killing them. But, if you use autologous cells, there’s no risk of rejection”, said Mark Daniell, Head of Corneal Research at CERA. The centre’s synthetic film could revolutionise corneal transplant surgery. “The scaffold that we’ve developed is clever in that it is very robust, and so can withstand the surgery, but is also incredibly thin, keeping it transparent. It doesn’t cause any inflammatory reactions, and is also biodegradable, leaving no trace in the body and no toxic product afterwards”, Daniell said. What’s more, the possibilities for CERA’s new patented treatment extend much further than the field of corneal research, and could have a significant impact on the wider world of transplant surgery.

“That’s really the premise of tissue engineering, that you can remake people’s organs using their own adult stem cells, without any risk of rejection”, said Daniell. CERA has already suggested the same regeneration technology could be used in other surgeries, such as skin and retina transplants, although this research is still in its early stages. CERA’s previous research has largely been funded by philanthropic and government grants, but the institute is now looking for venture capital investment in order to progress to the next stage in its corneal project: human trials.

As advances in tissue engineering and stem cell research continue to ignite the world of medicine, patients may soon have an alternative to lengthy organ transplant waiting lists. In Japan, attitudes towards organ donation might be slow to change, but the science is advancing rapidly. After decades of doubt over transplant surgery, strict laws and cultural norms may soon cease to prohibit transplant surgery in Japan and beyond.