At least four Japanese nationals have received illegal kidney transplant surgeries in Pakistan this year, sources close to the transplant patients said, amid growing global outrage over organ trafficking in the South Asian country.

It has also emerged that one of the Japanese patients was transported to Japan in a critical condition due to complications following the surgery.

All the Japanese transplant patients were directed to a Pakistani transplantation clinic by a Tokyo-based firm.

Information the patients were given when they decided to undergo the surgery suggests the organs they were to receive may have been purchased.

Organ trafficking is illegal in Japan and Pakistan, and patients undergoing such surgeries risk being charged with violating those laws. Experts also warn that living organ swaps also pose a health risk.

The Japanese Organ Transplant Law prohibits involvement in the organ trade by granting monetary incentives for organ donation or through unauthorized agents in or outside Japan.

The Health, Labor and Welfare Ministry is collecting information on the four cases that came to light Tuesday, and is working on steps to address organ trafficking.

Meanwhile, the company coordinating the transplants refused to comment on the Japanese citizens’ surgeries or their involvement.

As illegal organ trafficking and transplantation tourism continues, many countries worldwide, although not the United States, restrict the accommodation of foreign nationals hoping to obtain organ transplants. As a result, many people travel to Pakistan, where organ transplantations are more accessible.

According to the patients who underwent surgeries in Pakistan and their family members, the Tokyo-based company that coordinated the four transplants introduced itself as an advisory service on international transplantation. On its website, the firm also states that it has already coordinated transplants for more than 400 patients in China and the Philippines.

A man in his 60s from the Tokai region who was among the four people who used the firm’s services said he had paid about ¥10 million for the transplant. The man said he had been informed the price included an extra charge: gratuity for the donor. Initially the man was told the surgery would be carried out in Cambodia but the plan was changed, and in February the man received a kidney transplant in Pakistan. He recalled that the place where the surgery was carried out looked like a private house equipped for surgeries, and that he had not been given a chance to speak to a doctor even once.

Another man in his 50s from western Japan received a transplant at the same facility, also in February, but his body rejected the new kidney and the man had it removed. Upon return to Japan, pus formed in his wounds and the man was left almost unable to move.

Following a suggestion from the agent coordinating the transplants, both men visited Uwajima Tokushukai Hospital in Ehime Prefecture after returning to Japan to consult with Makoto Mannami, a surgeon with experience in transplant surgeries, about their recovery process.

Mannami has said he has no connection with the Tokyo-based agent.

“I only accepted the patients because they needed treatment,” he said, stressing his lack of involvement in the cases. “It is unacceptable that the (agent) uses my name without my consent.”

The four transplant patients who underwent operations in Pakistan came to him seeking treatment, Mannami said.

Until recently, China, the Philippines and Vietnam were the main travel destinations for Japanese patients seeking transplants abroad, as most candidates on the national waiting list at the Japan Society for Transplantation wait many years until they are matched with donated organs.

According to the Japan Organ Transplant Network, about 12,000 people were on the group’s waiting list for kidney transplants as of late July.

However, only around 100 organ donations from brain-dead donors occur every year, which means that patients have to wait for about 15 years on average for a transplant.

Various countries are short of donors. The concept that each nation should strive to provide organs for people seeking transplants domestically caught on in the 21st century, prompting the Transplantation Society, an international nongovernmental organization, to release its declaration on measures against transplant commercialism and transplant tourism in 2008 and 2018.

China and the Philippines were the first to prohibit giving transplants to foreign nationals. European countries and Australia prioritize locals and don’t accept foreign patients awaiting new transplants. According to the Japan Organ Transplant Society, Canada and the U.S. are the only countries offering donated heart transplants to foreign nationals.

But transplantation tourism is catching on in Asia. According to reports by U.K. national broadcaster the BBC, despite Pakistan’s efforts to curb the illegal organ trade by restricting donations of organ transplants to foreign nationals, the number of living donors in the poorest areas of Pakistan selling their organs continues to grow. About 100 surgeries that cost about ¥5 million each are performed each month, although the Pakistani government is cracking down on those involved with organ trafficking, according to the report.

Until now, there were no reports on Japanese patients receiving transplants in Pakistan. “But (Pakistan) may have become a new transplant tourism destination, given that most countries have introduced strict measures (against organ trafficking),” said Tsuyoshi Awaya, a professor at Okayama Shoka University who has surveyed patients who received transplants abroad.

“Patients who need a transplant but are on the waiting list for years in Japan will continue to seek such opportunities abroad, even if it involves a risk,” he said. “It’s impossible to tell them such practices aren’t allowed.”

Katsunori Yoshida of the Japan Society for Transplantation says the number of donors in Japan is on the rise.

“But it’s still not enough if we want to curb transplant tourism,” Yoshida said.