1517. Kidneys for Sale

By Kevin Sack, The New York Times, August 17, 2014

Kidney sellers in India show their scars. Iran is the only country where there is a legal market for kidneys.

RAMAT GAN, Israel — Aside from the six-figure price tag, what was striking was just how easy it was for Ophira Dorin to buy a kidney.

Two years ago, as she faced the dispiriting prospect of spending years on dialysis, Ms. Dorin set out to find an organ broker who could help her bypass Israel’s lengthy transplant wait list. Only 36, she had a promising job at a software company and dreams of building a family. To a woman who raced cars for kicks, it seemed unthinkable that her best days might be tethered to a soul-sapping machine.

For five years, Ms. Dorin had managed her kidney disease by controlling her diet, but it had gradually overrun her resistance. Unable to find a matching donor among family and friends, she faced a daily battle against nausea, exhaustion and depression.

A broker who trades in human organs might seem a difficult thing to find. But Ms. Dorin’s mother began making inquiries around the hospital where she worked, and in short order the family came up with three names: Avigad Sandler, a former insurance agent long suspected of trafficking; Boris Volfman, a young Ukrainian émigré and Sandler protégé; and Yaacov Dayan, a wily businessman with interests in real estate and marketing.

The men were, The New York Times learned during an investigation of the global organ trade, among the central operators in Israel’s irrepressible underground kidney market. For years, they have pocketed enormous sums for arranging overseas transplants for patients who are paired with foreign donors, court filings and government documents show.

The brokers maintain they operate legally and do not directly help clients buy organs. Dodging international condemnation and tightening enforcement, they have nimbly shifted operations across the globe when any one destination closes its doors.

The supply of transplantable organs is estimated by the World Health Organization to meet no more than a tenth of the need. Although there is no reliable data, experts say thousands of patients most likely receive illicit transplants abroad each year. Almost always, the sellers are poor and ill-informed about the medical risks.

The vast marketplace includes the United States, where federal prosecutors in New Jersey won the first conviction for illegal brokering in 2011.

But a Times analysis of major trafficking cases since 2000 suggests that Israelis have played a disproportionate role. That is in part because of religious strictures regarding death and desecration that have kept deceased donation rates so low that some patients feel they must turn elsewhere.

“When someone needs an organ transplant, they’ll do everything in their power,” said Meir Broder, a top legal adviser to Israel’s Ministry of Health.

That desperation was evident in the workings of the transplant tourism pipeline that delivered Ms. Dorin and other foreign patients to Costa Rica from 2009 to 2012. Through more than 100 interviews and reviews of scores of documents, The Times traced the network from the barrios of San José, Costa Rica’s gritty capital, to the glass towers of Ramat Gan, a bustling commercial district near Tel Aviv.

The Costa Rican government is not sure how many foreigners received suspicious transplants there. But The Times identified 11 patients — six Israelis, three Greeks and two American residents — who traveled to San José for transplants using kidneys obtained from locals. Two other Israelis who were located brought donors from Israel with them for procedures that most likely would not have been approved in their own country.

The network was built by a cast that included high-rolling Israeli brokers, a prominent Costa Rican nephrologist and middlemen who recruited donors from the driver’s seat of a taxi and the front counter of a pizzeria. In interviews and documents, four Israeli patients or sources close to them identified Mr. Dayan, known as Koby, as their conduit to Costa Rica.

The authorities in Costa Rica have been investigating the operation for more than a year. But it is not clear that the police in either country have linked the transplants to Mr. Dayan or other Israeli brokers. None of the organ recipients contacted by The Times said they had been interviewed.

Ms. Dorin’s path through the organ bazaar was circuitous, taking her to multiple brokers doing business on opposite sides of the world.

The odyssey began when her family was referred to Avigad Sandler, who explained that he was sending clients to Sri Lanka for $200,000 in cash, Ms. Dorin said. Her co-workers staged a fund-raiser, and her parents mortgaged their house to cover the rest.

When Ms. Dorin’s mother went to convert her shekels into dollars, the money-changer told her that his uncle had received a kidney in Sri Lanka for far less. He offered to arrange an introduction.

The uncle’s broker, Boris Volfman, requested $10,000 down and told Ms. Dorin she would have to take the remaining $140,000 to Sri Lanka. He suggested she change her dollars into 500-euro notes to keep the wad thin, she said.

The timing was unfortunate. The next day, the Israel Police arrested Mr. Volfman, along with Mr. Sandler and others, on suspicions of organ trafficking unrelated to Ms. Dorin’s case.

The setback did not last long. When Ms. Dorin mentioned her plight to a client, he told her that his father had received a transplant in Turkey five years before. “Why didn’t you come to me earlier?” he asked.

A meeting was arranged with Mr. Dayan, who explained that a transplant in Costa Rica would cost $175,000, Ms. Dorin said. He was careful not to specify that the package would include a kidney. “But it was understood,” Ms. Dorin recalled, “that the payment was for everything, including the organ.”

She said that some of the money was wired to a hospital in San José, and that she delivered a payment to Dr. Francisco José Mora Palma, the kidney specialist who oversaw her transplant. Dr. Mora then paid the equivalent of $18,500 to an unemployed 37-year-old man for his kidney, according to a confidential Costa Rican court document.

Just hours after Ms. Dorin arrived in San José in June 2012, Dr. Mora met with her and the donor at her hotel. There, she said, they signed affidavits in Spanish, a language she could not read, swearing that money would not change hands.

Ms. Dorin said she had doubts about Mr. Dayan’s assurances that everything was legal, but did not feel she had much choice.

“My situation was critical,” she said. “I didn’t feel very good, and my condition was getting worse. Even if I knew it was illegal, I don’t think I would have done anything different. It’s important to understand that these people, although greedy, do save lives.”

A Growing Market

Because most people can live with only one kidney, that organ accounts for the vast majority of living-donor transplants. Laparoscopy has made the surgery to remove a kidney fairly routine, although it is not risk-free. Living donors account for about 40 percent of the roughly 80,000 kidney transplants performed worldwide each year, according to the W.H.O.

Patients fortunate enough to find a living donor with the right blood type and antigens can avoid the lengthy wait for an organ from a cadaver. Kidneys from living donors are also preferred because they tend to last longer.

Long criminalized across the globe, the organ trade was handed an unequivocal rebuke at a worldwide conference of transplant practitioners in 2008. The group’s manifesto, called the Declaration of Istanbul, asserted that trafficking violated “the principles of equity, justice and respect for human dignity and should be prohibited.”

And yet the prospective market for trafficked kidneys has grown unabated as the gap between supply and demand widens each year.

In the United States, the number of kidney transplants has remained static for a decade at 16,000 to 17,000 a year. During the same period, the waiting list for kidneys from deceased donors has nearly doubled, passing 100,000 this year. The median wait time for an adult is more than four years, and more than 4,000 die waiting each year.

Some physicians and ethicists question the relative morality of allowing thousands to die just because the means of saving them is considered repugnant. A regulated marketplace, they say, could all but eliminate the shortage. It is no accident, they argue, that the only country that allows compensation for donors — Iran — effectively has no waiting list.

Experts list China, Egypt, India, Pakistan, Sri Lanka, Turkey, Eastern Europe and the former Soviet republics as hot spots for organ trafficking. But illicit transplants usually go undetected unless there is a surgical mistake or a payment dispute. Prosecutions are thwarted by false affidavits, toothless laws and lack of international cooperation, particularly regarding extradition.

Over the last decade, the authorities have pursued only a handful of cases worldwide. Few have sidelined the brokers, who seem bolder than ever. Some, like Mr. Volfman, who leases office space atop a mirrored skyscraper in Ramat Gan, have moved out of the shadows. They brazenly ply their trade even while under police scrutiny, posting Facebook photos of the luxury cars and five-star hotel rooms they rent on the road.

The Times found that brokers in recent years typically have charged clients $100,000 to $200,000 to cover expenses associated with a transplant. As with other scarce luxuries, pricing can be elastic.

In 2012, an 83-year-old Texas car dealer, John W. Wiesner, paid $330,000 to Mr. Sandler to arrange a transplant in Sri Lanka, Israeli court documents show.

In an email that April, Mr. Sandler told Mr. Wiesner he was being charged extra “due to the high risk” posed by his age, which would have disqualified him at most American hospitals. Mr. Wiesner did not have his own donor.

“If the details are acceptable, please wire $40,000 USD to the following bank account,” Mr. Sandler instructed.

Mr. Wiesner’s trip to Sri Lanka was pre-empted by Mr. Sandler’s arrest the next month. The Israel Police found $150,000 of Mr. Wiesner’s money and returned it, according to court filings. He then sued Mr. Sandler and others to recover the rest. The case was settled in March for $66,000, court records show. Mr. Wiesner and his lawyers declined to comment.

Mr. Sandler, 65, a former Israeli Army officer, had come under suspicion back in 2008 when European Union prosecutors investigated a trafficking network in Kosovo. Numerous attempts to contact him through lawyers and relatives were unsuccessful.

Haven in Costa Rica

With its lush rain forests and breathtaking beaches, Costa Rica had been a vacation destination long before the development of its medical tourism industry. But by 2012, about 50,000 visitors were spending $330 million a year on procedures as varied as root canals and tummy tucks, according to the Council for the International Promotion of Costa Rica Medicine. As revenues soared, the transplant trade revealed itself as the seamy underside.

Physicians have a financial incentive to treat foreign patients because of the country’s dual public-private medical system. Specialists like nephrologists and transplant surgeons are required to work at state-run hospitals, where they make perhaps $7,000 a month. But they can earn more by working after hours at private hospitals that cater to patients with means.

There, doctors are paid by the case, so the more transplants they perform, the more they make. One nephrologist in San José, Dr. José Fernando Mangel Morales, said he sometimes doubled his monthly income by handling a single transplant at a private hospital.

Dr. Mora, the chief of nephrology at the state-run Hospital Rafael Ángel Calderón Guardia, also had privileges at two private hospitals — Hospital Clínica Bíblica and Hospital La Católica. The Costa Rican authorities believe he had been arranging transplants for foreigners at the hospitals at least since 2009.

The doctor, now 64, was considered a pioneer within the country’s small nephrology community, assisting in more than 550 transplants over a 35-year career. By 2011, the foreign market had become important enough that he appeared in a promotional video.

In the United States, he said in thickly accented English, a kidney transplant might cost $250,000. “Here in Costa Rica,” he said, “it would cost more or less a third part, including the hotel and the ticket for the planes.”

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Dr. Mora recruited other doctors with promises of a sweet payday. In 2012, he tried to entice Dr. Clive Montalbert-Smith, a retired surgeon, to perform transplants on Israeli patients at Hospital La Católica. “Diez millones por los dos transplantes, una semana de trabajo,” Dr. Mora texted. Ten million colones (about $18,500 today) for two transplants, one week of work.

“He said it was nothing dishonest,” Dr. Montalbert-Smith said in an interview in San José, “that lawyers had written papers, that they are not paid donors. But if a foreigner comes here and the donor doesn’t know him and says he is an altruistic donor, the chance that it is trafficking is very high. I told him, ‘No thanks.’ It wasn’t easy to refuse.”

Dr. Mora did not respond to repeated requests for an interview, and his lawyer declined to comment.

The Costa Ricans who provided kidneys to foreigners were mainly men who had not finished high school and were either unemployed or held low-income jobs.

Two of the donations were arranged by Dimosthenis Katsigiannis, a Greek immigrant to Costa Rica, according to a search-and-seizure order obtained by The Times. Mr. Katsigiannis, 56, owns the Akropolis pizzeria, which at the time was across from the public hospital where Dr. Mora worked.

According to his lawyer, Mr. Katsigiannis received a call in 2009 from a relative who needed a transplant. He inquired among the doctors who frequented his restaurant and was directed to Dr. Mora. Then he let it be known that he was shopping for a donor.

The 38-year-old man who offered his services for about $5,500 was so satisfied that his older brother sought out a comparable deal, said Mr. Katsigiannis’s lawyer, Jesús Gilberto Corella Quesada. Mr. Corella said that Mr. Katsigiannis received no compensation. The brothers received their payments at the pizzeria, according to the search order.

“Obviously there was some money involved,” Mr. Corella said. “Nobody would donate, except if they were related or a friend, without being paid.” He disputed the brothers’ affidavits vowing that they took no money.

Subsequent sellers were recruited by Maureen Cordero Solano, 33, a police officer who drove a taxi after hours, according to the authorities. Like many who fall into organ brokering, Ms. Cordero had sold her own kidney in 2009 and met Dr. Mora in the process. She received $1,000 from him for each donor she supplied, according to the search order. She could not be reached, and her lawyer would not comment.

Some of the donors were solicited in Ms. Cordero’s cab. “She finds out they have an economic need and tells them there’s a way they can get a good amount of money,” said Jorge Chavarría Guzmán, the chief prosecutor in Costa Rica. “Then she puts them in contact with Dr. Mora.”

The Transplant Broker

Mr. Dayan, now in his late 50s, had been one of Israel’s go-to transplant brokers long before he began directing patients to Costa Rica. A favorite destination had been the Philippines until it banned transplants for foreigners in 2008.

According to a tax-fraud indictment issued in Israel last year, Mr. Dayan and his firm used dummy foreign companies to shield more than $30 million from 1999 to 2007, much of it from transplant brokering. The indictment charges that Mr. Dayan paid associates up to $40,000 for each donor they recruited, often through ads in Russian-language newspapers.

By 2011, he had opened operations in Costa Rica. “He told me he has a contract with Dr. Mora, that he was exclusive with him for Israelis,” said one Israeli who met with Mr. Dayan that year. “He told me he already sent several people and everything was successful.” The Israeli insisted on anonymity for fear of retribution.

Through documents and interviews, The Times traced the transplants for Ms. Dorin and two other Israelis back to Mr. Dayan. One, a 60-year-old retiree, identified Mr. Dayan as his broker in a lawsuit seeking repayment of a loan. A fourth client sued Mr. Dayan after plans for a transplant fell through. That court file includes an email from Mr. Dayan to Dr. Mora, dated Nov. 15, 2011, trying to schedule two transplants.

Mr. Dayan acknowledged during a brief interview in his office that he knew Dr. Mora. But he denied sending patients to Costa Rica. “No chance,” he said with a smile.

Wearing a gray suit and sporting a salt-and-pepper goatee, Mr. Dayan said he had heard from a patient that Dr. Mora was connecting Costa Rican donors with Israeli recipients. “I told Dr. Mora he was making mistakes that he took patients from outside Costa Rica,” Mr. Dayan said.

He declined to explain further. “I haven’t been in the business for a year and a half or two years,” he said. “We help people, but I don’t want to talk about it. I think this is going to make problems for patients.”

A spokesman for the Israel Police declined to comment on whether the agency was pursuing the Costa Rica case.

Although limited in scope, research suggests that patients who go abroad for transplants may bear higher risks of complications and lower rates of survival. In Costa Rica, at least two of the recipients had dangerous outcomes, including an Israeli businessman who underwent a transplant at Hospital La Católica on Nov. 30, 2012.

The procedure, which was overseen by Dr. Mora and Dr. Victor Hugo Monge Monge, a vascular surgeon, left the businessman with impaired kidney function and grotesque abdominal swelling, according to emails among physicians. In extremis, he flew to Los Angeles and checked into Ronald Reagan U.C.L.A. Medical Center, where he was stabilized.

Now 55, the businessman is back working full time. Interviewed in a Tel Aviv cafe on the condition that he not be named, he denied paying for anything other than the airfare and lodging of his donor.

He said he chose not to have the transplant at home because he assumed that “in Israel, they would not believe that this donor came without money.”

Suspicions Arise

The first clue that something was amiss in Costa Rica came in August 2012 when a nurse at the public hospital where Dr. Mora worked learned that its surgical equipment was being used at Hospital La Católica for a transplant.

Then in December 2012, Dr. Gabriel Danovitch, the nephrologist at U.C.L.A. who treated the Israeli businessman, told a Costa Rican doctor about his suspicions of trafficking. The chief prosecutor’s office in Costa Rica was subsequently notified, as were health officials there and in Israel.

Yet, Costa Rica’s investigation did not ramp up until after a bizarre episode on March 18, 2013, when a Costa Rican couple arrived at Ben Gurion Airport, near Tel Aviv.

Rosa, then 20, and Roberto, 26, were from the central highlands, where the lush volcanic hillsides are planted thick with sugar cane and coffee. (The Times is not publishing their last names because they are considered protected witnesses under Costa Rican law.) Neither had been out of the country, nor on a plane, so they were brimming with excitement. “Tomorrow I start a new stage of my life, thank you God for helping me,” Roberto posted on Facebook before leaving. “I hope all will go well. A unique and beautiful trip will happen.”

Instead, the couple caught the attention of the border police after deplaning with one piece of luggage, little money and plans only to meet a stranger at the exit, said Rodrigo X. Carreras Jiménez, the Costa Rican ambassador to Israel.

With Rosa in tears, the Israelis held the couple until they could be deported the next morning. “They finally confessed that they had come here to sell a kidney, of the young lady,” Mr. Carreras said. They also mentioned that Dr. Mora was their handler.

Rosa and Roberto, when contacted in Costa Rica, declined to grant a full interview. During brief exchanges, they said they did not know why they had been sent to Israel when the routine had been for recipients to travel to Costa Rica. “We didn’t know anything about anything,” Rosa said.

What they did know was financial distress. They had borrowed nearly $3,000 from a friend and were having trouble paying it back. Roberto made about $500 a month as a security guard, and Rosa was finishing high school. They had a baby to feed and were living in a tin-roofed shanty beside a fetid stream.

One day, Roberto said, he received a visit from a relative, Ms. Cordero, the taxi driver who recruited donors. She offered a way out. “A lady needs to live, and you need the money,” she said. When medical tests disqualified Roberto, Rosa stepped up.

The scene at the airport only got stranger when a nurse arrived asking to take Rosa’s blood, according to Mr. Carreras. A lawyer also showed up, and along with the nurse was sent away. The lawyer, Lior Lev, said in an interview that a client, whom he would not name, had dispatched him to check on the couple. Court records show that Mr. Lev has represented Mr. Dayan in other matters.

Crestfallen, Rosa and Roberto flew home.

Back in San José, unease about the foreign transplants was starting to bubble, even as new players sought a piece of the business.

Dr. Jorge Cortés Rodríguez, the medical director of Clínica Bíblica, was already nervous about the four transplants performed at his hospital by Dr. Mora’s team when the doctor asked to schedule another one. The prior procedures had been approved by hospital officials who accepted patients’ affidavits at face value.

“When you studied the paperwork, brought by a prestigious doctor with a team behind him,” Dr. Cortés said, “and you saw it was perfect with the legal stamps and the authorizations by the attorneys, you don’t think anything is wrong. But when it happens one time and it happens another time, then you start to get suspicious.”

On April 18, Dr. Cortés informed Dr. Mora that he would not approve the transplant. Dr. Mora took the news calmly. But Dr. Cortés soon received a visit in his office from a muscle-bound man with thick black hair that was shaved in a fade. He introduced himself in Slavic-accented English as Damian Goldstein.

The visitor, whom Dr. Cortés took to be a broker, demanded an explanation for the cancellation. “He started pushing me hard,” Dr. Cortés recalled, “saying that we need to do this for humanitarian reasons, that the patient is in very bad shape.”

The visitor backed down, but the encounter left Dr. Cortés shaken. “He really impressed me that he looked like a bad boy,” he said.

Building a Business

Damian Goldstein is a pseudonym used by a 30-year-old Israeli named Adi Vladlen Lishinski, The Times has determined from documents and interviews.

While in San José, Mr. Lishinski sublet a two-bedroom flat on the 17th floor of the country’s tallest building, where he made daily use of the gym and blared rock ‘n’ roll, according to building staff members. In a photograph posted on his Facebook page, he is seen surveying San José from the balcony, bare-chested and tattooed, sunglasses in place despite foreboding gray skies.

Mr. Lishinski had immigrated to Israel from Ukraine as a child. He began building a modest criminal record as a teenager, and by October 2011, he had jumped bail in a robbery case. He spent time in Sri Lanka and then, according to immigration records, arrived in San José on Oct. 10, 2012.

Shortly after, Mr. Lishinski stopped at a car dealership. The $20,000 he had to spend was not enough to buy the Grand Cherokee that caught his eye. But during several visits, he struck up enough of a relationship with the salesman, Carlos Zúñiga Forero, to reveal what had brought him to San José.

“He said he was making a living selling organs,” Mr. Zúñiga said. “He said it was legal because the people sign some papers.”

Mr. Lishinski explained that he hoped to establish a transplant tourism agency, but needed a local partner to incorporate under Costa Rican law. Flashing $100 bills, he offered Mr. Zúñiga several thousand dollars to sign on.

The salesman declined but referred Mr. Lishinski to a pair of lawyers. One of them, Federico Altamura Arce, co-signed incorporation papers for D & B Medical Treatment Solutions on Nov. 5, 2012, for a $1,000 fee. A notary required identification, and Mr. Lishinski submitted a copy of a passport bearing his real name.

Mr. Lishinski then wanted more — templates for contracts with hospitals and fill-in-the-blank affidavits for donors. But Mr. Altamura soon discovered that his client had been misleading him about the legalities of donation in Israel.

In a meeting, the lawyers told Mr. Lishinski they were no longer comfortable representing him. It did not sit well. Mr. Lishinski demanded to know who they were to question him when the transplants had been approved by Dr. Mora.

“He insulted me at one point and told me, to quote him, that I didn’t have balls because I wouldn’t do the document for him,” Mr. Altamura said. “Said I was a coward. I responded that as an attorney I have the right to choose what risks to take.”

Mr. Lishinski departed Costa Rica in late April 2013, and was arrested in the robbery case when he landed at Ben Gurion, court records show. A judge ordered him to perform community service at a nursing home, and to pay modest fines.

It could not be determined whether Mr. Lishinski arranged any transplants, or was associated with Mr. Dayan. But The Times learned through interviews that Mr. Lishinski is a longtime friend of Boris Volfman. They met as teenagers in a residential program for wayward juveniles in northern Israel, according to a mutual acquaintance.

In March, a reporter reached Mr. Lishinski by telephone and asked to discuss his work. “Have you talked with Mr. Boris?” he replied.

Beyond that, Mr. Lishinski declined to detail his overseas activities. “Actually, I don’t have any involvement in Costa Rica or Sri Lanka,” he said.

Mr. Volfman, however, granted a series of lengthy telephone interviews. While acknowledging that he and Mr. Lishinski had business dealings, he denied that his friend had worked for him in Costa Rica.

“The answer is no, clearly and completely no,” Mr. Volfman said. “He acted by himself without any connection to me.”

Mr. Volfman was otherwise circumspect about their association. “We’re trying to cooperate in a number of fields, trying to do something together,” he said.

Mr. Volfman, 30, personifies the generational evolution of the transplant tourism trade. Two years ago, after his arrest with Mr. Sandler, he set up his own agency. He consulted with lawyers about insulating the firm, put up a website (justsavelives.com) and issued news releases in search of markets.

He named his company Leshem Shamaim,or “In the Name of Heaven.”

“It’s God’s work,” Mr. Volfman explained.

Patients like Ms. Dorin said they found the youthful Mr. Volfman to be self-confident, earnest and smoothly reassuring. Photographs on social media depict him with piercing blue eyes, a shag of jet black hair and a distinctive tattoo that drapes his right shoulder. Married with a young son, he owns a condominium overlooking the Mediterranean in Ashdod, south of Tel Aviv.

Mr. Volfman sold his own kidney in Colombia as a young man, according to court records. He said that while working for Mr. Sandler, he accompanied patients to Sri Lanka. But he denied that they dealt in trafficked organs.

In 2007, Mr. Volfman was charged in the abduction of a man who told the police that Mr. Volfman had used him to hack into hospital databases in search of kidney patients. Mr. Volfman pleaded guilty to reduced charges and was sentenced to two months in jail, according to court records.

His name emerged again when European Union prosecutors investigated organ trafficking in Kosovo. That led to Mr. Volfman’s two-week detention in Israel in May 2012.

Four months after leaving jail, Mr. Volfman incorporated Leshem Shamaim. He said the company, with six employees, had handled perhaps 15 transplants in its first 18 months.

In the interviews, conducted in March while Mr. Volfman said he was traveling in Europe, he explained that for about $30,000, the firm would accompany clients abroad and provide contacts, medical testing, transport, lodging and translation.

But Mr. Volfman said patients decided which transplant centers to engage, and paid them directly.

“In our company, we don’t have any contact with the organ,” he said. “All we can do is obligate the client to make sure that this is not something that has to do with organ trafficking. If a person decides to break the law, that’s between that person and the law.”

Regardless, Leshem Shamaim’s aggressive pursuit of new venues has raised red flags on several continents.

In April 2013, one of Mr. Volfman’s employees wrote to the Peruvian Health Ministry to say that Leshem Shamaim would pay $10,000 per transplant if the firm was granted exclusive rights to bring patients to Lima. The ministry’s lawyers concluded in a memo that such an arrangement would violate the country’s antitrafficking laws.

Two months later, the Leshem Shamaim representative emailed a similar solicitation to officials in Singapore. The letter prompted the head of nephrology at National University Hospital to caution her colleagues: “I think they are on the prowl” for commercial transplants.

A Case Takes Shape

On June 18, 2013, Costa Rican police officers raided Hospital Calderón Guardia and made a show of arresting Dr. Mora while he was still dressed in his white lab coat. The Organismo de Investigación Judicial, Costa Rica’s F.B.I., also arrested Ms. Cordero, the taxi driver, and seized medical records from Dr. Mora’s offices.

The doctor was jailed for four months before paying bail of about $180,000. Scheduled to retire soon, he did not return to work.

A close friend, Dr. Manuel Cerdas Calderón, the president of Costa Rica’s nephrology society, visited Dr. Mora in jail. “He said they did the kidney transplants to save lives,” Dr. Cerdas said. “That is the only reason. Dr. Mora has lost many things: money, patients, his position, prestige. He can never come back.”

The records seized from Dr. Mora led the authorities to multiple kidney sellers and prompted the arrests in October of Dr. Monge, the vascular surgeon who transplanted the organs, and of the two urologists who removed them. The suspects declined to comment.

The police also swept into the Akropolis pizzeria and arrested Mr. Katsigiannis. Formal charges against him, Dr. Mora and the three other doctors are expected this month, said Tatiana Vargas Vindas, a spokeswoman for the chief prosecutor. The government will not charge Ms. Cordero because she is cooperating with prosecutors. It will also not pursue those who sold kidneys, Ms. Vargas said. They are considered victims and have been placed in a government protection program.

“Nobody is in good condition — monetary, social or health,” said Henry Madrigal Ledezma, head of the trafficking unit of the Organismo de Investigación Judicial. “Nobody is attending to them, no hospital, no doctor.”

Top officials at Hospital La Católica, where most of the transplants took place, did not respond to requests for comment. Clínica Bíblica said in a statement that it could not have suspected that donors and recipients would arrange transplants based on “false statements and forged agreements.”

The scandal prompted the Costa Rican Legislative Assembly to pass a law in March that toughens the restrictions on trafficking, holds doctors accountable for illicit procedures and establishes a national wait-list system.

In Israel, the State Attorney’s Office declined to discuss the status of the tax-fraud case against Mr. Dayan. There are no formal charges against Mr. Sandler, Mr. Volfman and their associates, but the office continues to investigate with the intention of seeking indictments.

The noose seemed to tighten in April when the Israel Police arrested one of Mr. Volfman’s lieutenants. At a detention hearing, a police superintendent, Meir Arenfeld, said that the primary suspect in the operation — presumably Mr. Volfman — was abroad and “from what we understand, has no intention of coming back.”

He said the police and prosecutors were examining transplants arranged by Leshem Shamaim in Turkey. Late last year, Israeli nephrologists noticed that kidney recipients were returning from Ankara. One of them bore medical records forwarded by a Leshem Shamaim employee.

“It is clear to us that these people sold their bodies for pennies,” Mr. Arenfeld said of the donors. He said that prior arrests had not seemed to deter the brokers, adding, “We see a pattern of behavior that is repeating itself.”