Ahad J. Ghods

During the past decade, the number of transplantation from living kidney donors has substantially increased worldwide. The rate of increase varies from one country to another. The risk of unilateral nephrectomy to the donor includes perioperative mortality and morbidity plus the long-term risk of living with a single kidney. The rate of perioperative mortality and morbidity is about 0.03% and 10%, respectively. More attention is required to prevent serious complications of laparoscopic donor nephrectomy. A grading system in recording perioperative complications is necessary for making it available to each potential donor. The number of studies on long-term outcome of living donors is very limited. The overall evidence suggests that the risk of end-stage kidney disease is not increased in donors, however, mild renal failure, hypertension and proteinuria are not uncommon in living donors. There is also concern that the incidence of cardiovascular disease may be higher in kidney donors. Establishing living donor registry and follow-up is extremely important. Only through these registries the long-term risk of kidney donation will become more apparent. Because of severe shortage of transplantable kidneys, some transplant centers are now using donors with comorbidities and few centers are involved in transplant tourism with inadequate donor screening and follow-up. Prevention of these unacceptable practices in living kidney donors was emphasized in Amsterdam Forum in 2004 and Istanbul Summit in 2008.

The first renal transplantation in Iran was carried out in 1967. Between 1967 to 1988 almost all renal transplants were from living-related donors and the number of renal transplants performed was much lower than the national demand. In 1988, a compensated and regulated living-unrelated donor renal transplantation program was adopted. As a result, the number of renal transplants performed substantially increased such that in 1999, the renal transplant waiting list was completely eliminated. By the end of 2006, a total of 21251 renal transplants were performed (3641 from living-related, 16544 from living-unrelated and 1066 from deceased-donors). In this program, many ethical problems that were associated with paid kidney donation were prevented. Currently, Iran is the only country with no renal transplant waiting lists, and> 50% of patients with end-stage renal disease have functioning grafts. In April 2000, the legislation was passed by parliament accepting brain death and allowing deceased-donor organ transplantation. By the end of 2006, 18 brain death identification units, 13 organ procurement units were organized, and a total of 1546 deceased-donor organ transplantations were performed (1066 kidney, 327 liver, 122 heart, 20 lungs, 7 pancreas-kidney, 2 heart-lungs and 2 small bowel transplants). The number of deceased-donor organ transplants have slowly but steadily increased in the country. The majority of deceased-donor kidney, liver, and pancreas transplants have been performed by transplant team of Shiraz University of Medical Sciences.

Since the 1980s, many countries have passed legislation prohibiting monetary compensation for organ donation. Organ donation for transplantation has become altruistic worldwide. During the past two decades, advances in immunosuppressive therapy has led to greater success in transplantation and to increased numbers of patients on transplant waiting lists. Unfortunately, the altruistic supply of organs has been less than adequate, and severe organ shortage has resulted in many patient deaths. A number of transplant experts have been convinced that providing financial incentives to organ sources as an alternative to altruistic organ donation needs careful reconsideration. In 1988, a compensated and regulated living-unrelated donor renal transplant program was adopted in Iran. As a result, the number of renal transplants performed substantially increased such that in 1999, the renal transplant waiting list was completely eliminated. By the end of 2005, a total of 19,609 renal transplants were performed (3421 from living related, 15,356 from living-unrelated and 823 from deceased donors). In this program, many ethical problems that are associated with paid kidney donation also were prevented. Currently, Iran has no renal transplant waiting lists, and >50% of patients with ESRD in the country are living with a functioning graft. In developed countries, the severe shortage of transplantable kidneys has forced the transplant community to adopt new strategies to expand the kidney donor pool. However, compared with the Iranian model, none of these approaches has the potential to eliminate or even alleviate steadily worsening renal transplant waiting lists.

Currently, the buying and selling of kidneys through "transplant tourism" is occurring at an increasing rate, both in developed and developing countries. Since 1988, Iran has adopted a compensated and regulated living-unrelated donor renal transplant program, and by providing financial incentives to volunteer living donors, has eliminated the renal transplant waiting list. In the Iranian model of renal transplantation program, regulations have been put in place to prevent transplant tourism. Foreigners are not allowed to undergo renal transplantation from Iranian living-unrelated donors. They also are not permitted to volunteer as kidney donors for Iranian patients. A study at the transplant unit of Hashemi Nejad Kidney Hospital in Tehran, Iran, showed that of 1881 renal transplant recipients, 19 (1%) were Afghani or Iraqi refugees, 11 (0.6%) were other foreign nationals, and 18 (0.9%) were Iranian immigrants. Renal transplantations seemed ethically acceptable to all refugees and foreign nationals. However, transplantation of Iranian immigrants who had been residing abroad for years constituted true transplant tourism.