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Volume: 17 Issue: 1 January 2019 - Supplement - 1

FULL TEXT

Living Unrelated Kidney Transplantation: Does It Prevent Deceased-Donor Kidney Transplantation Growth?

Objectives: It is usually assumed that an active living-donor transplant program inhibits the growth of a deceased-donor kidney transplant program. In our 33-year experience, we found the contrary to be true.

Materials and Methods: From 1984 until 2017, we performed a total of 4966 kidney transplant procedures. All cases were registered through the Collaborating Transplant Study (Heidelberg, Germany).

Results: During the first 16 years, only living-donor kidney transplant procedures were done. Our first unrelated living-donor kidney transplant procedure was in 1986 and involved a wife to husband donation. This breakthrough in our country was the first in our unrelated living-donor kidney transplant program. In 2000, the Iranian Parliament passed the deceased-donor transplant act, and we have started deceased-donor kidney transplants since then. Despite a jam-packed living-donor kidney transplant program, our deceased-donor kidney transplant program has grown steadily since then and now comprises more than 50% of our kidney transplant procedures. When we compared the outcome of these programs, the 5-year survival from Collaborating Transplant Study report of 3527 cases of 114 living-related donor procedures was 90%. The 5-year survival rates for living unrelated-donor (n = 2689) and deceased-donor (n = 724) transplant procedures were 88% and 83%, respectively (P = .001).

Conclusions: Our data showed that deceased-donor kidney transplant procedures have steadily increased despite an active unrelated living-donor kidney transplant program. Wait lists for kidney transplant can be significantly reduced by following our model, both in developed and in developing countries.


Key words : Deceased-donor renal transplantation, Ethics, Iranian model, Living related kidney donor, Living unrelated kidney donor, Reward gifting

Introduction

Unrelated living-donor kidney transplants (LDKT) from spouse and other unrelated donors have similar patient and graft survival rates as related LDKT, even with 0 mismatches.1 These procedures are valuable sources of kidney organs for transplant, which provide not only better graft survival and half-life compared with deceased-donor kidney transplant (DDKT) procedures but also can decrease time on a wait list.1 Transplantation in the Middle East started in Iran in 1967 with renal transplantation,2 and Iran has a unique living unrelated reward-gifting program for renal transplantation.3 Although the Iranian model for kidney transplant has eliminated transplant tourism,4 some concerns exist regarding the effects of this unique program on the progression of the deceased-donor program.5 With regard to data from one center in Iran, it was concluded that terminating the unrelated LDKT program has increased DDKT.5 It is well-known that transplant tourism and purchasing kidneys illegally abroad are serious hindrances to the development of DDKT.6 Here, we report our experience with more than 4996 kidney transplant procedures, which started 33 years previously and has been maintained in both eras, that is, both before implementation of the DDKT program and after its implementation.

Materials and Methods

From 1984 to 2017, our center performed 4966 kidney transplant procedures. All cases in our center have been registered with the Collaborating Transplant Study (CTS) at Heidelberg, Germany, and all data reported here are from the CTS. Our transplants during earlier years were only LDKT because there was not a law to allow DDKT. The Iranian parliament later passed an act to allow DDKT; therefore, there are now both LDKT and DDKT programs.

The number and type of kidney transplants and survival rates of related LDKT, unrelated LDKT, and DDKT procedures were obtained from the CTS database.

Results

During the first 16 years, only LDKT procedures were done. Our first unrelated LDKT was in 1986 and involved a wife to husband donation, leading to the first unrelated LDKT program in our country and the Middle East, which was a breakthrough.7 In 2000, the Iranian Parliament passed the deceased-donor transplantation act, and we started the DDKT program since then. Deceased-donor kidney trans-plant procedures have steadily increased and now make up more than 50% of our kidney transplant procedures. Figure 1 shows that, despite an active unrelated LDKT program, there has been a steady increase in the rate of DDKT.

Among the first 3527 cases from the CTS report, the 5-year survival of 114 related LDKT recipients was 90%. The 5-year survival rates for unrelated LDKT (n = 2689) and DDKT (n = 724) recipients were 88% and 83%, respectively (P = .001; Figure 2).

Discussion

The first renal transplant in the Middle East Society of Organ Transplantation region and Iran was performed in 1967 in Shiraz, Iran.2,8-12 From this breakthrough up to the Islamic revolution of Iran in 1979, about 112 transplant procedures were conducted,13 mostly from living related donors.8,14 From 1980 to 1984, no transplant procedures were performed in Iran; instead, around 400 Iranian patients were sent by the Ministry of Health to other countries (mostly the United Kingdom) for renal transplant procedures.12,15

In 1984, 2 transplant teams started transplant procedures from living related donors.13 Specifically, the process was started in Tehran, Iran by Professor Iraj Fazel.1,8,9 Professor Nasser Simforoosh was the second pioneer of renal transplant procedures and started kidney transplant procedures in 1984 at the Shahid Labbafinejad Hospital Medical Center.9 This program of renal transplantation is Iran’s center of excellence16 and has completed more than 4996 kidney transplant procedures, actively performing both DDKT and unrelated LDKT procedures.7,17 The first living unrelated allograft transplant in Iran and the Middle East18 was done in January 1987 in the Shahid Labbafinejad Hospital in Tehran, involving a wife to husband donation.1,8-10 This was a break-through in renal transplant in Iran.18 At that time, due to the Iran-Iraq war (1980-1988), economic sanctions, lack of sufficient dialysis facilities, and other countless problems, many renal patients were dying.19 In 1988, many patients with end-stage renal disease needed a renal transplant but had no living related donor. Deceased-donor transplant procedures had not yet been implemented, and there was a long wait list. For these reasons, the living unrelated reward-gifting program was established by the government in 1988. 7,12, 19,20

While the Iranian model (reward gifting) was in progress, Dr. Fazel13 received religious approval (Fatwa) from the Supreme Leader of Iran, the late Imam Khomeini, in 1989, who recognized brain death and allowed deceased-donor organ transplant. This religious approval was given for the first time in the entire Shia community.13 The number of renal transplants that were performed increased rapidly such that, by 1999, the renal transplant wait list was eliminated in Iran.12 Iran also has the most active renal transplant program, especially DDKT program, in the Middle East.21

In the Iranian model, if a patient has no related donor, then he or she is referred to the charity organization named Dialysis and Transplant Patients Association (DTPA) to find a suitable living unre-lated donor. The DTPA is the exclusive authority with rights to handle the matching of donors and recipients.18 The unrelated donors, once registered at DTPA, are systematically evaluated.18 After the donor is confirmed to be in good health and has provided valid informed consent, donors are introduced to potential recipients.18 Most members of DTPA are end-stage renal disease patients; DTPA is a nonprofit charity run by aids of the people. “Middleman” or agency intermediacy is illegal and prohibited.18 Transplant procedures are done in university hospitals, and transplantation and dialysis are free of charge for all Iranian citizens.18 After transplant, the living unrelated donor receives an award from the government and from the recipient (for poor recipients, this reward is given by DATPA).18 The university hospital and the transplant teams receive a fixed amount of payment from the government for each transplant. The rewarding gifts are kept to a range that most recipients of middle to poor socioeconomic classes can afford, especially with the help of the charity foundations.18 This program is run by the Ministry of Health and Medical Education of Iran. Kidney transplant to a foreign citizen is illegal except for countries that do not have transplant programs. In this case, the donors have to be from the same country.18,22

Our center has been active for the past 33 years, contributing to more than 4996 kidney transplant procedures, and we are running a busy living-donor program. Despite these facts, our deceased-donor program has grown steadily in our center, with more than 50% of our transplants from deceased donors (Figure 1).

Conclusions

The Iranian model of kidney transplant has decreased the wait list time for kidney transplant and has eliminated transplant tourism.4 There are many controversial ethical issues regarding the Iranian model of transplantation, and, of course, some aspects of this model need reform and change. There is also some concern regarding the effects of this unique program on the progression of DDKT. Our data prove that DDKT has grown steadily despite an active unrelated LDKT program. Our data show that time on wait lists for kidney transplant can be significantly reduced by following our model, for both developed and developing countries.


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Volume : 17
Issue : 1
Pages : 250 - 253
DOI : 10.6002/ect.MESOT2018.P110


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From the Department of Urology and Kidney Transplantation, Shahid Labbafinejad Hospital, Urology Nephrology Research Center, Shahid Beheshti Medical University, Tehran, Iran
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare.
Corresponding author: Mohammad Nadjafi-Semnani, Department of Urology and Kidney Transplantation, Shahid Labbafinejad Hospital, Urology Nephrology Research Center, Shahid Beheshti Medical University, Unit 4, 17th St. North Kargar St., Tehran, Iran 1438837316
Phone: +98 9151611485
E-mail: monadjafi@gmail.com , nadjafi@sbmu.ac.ir