Liver transplantation is the gold standard of care in patients with end-stage liver disease. The estimated need for liver transplant in Syria is 1000 cases every year. Yet there is no liver transplantation in Syria. Traveling to Iran or Europe for a liver transplant is a luxury few Syrian can afford, not to mention the bureaucratic hurdle of obtaining governmental financial support if any.

There is currently an on-going debate on which type of donor for liver transplant shall we start with in Syria; living donor liver transplant (LDLT) versus deceased donor liver transplant (DDLT). The program should initially depend on deceased donors because a) LDLT requires good experience which is presently lacking in Syria and b) living donor partial hepatectomy carries a considerable risk of morbidity and mortality as reported by many large centers in the west

In 2003, a new national Syrian legislation was enacted and authorized the use of organs from both volunteer strangers and deceased donors. As a result, the kidney transplant rate jumped from 7 kidney transplants per million populations (pmp) in 2002 to 17 pmp in 2007. This increase was from unrelated donors. Regrettably, practices have developed that have gone beyond the limits of ethical and legal acceptability. Under-the-table payments by the recipient family to the vendor’s broker are customary and well known. This model is considered to be in violation of the Istanbul Declaration. Paid kidney donation has increased from none in 2002 to about 70% of total transplants in year 2010 as poverty makes this option attractive

Starting an unrelated kidney donor program in Syria has decreased the urge or need to start a deceased donor program as most patients manage to buy kidneys rather than wait for a deceased donor and also economically is more attractive for the state. In such a scenario, many transplant physicians would favor unrelated donation which is less expensive and readily available with better outcome over deceased program. Furthermore, the health authorities remain silent on “organ selling practices” which saves them money spent on dialysis. Consequently, the reputation of transplantation has been tarnished making it difficult to gain the trust of the public to donate after death. The interest in deceased donation has been negatively affected by that systematic approach to use the poor people as the source of organ. As a result, ten years after the enactment of the 2003’ law that permits retrieval of organs from deceased, there is no deceased donor program in Syria.

This lack of interest has affected starting the liver program which relies on deceased donation especially that the need for kidneys is more than livers.

In addition there is a concern that an unrelated living donor liver program might lead to death of many donors who will be coerced in donation by poverty. Therefore, the transplantation society and the transplant community have to define how much risk we are willing to accept in LDLT for both donor and recipient.

Conclusion: Paid kidney donation in actual effect becomes a hindrance to establishing deceased liver donation, as it decreases the urge to start a deceased program and tarnishes the reputation of transplantation.