| Abstract|| |
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 livingunrelated 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 livingrelated, 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.
Keywords: Organ transplantation, Transplantation in Iran, Iranian model, Transplantation ethics
|How to cite this article:|
Ghods AJ. Organ Transplantation in Iran. Saudi J Kidney Dis Transpl 2007;18:648-55
| Introduction|| |
Over the past three decades, with improved organ transplantation success, the number of indications for organ transplantation have continuously grown and the need for organ donation has steadily increased. In the developed countries, as in the United States and Europe, the field of organ transplantation has so markedly expanded that the supply of transplantable organs has failed to match the demand. Consequently, thousands of patients die awaiting organ transplantation. The situation is even more disappointing in the developing countries, where organ transplantation is limited to a constricted scale of renal transplant activities. The transplantation programs of vital organs such as liver, heart and lungs are either sparse or non-existent. At the end of 2004, the prevalence of patients with end-stage renal disease (ESRD) was 2045 per million people (pmp) in Japan, 1505 pmp in North America, 585 pmp in Europe, 190 pmp in the Middle East and 70 pmp in Africa. From comparison of ESRD prevalence values in developed and developing countries, it can be concluded that in developing countries a large number of patients with ESRD and almost all patients with end stage failure of vital organs die while awaiting transplantation. Iran is a developing country located in the Middle East and has approximately 70 million inhabitants. It has a unique but ethically controversial renal transplant program. In 1988, a compensated and regulated livingunrelated donor renal transplant program was adopted. As a result, the number of renal transplant centers and renal transplantations that were performed rapidly increased. By 1999, the renal transplant waiting list in the country was eliminated.  However, the Iranian live kidney donation did not prevent the establish-ment of deceased donor organ transplantation programs. Since the legislation accepting brain death and deceased-donor organ transplantation was passed by the parliament on April 6 th 2000, the number of deceased organ transplants has steadily increased. In this article, we review the results of living and deceased organ transplantations in Iran.
| Living-Donor Organ Transplantation|| |
By the end of 2006, a total of 1794 bone marrow, 20185 living-donor kidney (3641 from living-related and 16544 from living-unrelated donors) and 11 living-donor liver transplants were performed in Iran.
The first bone marrow transplantation was performed in 1991. Currently, there are 3 bone marrow transplant centers in the country. However, the majority of 1794 transplants have been performed at bone marrow transplant center of Shariati Hospital, Tehran University of Medical Sciences. Eleven of total 338 liver transplants are from live donors and all have been carried out at transplantation center of Nemazee Hospital at Shiraz University of Medical Sciences.
The first renal transplantation also was performed in Shiraz from live donor in 1967. Currently, there are 25 renal transplant centers in Iran. From 1967 to 2006, a total of 21251 renal transplants were performed. (17% from living-related, 78% from living-unrelated and 5% from deceased-donors). The main source of kidney donations are living-unrelated donors. Living-unrelated donor renal transplantation were carried out by Iranian model transplantation protocol since 1988. 
From 1967 to 1985, the number of patients who were undergoing dialysis steadily increased in Iran, but the renal transplantation program lagged behind dialysis; approximately 100 renal transplants were performed. There was a long renal transplant waiting list and few patients traveled abroad for transplantation; the majority of these transplants were performed in the United Kingdom from living-related donors. This prompted health authorities to establish renal transplant facilities inside the country. Two renal transplant teams were organized, and between 1985 and 1987, a total of 274 renal transplants from living-related donors were performed. 
In 1988, a government funded and regulated living-unrelated donor renal transplantation program was adopted. As a result, the number of transplant teams increased from two to 25. The number of renal transplantations that were performed increased rapidly such that by 1999, the renal transplant waiting list was eliminated. ,, [Figure - 1], shows the annual number of renal transplants that were performed in Iran from 1984 to 2006.
In the Iranian model of living-unrelated renal transplant program, the transplant physician should emphasize the advantages of livingrelated donor compared with living-unrelated donor renal transplant and recommend renal transplantation from a living-related donor. If the patient has no living-related donor, then the patients is referred to the Dialysis and Transplant Patients Association (DATPA) to locate a suitable living-unrelated donor. Those who volunteer as living-unrelated donor also contact DATPA. All members of DATPA are patients who have ESRD and receive no incentives for finding a living-unrelated donor or for referring the patient and donor to a renal transplant team. Currently, there are 302 dialysis units, 25 transplant centers, and 80 DATPA offices all over the country. There is no role for a broker or an agency in this program. All renal transplant teams belong to university hospitals, and the government funds all the hospital expenses of renal transplantation. After renal transplantation, the living-unrelated donor receives an award and health insurance from the government. A majority of living-unrelated donors also receive a rewarding gift (arranged and defined by DATPA before transplantation) from the recipient or, if the recipient is poor, from one of the charitable organizations. The government also provides essential immunosuppressive drugs to all transplant recipients at a greatly subsidized and reduced price. Charitable organizations also are very active in providing these drugs or in funding any expenses of renal transplantation to poor patients. Renal transplant teams receive no incentives from the recipient or from the government's award. The program is under the close scrutiny of the transplant teams and the Iranian Society for Organ Transplantation regarding all ethical issues.
To prevent transplant tourism, foreigners are not allowed to undergo renal transplantation from Iranian donors. Also, they are not permitted to volunteer as kidney donors to Iranian patients. Foreigners can receive a transplant in Iran, but the donor and the recipient should be from the same nationality, and authorization for such transplantation should be obtained from the Center for Management of Transplantation at the Ministry of Health. ,,
The donor and the recipient evaluations in all transplant centers are very similar. In our transplantation unit at the Hashemi Nejad Kidney Hospital in Tehran, the selection and the preparation of all potential renal transplant recipients and living kidney donors are carried out by complete clinical and psychological tests and imaging. Recently, the European Best Practice Guidelines for Renal Transplantation and the Amsterdam Forum on the Care of the Live Kidney Donor Medical Guidelines are used for this purpose. , From 1986 through 2000, for all living kidney donors, a voluntary consent was assessed by the "Donor Selection Panel," which consisted of nephrologists, transplant surgeons and members of nursing staff to exclude the possibility of coercion on kidney donors. Since 2000, the evaluation and the selection of potential donors and recipients has been carried out independently, first by transplant nephrologists, then by members of the surgical team.
Unfortunately, there is no national transplant registry in Iran to report the short-and longterm results of transplantation in all transplant recipients and kidney donors. Most renal transplant teams report their own results as singlecenter experiences. ,, The ESRD Office of Iran has only demographic data but lacks the short- and long-term results of transplantation, so the results from the Hashemi Nejad Kidney Hospital (a pioneering transplant center and one of the largest in Iran) are presented here as an example for the whole country. From April 1986 to January 2006, a total of 1995 renal transplants were performed in our hospital, 496 (25%) were from living-related donors, and the remaining 1499 (75%) were from living-unrelated donors. A total of 743 (37%) recipients were females, and 1252 (63%) were males. Their ages ranged from 8 to 68 yr. In one of our studies we reported a significant gender disparity in living-unrelated kidney donors (91% male, 9% female; age range 21 to 37 yr).  In a recent data analysis, the overall patient survival rates were 93.8, 87.8, and 76% and the overall graft survival rates were 90.4, 75.4 and 52.8% at 1, 5, and 10 yr, respectively. There were no significant differences in graft survival rates between recipients of one HLA haplotype-matched living-related donor and living-unrelated donor recipients. In living-unrelated donor renal transplant recipients the patient survival rates were 93.9, 87.1 and 72.2% and the graft survival rates were 90.5, 74.4 and 48.8% at 1, 5, and 10 yr, respectively [Figure - 2].
The ethical issues related to the Iranian model of paid kidney donation include ethical successes that support the Iranian model,  and several ethical failures that can be overcome through public education, and further governmental funding for social support of the donors. If revised properly, our donation model can be more appealing to other developing countries to implement as a viable option for renal replacement therapy. 
The ethical successes of our living-unrelated donation program include the absence of brokers or agencies that mediate the process of donation. The association for patients with ESRD is a charitable organization and receives no incentives from donors or recipients. The government funds all hospital expenses of renal transplantation. All transplant candidates either rich or poor have equal access to renal transplant facilities; the elimination of the waiting lists is the evidence for this equity. We also conducted a study on renal transplant recipients and their living-unrelated donors to determine which socioeconomic classes received transplants more from paid kidney donors.  All of these donors and recipients were grouped according to their level of education, which showed no significant differences. Then they were grouped according to whether they were poor, rich, or middle class. The results showed that >50% of kidneys from paid donors were transplanted into patients from poor socioeconomic class. Secondly, the paid kidney donation model did not inhibit the establishment of a deceased-donor organ transplantation program that grew rapidly over the past few years. Thirdly, since the adoption of the living-unrelated donor model, the number of living-related donor transplants has decreased (in 2006 only 13% of all renal transplants were from related-donors). We believe that this is due partly to elimination of coercive living-related donor transplants with the availability of the paid kidney donation program. The compensated and regulated living-unrelated donor renal transplantation may be more ethical to perform than transplantation from a living-related donor or spouse who is under some degree of family pressure or emotional coercion. Fourthly, our paid kidney donation program has eliminated the need of Iranian patients travel abroad for commercial or illegal transplants that have many medical and ethical drawbacks. Finally, the regulated paid kidney donation prevented commercial organ donation and transplantation. We conducted a study of the nationalities of transplant recipients that demonstrated the overwhelming majority of patients were Iranians; 30 (1.6%) recipients were foreigners who received kidneys from living-related donors or from living-unrelated donors of the same nationality.  Another study to investigate the access of a very large population of Afghan refugees to renal transplantation in Iran showed that 62 patients received renal transplantation in Iran; the donors were living-related donors in 9, spouses in 2, Afghani living-unrelated donors in 50, and deceaseddonor kidney in one.  This study concluded that transplantation of the refugees were not exploited in commercial donation or transplantation.
However, there are ethical failures that still remain in the Iranian model. First, due to the small amount of governmental donor award (approximately $1200 USD) that is not enough to satisfy the majority of kidney donors, recipients provide rewarding gifts to donors. If the recipient is poor, then the rewarding gift is provided by charitable organizations. This has resulted in a form of directed paid kidney donation, meaning that the transplant candidate and the volunteering kidney donor meet each other in a DATPA meeting for arrangement of rewarded gifting to be paid to the donor after transplantation. Providing sufficient financial incentives and some social benefits to each living-unrelated donor by the government will eliminate rewarding gifts and will make the Iranian model a non-directed paid kidney donation program whereby the donors and the recipients will not know each other at least before transplantation. The only social benefit that is awarded to Iranian kidney donors is health insurance. Providing more legal and social benefits to paid kidney donors, in addition to financial incentives, will satisfy them better in the long- term. There are some legal and social items of benefits for warinjured veterans in different societies. Several of these items can be legalized and offered to each kidney donor in addition to financial incentives as a token of appreciation and compensation by society.
Unfortunately, the public and media in Iran have inadequate awareness of the ethical issues relating to organ transplantation. The public should be better educated about these issues. The advent of laparoscopic live-donor nephrectomy, and their encouraging results will have positive impact on increasing the number of living related kidney donations and assuring the public to the improved safety and efficacy of the donation procedure.  Finally, there is a necessity to establish a donor registry to study the long-term medical and socioeconomic consequences on all living kidney donors.
| Deceased Donor Organ Transplantation|| |
From 1977 to 1979, only 14 deceased-donor kidneys were received from Euro-transplant Foundation and were transplanted successfully.  After a long cessation of the deceased based renal transplantation, the Iranian parliament passed a legislation that accepted the concept of brain death and allowed deceaseddonor organ transplantation in April 2000. The resolution of the parliament depended on 1989 approving religious decrees (fatwas) obtained from almost all top Islamic leaders in the country. This Organ Transplantation Act permitted the Ministry of Health to establish deceased-donor organ transplantation at university hospitals. The ESRD Office of the Ministry of Health was changed to Center for Management of Organ Transplantation. By the end of 2006, 18 brain death identification units and 13 organ procurement units were organized, and a total of 1546 decease-donor organ transplantations were performed (1066 kidney, 327 liver, 122 heart, 20 lungs, 7 pancreaskidney, 2 heart-lungs and 2 small bowel transplants). The number of deceased-donor organ transplants have slowly but steadily increased in the country. No financial incentives are provided for deceased-donor organ sources. [Figure - 3] shows the trends of deceased-donor kidney transplants in Iran from the year 2000 to 2006. The majority of deceased-donor kidney, liver and pancreas transplants have been performed by transplant team of Shiraz University of Medical Sciences.
The transplantation activity of this transplant team demonstrates that the main reasons hindering the deceased-donor organ transplantation in Iran include the lack of public education, infrastructural deficiencies, and inadequate funding of transplant centers rather than being all due to religious or cultural barriers in the society. We believe that, if the Ministry of Health provides enough facilities and funding, it can encourage all other transplant teams in the country to use organ transplant activities of Shiraz University team as a model. This approach will remarkably increase the number of deceased-donor organ transplantation in Iran.
| References|| |
|1.||Grassmann A, Gioberge S, Moeller S, Brown G. ESRD patients in 2004: Global overview of patient numbers, treatment modalities and associated trends. Nephrol Dial Transplant 2005;20:2587-93. [PUBMED] [FULLTEXT]|
|2.||Ghods AJ, Ossareh S, Savaj S. Results of renal transplantation of the Hashemi Nejad Kidney Hospital- Tehran. In: Cecka JM, Terasaki PI, editors. Clinical Transplants 2000. Los Angeles: UCLA Tissue Typing Laboratory; 2001. p. 203-10. |
|3.||Ghods AJ, Savaj S. Iranian model of paid and regulated living-unrelated kidney donation. Clin J Am Soc Nephrol 2006; 1:1136-45. [PUBMED] [FULLTEXT]|
|4.||Ghods AJ. Renal transplantation in Iran. Nephrol Dial Transplant 2002;17:222-8. [PUBMED] [FULLTEXT]|
|5.||The EBPG Expert Group on Renal Transplantation: European best practice guideline for renal transplantation (part 1). Nephrol Dial Transplant 2000;15:3-39. |
|6.||A Report of the Amsterdam Forum on the Care of the Live Kidney Donor:Data and medical guidelines. Transplantation 2005;79: S53-66. |
|7.||Fazel I. Renal transplantation from living related and unrelated donors. Transplant Proc 1995;27:2586-7. [PUBMED] |
|8.||Mehraban D, Nowroozi A, Naderi GH. Flank versus transabdominal living donor nephrectomy: A randomized clinical trial. Transplant Proc 1995;27:2716-7. [PUBMED] |
|9.||Einollahi B. Iranian experience with the non- related renal transplantation. Saudi J Kidney Dis Transpl 2004;15:421-8. [PUBMED] [FULLTEXT]|
|10.||Ghods AJ, Nassrollahzadeh D. Gender disparity in a live donor renal transplantation program: Assessing from cultural perspectives. Transplant Proc 2003;35: 2559-60. |
|11.||Haghighi AN, Ghahramani N. Living unrelated kidney donor transplantation in Iran. Nat Clin Pract Nephrol 2006:2:E1. |
|12.||Ghods AJ. Should we have live unrelated donor renal transplantation in MESOT countries? Transplant Proc 2003;35:2542-4. [PUBMED] [FULLTEXT]|
|13.||Ghods AJ, Ossareh S, Khosravani P. Comparison of some socioeconomic characteristics of donors and recipients in a controlled living unrelated donor renal transplantation program. Transplant Proc 2001;33:2626-7. [PUBMED] [FULLTEXT]|
|14.||Ghods AJ, Nasrollahzadeh D. Transplant tourism and the Iranian model of renal transplantation program: Ethical considerations. Exp Clin Transplant 2005;2:351-4. |
|15.||Ghods AJ, Nasrollahzadeh D, Kazemeini M. Afghan refugees in Iran model renal transplantation program: Ethical considerations. Transplant Proc 2005;37: 565-6. [PUBMED] [FULLTEXT]|
|16.||Ghods AJ. Changing ethics in renal transplantation: Presentation of Iran model. Transplant Proc 2004;36:11-3. [PUBMED] [FULLTEXT]|
|17.||Simforoosh N, Basiri A, Tabibi A, Shakhssalim N. Laparoscopic donor nephrectomy: An Iranian model for developing countries: A cost-effective no-rush approach. Exp Clin Transplant 2004;2:249-53 [PUBMED] [FULLTEXT]|
|18.||Broumand B. Transplantation activities in Iran. Exp Clin Transplant 2005;3:333-7. [PUBMED] [FULLTEXT]|
|19.||Malek-Hosseini SA, Salahi H, Bahador A, et al. Cadaveric renal transplantation at southern Iran (Shiraz) organ transplant center. Exp Clin Transplant 2004;2:104. |
Ahad J Ghods
Professor of Medicine, Hashemi Nejad Kidney Hospital, Iran University of Medical Sciences, Vanak Square, Tehran
[Figure - 1], [Figure - 2], [Figure - 3]