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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2008  |  Volume : 19  |  Issue : 4  |  Page : 664-668
Renal Transplantation from Deceased Donors in Iran

Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran

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How to cite this article:
Abbaszadeh S, Nourbala MH, Taheri S, Ashraf A, Einollahi B. Renal Transplantation from Deceased Donors in Iran. Saudi J Kidney Dis Transpl 2008;19:664-8

How to cite this URL:
Abbaszadeh S, Nourbala MH, Taheri S, Ashraf A, Einollahi B. Renal Transplantation from Deceased Donors in Iran. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2022 Nov 27];19:664-8. Available from: https://www.sjkdt.org/text.asp?2008/19/4/664/41336

   Introduction Top

The use of renal replacement therapy (RRT) is increasing worldwide and Iran is no exception. One reason for this increasing trend in Iran is an increase in health aware­ness, which could be a consequence of an increase in the gross domestic product. More­over, a large number of patients including older and sicker ones, who were previously considered unsuitable for receiving treatment, were referred for RRT in more recent years.

The introduction of new immunosuppre­ssive agents (eg. cyclosporine and mycophe­nolate mofetil) in the past 20 years along­side the improvements achieved in infection prophylaxis, strategies, has resulted in a remarkeable improvement in both recipient and graft survival rates. These factors have made kidney transplantation the treatment of choice for patients with end-stage renal disease (ESRD).

Living donor transplantation offers better short and long-term survival rates among the recipients compared to an allograft pro­cured from a deceased donor. [1] However, transplantation from a living donor does have one serious disadvantage; the donor undergoes a major operative procedure that is associated with morbidity, mortality and the potentially negative long-term conse­quences of living with a single kidney. Peri­operative mortality after living kidney do­nation has been estimated to be 0.03%; morbidity, including minor complications is < 10%. [2],[3]

Overwhelming evidence shows that kidney transplantation from deceased donors is a successful and effective method to treat patients with ESRD. Although renal trans­plantation in Iran is characterized by use of living donors as the major source of renal allograft, efforts have been made to extend the use of deceased donors as a source of kidney allograft, throughout the country. [4] Despite religious authorization, especially Imam Khomeini's fatwa, there were only sporadic cadaveric transplantations until 2000, when the parliament passed the law legali­zing cadaveric donor organ transplantation; the trend of kidney transplantation from cada­vers rose, after this legislation was enacted.

   Renal replacement therapy in Iran Top

Renal replacement therapy is a general term that encompasses the different moda­lities used in the treatment of ESRD inclu­ding hemodialysis, peritoneal dialysis, and kidney transplantation. The incidence and prevalence of RRT in Iran is increasing; however, this increase is seen much more in renal transplantation compared to other types of RRT. [4] This is mainly due to the unique kidney transplantation program in this coun­try. The epidemiology of ESRD in Iran is that middle-aged patients predominate nece­ssitating higher intensity support, because of high mortality rate among the HD popu­lation. This reason beside the high emotio­nal and financial constrains of dialysis on the government, patients and the society led to development of a compensated program for renal transplantation from living unre­lated donors (LURD).

In Iran, all RRT modalities are provided free of charge and are accessible to all people. The government pays fixed reimbursement rates for dialysis and transplantation in both public and private hospitals. The number of people on any form of RRT in Iran, which has a population of 70,000,000 reached 25,000 and is predicted to be around 40,000 in the next five years. The prevalence of ESRD in Iran is 357 per million population (pmp) with an annual incidence of 57 pmp. Currently, the proportion of patients on various modalities of RRT including hemo­dialysis, peritoneal dialysis and renal trans­plantation is 48.3%, 3.2% and 48.5%, res­pectively. [5]

   History of renal transplantation in Iran Top

The first renal transplantation in Iran was performed in 1967 in the Shiraz University Hospital from a living related donor. How­ever, because of the limited kidney trans­plantation activities in Iran, the government continued to send ESRD patients abroad for undergoing kidney transplantation for more than a decade after this. For example, bet­ween 1980 and 1985, in the early period fo­llowing the Islamic revolution and during the devastating war with Iraq, about 400 patients traveled abroad to receive a renal allograft. However, high costs of kidney transplan­tation abroad concomitant with increasing number of patients on the waiting list made the government promote endeavors for pro­viding enough renal transplantation facili­ties inside the country. Although the proce­dure started to increase, because of not using kidneys from deceased donors, there was a shortage of living related donors. Hence, in 1988, a government-regulated and funded kidney transplantation program using kidneys from LURD was established in Iran. Consequently, the number of kidney transplantations increased dramatically. [6] How­ever, this program fired up some challenges particularly concerning the ethical issues involved. In 2000, the Iranian parliament passed the required legislations to permit using cadaver organs for kidney transplan­tation.

   Kidney transplantation from deceased donors in the Baqiyatallah Hospital Top

The Baqiyatallah Hospital is one of the leading kidney transplantation units in the Middle East, with over 2500 kidney trans­plantations performed since 1992. Since the year 2000, the number of cadaveric kidney transplantations has shown a good increa­sing trend in this transplant center [Figure 1]. The first transplant of this type was performed in 2003 and during that year we performed eight cadaver donor renal trans­plants. How-ever, in the subsequent year, the number of such transplants decreased to three, but in 2005 and 2006, the number of kidney transplantations from deceased donors reached 15 and 20, respectively. Although the trend seems encouraging, this type of kidney transplantation comprises less than 10% of transplantation activities in this unit, which is comparable with national statistics in Iran. In other countries, the epidemiology of kidney transplantation is quite different. In the United States, the proportion of kidney transplantation from deceased donors is noticeably high with about half of all renal transplants being performed from cadaver source; [7] conco­mitantly, the proportion of living donation is also rapidly increasing in this country. On the other hand, in India, less than 2% of renal transplantations are from brain-dead heart beating cadaver donors. [8] In Turkey, where the total number of renal transplants performed in 2003 was 605, deceased donors constituted 25.6%. [9] In Latin America, 53% of all kidney allografts come from cadavers. [10] Egypt has no legislation for ca­daveric organ procurement; hence, all solid organ transplantations in this country are from living donors. [11] On the other hand, almost all organ transplantations in Spain are from cadaver source. [12] In Iran, despite the increasing trend of cadaveric kidney transplantation, this type of kidney trans­plantation still constitutes a minor pro­portion of kidney transplantation practice.

   Where is the problem; what more can we do? Top

There is probably no dispute on the advan­tages of organ procurement from deceased persons, because of the absence of side effects to a potential healthy donor, along­side its life saving promise. In countries where kidney transplantation from cadaver donors is negligible, we should first find that where the problems are and what we can do for overcoming them. One of the most important impediments for establi­shing an effective system for organ procure­ment from deceased donors could be a lack of capable health authorities, who are inte­rested in expanding cadaveric kidney trans­plantation. One could argue that the exis­tence of a government-regulated LURD kidney donation program in Iran, may be act as a barrier to promoting renal trans­plantation from deceased donors in this country. Although we believe that LURD kidney transplantation should not be com­pletely banned, it should be used only for bridging the gap between demand and supply, and not as the first choice. Edu­cating the society about the advantages of cadaveric kidney transplantation and changing the cultural barriers are other endeavors, which should be undertaken. Additionally, despite the arguments against it, it may be beneficial to consider some financial gifts to the families of the deceased donors, as we do in living unrelated donations. Finally, as another potentially effective way for increa­sing cadaveric donations, we can set some barriers and restrictions for receiving a kid­ney allograft from a living unrelated source and promoting patients towards cadaveric kidney transplantation as the initial choice.

Since the establishment of the Iranian Net­work for Organ Procurement, and after the governmental approval justifying cadaveric organ transplantation, the cadaveric renal transplant activity in the country has in­creased from about 10 in 1999 to 207 in 2005. Presently, cadaveric kidney trans­plantations account for 10% of the total annual transplantations in Iran. [4],[5]

   Discussion Top

The purpose of renal transplantation is to prolong and maintain a good quality of life for patients with ESRD; [13] it is more cost­effective and it allows return to a more nor­mal lifestyle than does maintenance dialysis therapy. [13],[14],[15] Although the rate of compli­ cations in the donor after nephrectomy is low, this procedure is not without risks. A number of studies have reported a peri­operative donor mortality rate of 0.02%­ 0.03%; [2],[3],[16] however, cadaveric donor kidney transplantation, thanks to scientific and tech­nical advancement, is considered as a suc­cessful daily procedure. Over one million people worldwide have received organs from the cadaveric source and some of them have survived for more than 25 years. [14] The five year survival rate for most organ transplants is around 70%. [14] The ever-increasing need to transplant organs has led to different approaches and methods in different coun­tries aimed at increasing transplant organ procurement.

In industrialized countries, the majority of donor organs come from cadaver donors whereas in countries with lower incomes, the majority of cases are from live donors. [7] However, the ever-increasing gap between demand and supply has made industrialized countries to use more organs from living donors in a way that in the year 2001, organ procurement from living donors exceeded that from cadavers in the US. [17]

Cadaveric donation rates are 26.5 pmp in the United States, 25 pmp in England and 23.1 in Australia and 49.2 pmp in Spain. [5],[7],[14] Among Islamic countries, the rate of cadaveric kidney transplantation in Saudi Arabia and Turkey is higher than that of Iran, whereas Lebanon, Egypt and Pakistan have lower cadaveric renal transplantation rates. [7],[18]

   Conclusion Top

Newly developed effective immunosup­pressive protocols, are prolonging graft and patient survival after kidney transplantation. The number of cadaver kidney transplanta­tions in our hospital in Iran is annually in­creasing although the increase is not suffi­cient to meet the demand. In our opinion, the most logical way to expand donor pool and to maximize its efficacy and advantage is to promote organ transplantation from deceased donors.

   References Top

1.Ramcharan T, Matas AJ. Long-term (20-37 years) follow-up of living kidney donors. Am J Transplant 2002;2(10):959-64.  Back to cited text no. 1    
2.Bay WH, Hebert LA. The living donor in kidney transplantation. Ann Intern Med 1987;106(5):719-27.  Back to cited text no. 2    
3.Najarian JS, Chavers BM, McHugh LE, Matas AJ. 20 years or more of follow-up of living kidney donors. Lancet 1992;340 (8823):807-10.  Back to cited text no. 3    
4.Einollahi B. Iranian experience with the non-related renal transplantation. Saudi J Kidney Dis Transpl 2004;15(4):421-8.  Back to cited text no. 4    
5.Mahdavi-Mazdeh M, Heidary-Rouchi A, Norouzi S, Aghighi M, Rajolani H, Ahrabi S. Renal replacement therapy in Iran. Urol J 2007;4(2):66-70.  Back to cited text no. 5    
6.Fazel I. Renal transplantation from living related and unrelated donors. Transplant Proc 1995;27(5):2586-7.  Back to cited text no. 6    
7.2004 Donation and transplantation preliminary figures. IRODaT ORGANS AND TISSUES 2005;1:7-10.  Back to cited text no. 7    
8.Sakhuja V, Sud K. End-stage renal disease in India and Pakistan: Burden of disease and management issues. Kidney Int Suppl 2003;83:S115-8.  Back to cited text no. 8  [PUBMED]  
9.Suleymanlar G, Serdengecti K, E-Rek E. Epidemiology of end-stage renal disease in Turkiye. Turkiye Klinikleri J Int Med Sci 2005;1(21):1-8.  Back to cited text no. 9    
10.Cusumano A, Garcia-Garcia G, Di Gioia C, et al. End-stage renal disease and its treatment in Latin America in the twenty­first century. Ren Fail 2006;28(8):631-7.  Back to cited text no. 10    
11.Masri MA, Haberal MA, Shaheen FA, et al.Middle East Society for Organ Trans­plantation (MESOT) Transplant Registry. Exp Clin Transplant 2004;2(2):217-20.  Back to cited text no. 11    
12.Matesanz R, Miranda B, Felipe C. Organ procurement and renal transplants in Spain: the impact of transplant coordination. Spanish National Transplant Organization (ONT). Nephrol Dial Transplant 1994;9(8): 1204.  Back to cited text no. 12    
13.Ahmadnia H, Shamsa A, Yarmohammadi A, Darabi M, Asl Zare M, Kidney trans­plantation in older adults: does age affect graft survival? Urol J 2005;2(2):93-96.  Back to cited text no. 13    
14.Kazemeyni SM, Bagheri AR, Heidary AR. Worldwide cadaveric organ donation systems. Urol J 2004;1(3):157-64.  Back to cited text no. 14    
15.Feest TG, Rajamahesh J, Byrne C, et al. Trends in adult renal replacement therapy in the UK: 1982-2002. Q J Med 2005;98 (1):21-8.  Back to cited text no. 15    
16.Ballesteros Sampol JJ. Indications, morbidity and mortality of the open nephrectomy. Analyses of 681 cases and bibliographic review. Arch ESP Urol 2006;59(1):59-70.  Back to cited text no. 16    
17.Davis CL, Delmonico FL. Living-donor kidney transplantation: a review of the current practices for the live donor. J Am Soc Nephrol 2005;16(7):2098-110.  Back to cited text no. 17    
18.Erek E, Suleymanlar G, Serdengecti K. Nephrology, dialysis and transplantation in Turkey. Nephrol Dial Transplant 2002;17 (12):2087-93.  Back to cited text no. 18    

Correspondence Address:
Mohammad Hossein Nourbala
Nephrology and Urology Research Center, Department of Dialysis, Baqiyatallah Hospital, Mullasadra St., Tehran
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Source of Support: None, Conflict of Interest: None

PMID: 18580034

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