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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2019  |  Volume : 30  |  Issue : 5  |  Page : 1111-1117
Living-unrelated kidney donor transplantation: Legalization in exceptional circumstances?

Renal Transplant Unit, National Institute of Solid Organ and Tissue Transplantation, Dow University of Health Sciences, Ojha Campus, Karachi, Pakistan

Click here for correspondence address and email

Date of Submission19-Feb-2019
Date of Acceptance02-Apr-2019
Date of Web Publication4-Nov-2019


The prevalence of end-stage renal disease (ESRD) morbidity and mortality is mounting. Kidney transplantation offers a good means of survival and improves longevity of patients with ESRD. However, not everyone is fortunate to benefit from this lifesaving renal replacement therapy due to the lack of available kidneys, one of the many reasons. It eventually expands the number of patients on waiting list of kidney transplantation. At present, deceased and living-related kidney donor transplantation models are widely used, but with limited success to keep up with the pace of burgeoning ESRD. A debate over the legalization of unrelated living kidney donor transplantation has erupted lately. This short review articles focuses on issues surrounding kidney transplantation in Pakistan and draws an informed conclusion regarding pragmatic legalization of unrelated living kidney donor transplantation in exceptional circumstances. Finally, this article also offers a food for thought for countries facing analogous picture in the field of kidney transplantation.

How to cite this article:
Hamid Rb, Khan MT. Living-unrelated kidney donor transplantation: Legalization in exceptional circumstances?. Saudi J Kidney Dis Transpl 2019;30:1111-7

How to cite this URL:
Hamid Rb, Khan MT. Living-unrelated kidney donor transplantation: Legalization in exceptional circumstances?. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2021 Sep 25];30:1111-7. Available from: https://www.sjkdt.org/text.asp?2019/30/5/1111/270267

   Kidney Transplantation Top

The burden of morbidity and mortality associated with kidney failure is enormously high. Kidney transplantation is the best treatment modality available to patients suffering from end-stage renal disease (ESRD), especially for those with comorbidities.[1] In contrast to hemo-dialysis or peritoneal dialysis, kidney transplantation leads to a better quality of life and higher survival rate. Due to promising results, the need of kidney transplantations has intensified over a period of time; however, one of the key determinants limiting the use of this treatment option is the shortage of available donor kidneys.[2] As a result, a massive number of patients are deprived from kidney transplantation and are on ever-growing waiting list of deceased kidney donor transplantations. Perhaps, thousands of patients, while in-waiting for their kidney transplantation, cease to survive. However, some would prefer, often under the influence of others, to ask blood relatives for organ donation; similarly, sometimes, recipients may be approached by prospective donors through social media platform and in exceptional circumstances, donors might contribute toward humanity by giving their organ in transplantation directory by nondirect donation.[3] Pakistan presently experiences 100 new ESRD cases per million populations. Of them, only 10% receive dialysis and nearly 5% kidney transplantation for the reason of the lack of procurement of the kidneys and expensive renal replacement therapy.[4] Every year in Pakistan, as per conservative estimate, over 150,000 patients lose their lives to end-stage organ failure. These numbers include about 15,000 patients with kidney failure and can be reduced if available kidney tally is improved.[5]

   Kidney Transplantation in Pakistan Top

In Pakistan, kidney transplantation got initiated in the mid-1980s with the kidney donations was coming entirely from living-related donors pool. To counteract the kidneys demand and supply gap, living-unrelated kidney donor became the mainspring of kidney transplantation in Pakistan by the 1990s. However, the kidney trade had already become a full-fledged money-spinning business for middlemen and private sector hospitals in Pakistan by 2003. More specifically, kidney tourism enterprise was predicted to be yielding US$ 15 million in Pakistan. By doing so, the integrity of such transplants, including that of living-unrelated kidney transplants, have been impeached regarding the illicit organ trade, commercial transplants and transplant tourism.[6],[7]

   Models of Kidney Transplantation Top

Deceased donor kidney transplantation

Deceased organ is legitimate, universally acceptable and is widely practiced method of organ donation. It provides a means of saving lives of patients who are dying from irreversible organ damage by obtaining organs from a healthy person postdeath. The catch-22 situation here is that we, as a Muslim society, should not maltreat the human body after death. However, in the light of Fiqha and scientific research, the 4th conference of the Islamic Fiqha Council in Kingdom of Saudi Arabia permitted deceased organ transplantation subject to the appropriate permission granted by deceased before death or by his/her family members or by authorities in case of unknown identity of deceased or no family members. Similarly, the Constitution of Pakistan also permits deceased organ donation conditionally on acquiring written and verified authorization for organ donation from the donor before death with age no <18 years. It is also a well-known fact that human body experiences decomposition after death, and hence, it is prudent to donate and save lives. Indeed, Allah also testifies in Qur'an (Chapter 5, Verse 32): “whoever saves one life - it is as if he had saved entire humankind.” However, despite the fact, it cannot resolve the snowballing demand of kidney transplantations on its own. In such circumstances, living kidney donation comes to rescue; nevertheless, with inherent ethical concerns.[5]

Living donor kidney transplantation

Living kidney donation undeniably saves lives, improves outcomes and minimizes waiting time for recipients. However, it also brings backlash related to ethical issues that need to be copiously addressed. For instance, living organ donation apparently encroach on the primary tenet of medicine; “primum non nocere” (above all, do no harm). As such, it renders healthy person to donate an organ and be a patient for the sake of an unhealthy person who needs an organ to survive. The main ethical issue regarding living-related organ donation is the likelihood of unnecessary influence, emotional pressure, and compulsion. On the other hand, living- unrelated organ donation misses genetic coherence with the recipient. The living-unrelated organ donations and recipient could be emotionally linked (for example, a spouse), they could be well known to each other but not emotionally close (for example, workmates), or they could be downright unfamiliar. In addition to above, few other kidney transplant models have also developed to address conditions in which a donor is unable to provide kidney due to incompatibility despite desire to donate.[3]

Kidney swapping (Kidney exchange transplantation)

The kidney exchange transplantation (kidney swapping) is well-recognized treatment modality to increase the kidney numbers in living donor kidney transplantation pool. It is practiced globally, but its usage is uncommon in developing nations because of the intricacies of donor issues, dearth of awareness, and logistic obstacles. The motives for this paired exchange kidney transplantation are immunological incompatibility, ABO blood group incompatibility, human leukocyte antigen incompatibility, chronological, and financial incompatibility. This kidney transplantation model addresses the unavailability of organs by reaching the cohort of living kidney donors who wish to provide a kidney to a family member but are handicapped due to incompatibility issues. The key motivation of donor is safeguarding the best possible result for his or her originally anticipated kidney recipient. Another model called living undirected donation, encompasses the donation of kidney into the kidney transplant bank, in scenarios where donor is unable to give kidney because of incompatibility, with the obvious hope that the donor’s family member will be given precedence for a kidney transplant from a deceased donor.[3],[8]

   The Issue of Kidney Commercialization Top

Commercial kidney transplantation enterprise has effectively materialized as an amenity accessible for accelerated kidney transplantation for individuals in-waiting for deceased donor kidney. Without a misgiving, the international illicit kidney organ trade is growing unchecked. It has been projected that annually between 5% and 10% of kidney transplants occur as result of organ trafficking. This urged the World Health Organization (WHO) to conceive transplant associated laws. In 1991, the WHO specified that “Adult living persons may donate organs but in general such donors should be genetically related to recipients.” These steps were established to downscale kidney trafficking; nevertheless, the subsequent scarcity of kidney donors for transplant was soon recognized universally. Henceforth, the WHO revisited its transplantation guidelines backing up the living unrelated kidney donor transplant by spouses and close friends. Ever since the available kidneys pool from all the groups of living donor have increased exponentially.[6],[9]

Despite human organs commercialization proscribed by law in almost all countries, numerous patients from developed countries such as the United States, Canada, Italy, Japan, Israel, and the Persian Gulf countries travel frequently to developing nations in search for commercial transplantation. Over the years, Pakistan has developed as one of the leading centers for kidney trafficking due to the lack of by-laws, and existence of a massive underprivileged rural population has further boosted the business of kidney shoppers. International kidney trade bargainers strategically aim several countries and particular geographical settings within. The kidney commercialization in Pakistan is most dominant in Punjab, and it is suggested that traders have allied directly with private sector hospitals. In addition, small towns and villages and even ghettos in larger urban cities are also subject to illicit kidney trade business. As per the WHO statistics, 66,000 commercial kidney transplants are performed every year globally. Of them, around 1200–2400 occur in Pakistan, sadly rendering approximately 2000–4000 ESRD cases in Pakistan disadvantaged from kidney transplantation who might have been eligible candidate for a kidney transplant. They could be recipients of kidney donation if the illegitimate kidney trade were to end.[6],[9] Pakistan had no law and enforcement regarding the organ trade until the year 2007. Following orders of Supreme Court of Pakistan on cruel exploitation of underprivileged community, Government of Pakistan introduced the “Transplantation of Human Organs and Tissues Bill 2007” in the National Assembly which was endorsed into the law in March 2010. The bill recommended the number of steps which included the organ donation limited only to close blood relatives who are >18 and prohibition of organ donations by those who are unrelated to the organ recipients and in case found guilty of being illicit organ trader, 10 years’ incarceration will be sentenced.[10]

What is the solution that could beat both ESRD and fear of illegal kidney organ trade and provide us with win-win situation? Perhaps, the answer lies in legalizing living-unrelated kidney transplantation in exceptional circumstances.

   Living-Unrelated Kidney Transplantation Top

At present, there are two categories of living-unrelated donors kidney transplantation; (1) Altruistic model and (2) Compensated model (also known as Iranian Model). The altruistic living-unrelated kidney donor transplantation includes a selfless donation of the kidney by close friends, spouses, and partners or by outsiders driven by emotions and empathy and is morally acceptable throughout the world. Notwithstanding that the altruistic model has stayed unable to meet the shortage of kidney donors, leading to deaths of ESRD patients while in kidney transplant waiting list. The lack of kidneys in donor pool further provokes the practice of commercial transplants and transplant tourism. Due to these shortcomings, kidney transplant experts suggested giving financial or social incentives to living-unrelated kidney donors to increase the sum of available kidneys. They emphasized that the concept of self-interest (financial remuneration) to condition the human conduct and behavior is considerably better than altruism since only in rare circumstances does the humans display selfless generosity toward others. On the other hand, the compensated model significantly changed the dynamics of ESRD and kidney transplantation in Iran and hence also regarded as Iranian model. This model was introduced by Dialysis and Transplant Patients’ Association, and primary task is to arrange appropriate donors for kidney transplant recipients and subsequently offering lifelong health insurance coverage as a form of token of appreciation. The said model has successfully condensed the kidney transplant waiting list, granting the second life to ESRD patients. It is of note that around 75% of the kidney transplants performed in Iran is based on this model.[2],[7]

   Literature Regarding Outcomes of Living-Unrelated Kidney Transplantation Top

Other than being underutilized source of kidney transplant, unrelated kidney donor transplant has also been extensively disputed over outcomes in comparison with living-related kidney donor transplant. A study conducted by Cortesini et al showed graft survival rate of 91% and 87% in living-related and living-unrelated kidney transplantation, respectively. They concluded unrelated kidney transplant as a good alternative to deceased organ unavailability.[11] Voiculescu et al demonstrated similar graft rejection rate in living-unrelated kidney transplant cases with that of living related. However, posttransplant infection rate was significantly high in living-related kidney transplant patients.[12] Another study conducted by Kizilisik et al and Wolters et al reported no difference in outcomes from living-related and living-unrelated kidney transplantation and suggested living-unrelated kidney transplantation as an important source of kidney organ pool.[13],[14] Similarly, Simforoosh et al communicated comparable patient survival rates in both living-unrelated and -related kidney transplantation in 2155 transplant cases they assessed.[15] Ahmad et al, in their retrospective study, established that outcomes such as estimated GFR, patient survival, and graft rejection were similar in both living-unrelated and -related kidney transplantation.[16] Research studies conducted in Iran, Brazil, and Egypt have reported favorable outcomes compared to living-related and deceased kidney donor transplant.[17],[18],[19] Sesso et al reported that living-unrelated kidneys as a good alternative to deceased kidney donors.[17] Few more studies conducted latterly were also of the conclusion that the living-unrelated and living-related kidney transplantations are indeed equivalent in terms of graft and patient survival out-comes.[20],[21],[22],[23] On the other hand, a study by Sever et al concluded that survival rate with living-unrelated kidney transplant is lower compared to conventional living-related transplantations.[24] However, recently, a systematic review and meta-analysis by Simforoosh et al demonstrated that there was no significant difference between living-related and -unrelated kidney donor transplantation in graft survival rate and acute rejection rate and is fair to practice.[2]

   Role of Kidney Transplant Team in Successful Unrelated Kidney Donor Transplantation Top

In order for the living-unrelated kidney donor transplantation to be ethically acceptable, the kidney transplant team should play the part of moral agents who should be held responsible for their conducts. A transplant team should consider the following ethical principles while assessing for prospective living-unrelated kidney donor candidates:

  1. Respect of autonomy suggests that an unrelated living kidney donor should be given the freedom of choice and no coercion should be used including the internal (sense of obligation or duty) or external (such as family member). It can be attained by taking informed consent
  2. Nonmaleficence (do no harm) underlines that intentional injury should be avoided for everybody. The kidney transplant surgeon and physician should meticulously weigh risk and benefit for the recipient as well as the donor
  3. Beneficence (do good) educates to ensure good for donors. The donor’s well-being should be considered first; and
  4. Justice refers to unbiased treatment for living unrelated kidney donors on the basis of socioeconomic status.[7]

In the light of above discussion, several questions could be raised; (1) Do we possess enough kidneys in transplantation pool to combat burgeoning ESRD? (2) Is long-term dialysis a good solution? (3) Do we really have all the above models presently functioning in Pakistan to increase the survival and improve quality of life of ESRD patients? (4) Does legalizing unrelated living kidney donation in certain circumstances would lead to illegal organ trade if wisely implemented? And answer to all these questions is perhaps “No.” The most likely solution to resolve the kidney pool issue is to bring all the available kidney transplantation models in action in Pakistan. We do have transplantation models in a functional state such as deceased organ donation, living-related and -unrelated kidney donation, kidney swapping which was recently performed for the first time in Sindh Institute of Urology and Transplantation in 2017;[8] however, the laws regarding them, especially unrelated living kidney donation needs to be revisited. Considering scenarios such as deceased organ donation could not compensate for increasing kidney requirements for transplantation and results in unnecessary waiting for ESRD patients, living kidney donation hampers transplantation due to incompatibility issues, kidney swapping is relatively new modality especially in developing countries and would take time to be in a fully functional state in Pakistan and most significantly, illegal organ donation not only risks the life of donor but also of recipients as it is usually done in a low resource setting, legalizing unrelated living kidney donation, in special circumstances where there is no other option, would offer a great medium to enrich kidney transplantation pool. However, an ethical issue regarding living unrelated kidney donation is that organ is being sold or that the motivation of the donor is financial remuneration. Not only it increases the likelihood of manipulation of underprivileged community but also escalates the risk that prospective donors will hide appropriate medical information.[3] We believe that instead of remuneration in the form of money, lifetime health insurance coverage for the donor should be given to discourage psychological motivation stemming from money. The whole process of unrelated kidney donation could be legalized and would ultimately improve the safety of both donor and recipient.

   Conclusion Top

The vision of artificial kidney is still far from reality. Legalization of unrelated living kidney donor transplant, however only in certain circumstances, by law would significantly improve safety for both donors and recipients as implemented by other nations. Living unrelated kidney donor transplantation is the safe surgical procedure and results are consistent with living-related kidney donor transplants; however, it still requires further research. It certainly offers a good opportunity to increase the available kidney tally in donor pool. It is also recommended that health-care team and community should approach unrelated kidney transplantation pragmatically and objectively and treat social, ethical, and religious concerns as flexible viewpoints rather hindrance to kidney transplantation. Only this way, we can be on a trajectory to improve the quality of life of ESRD patients.

Key Question: Does this article relate to Kidney Transplantation Issues and Laws in your country?

Though this review article very briefly highlights the current kidney transplantation-related issues in Pakistan, it reflects the problems faced in the field of kidney transplantation by other nations as well. It is high time to acknowledge the gravity of the issue and work on it.

Conflict of Interest: None declared.

   References Top

Beladi Mousavi SS, Alemzadeh Ansari MJ, Parsi A, Kiani E. Reasons for renal donation among living unrelated renal donors in Khuzestan province, Southwestern Iran. Int J Organ Transplant Med 2013;4:21-4.  Back to cited text no. 1
Simforoosh N, Shemshaki H, Nadjafi-Semnani M, Sotoudeh M. Living related and living unrelated kidney transplantations: A systematic review and meta-analysis. World J Transplant 2017:7:152-60.  Back to cited text no. 2
Institute of Medicine. Ethical considerations in living donation. In: Catharyn T. Liverman JF, editors. Organ Donation: Opportunities for Action. The National Academies Press: Washington, DC; 2006. p. 263-79.  Back to cited text no. 3
Rizvi SA, Naqvi SA, Zafar MN, et al. A renal transplantation model for developing countries. Am J Transplant 2011 ; 11:2302 7.  Back to cited text no. 4
Hafeez M. Deceased organ donation in Pakistan ? A haunted will or an under-researched topic? J Pak Med Assoc 2018:68: 1852-3.  Back to cited text no. 5
Akhtar F, Bari OH. Living-unrelated kidney selling in Pakistan: Can organ transplantation law and social action create a new model for developing countries? World Med Health Policy 2010:2:133-46.  Back to cited text no. 6
Jain KG. Unrelated renal transplantation: A Problem or a Solution? Available from: http :// ezusi. org/journal/index. php/current- articles/item/8-unrelated-renal-transplantation- a-problem-or-a-solution.html. [Last accessed on 2018 Dec 28].  Back to cited text no. 7
Nizam N, Mazhar F, Abbas K, et al. Kidney Swap in Pakistan: Experience at the Sindh institute of urology and transplantation. Exp Clin Transplant 2017:15:76-8.  Back to cited text no. 8
Kapoor A, Kwan KG, Whelan JP. Commercial renal transplantation: A risky venture? A single Canadian centre experience. Can Urol Assoc J 2011:5:335-40.  Back to cited text no. 9
Kazim SF. Organ donation law in Pakistan: An overview of the current situation. J Pak Med Assoc 2008:58:99-100.  Back to cited text no. 10
Cortesini R, Pretagostini R, Bruzzone P, Alfam D. Living unrelated kidney transplantation. World J Surg 2002:26:238-42.  Back to cited text no. 11
Voiculescu A, Ivens K, Hetzel GR, et al. Kidney transplantation from related and unrelated living donors in a single German centre. Nephrol Dial Transplant 2003:18:418-25.  Back to cited text no. 12
Kizilisik AT, Ray JM, Nyländer WA, Langone AJ, Helderman JH, Shaffer D. Living donor kidney transplantation in a veterans ādministration medical center. Am J Surg 2004:188: 611-3.  Back to cited text no. 13
Wolters HH, Heidenreich S, Dame C, Brockmann JG, Senninger Ν, Krieglstein CF. Living donor kidney transplantation: Impact of differentiated immunosuppressive regimen. Transplant Proc 2005:37:1616-7.  Back to cited text no. 14
Simforoosh N, Basiri A, Fattahi MR, et al. Living unrelated versus living related kidney transplantation: 20 years’ experience with 2155 cases. Transplant Proc 2006:38:422-5.  Back to cited text no. 15
Ahmad N, Ahmed K, Khan MS, et al. Living-unrelated donor renal transplantation: An alternative to living-related donor transplantation? Ann R Coll Surg Engl 2008:90:247-50.  Back to cited text no. 16
Sesso R, Josephson MA, Anção MS, Draibe SA, Sigulem D. A retrospective study of kidney transplant recipients from living unrelated donors. J Am Soc Nephrol 1998:9: 684-91.  Back to cited text no. 17
Ghods AJ. Renal transplantation in Iran. Nephrol Dial Transplant 2002:17:222-8.  Back to cited text no. 18
Barsoum RS. The Egyptian transplant experience. Transplant Proc 1992:24:2417-20.  Back to cited text no. 19
Ishikawa N, Yagisawa T, Kimura T, et al. Kidney transplantation of living unrelated and ABO-incompatible donor-recipient combinations. Transplant Proc 2013:45:1242-4.  Back to cited text no. 20
Santori G, Barocci S, Fontana I, et al. Kidney transplantation from living donors genetically related or unrelated to the recipients: A single-center analysis. Transplant Proc 2012:44:1892-6.  Back to cited text no. 21
Matter YE, Nagib AM, Lotfy OE, Alsayed et al. Impact of donor source on the outcome of live donor kidney transplantation: A single center experience. Nephrourol Mon 2016:8: e34770.  Back to cited text no. 22
Ali AA, Al-Saedi AJ, Al-Mudhaffer AJ, Al-Taee KH. Five years renal transplantation data: Single-center experience from Iraq. Saudi J Kidney Dis Transpl 2016:27:341-7.  Back to cited text no. 23
Sever MS, Kazancioğlu R, Yildiz A, et al. Outcome of living unrelated (commercial) renal transplantation. Kidney Int 2001:60: 1477-83.  Back to cited text no. 24

Correspondence Address:
Muhammad Tassaduq Khan
Renal Transplant Unit, National Institute of Solid Organ and Tissue Transplantation, Dow University of Health Sciences, Ojha Campus, Karachi
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DOI: 10.4103/1319-2442.270267

PMID: 31696850

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