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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 2  |  Page : 563-567
Unrelated donors in kidney transplantation: Myths and the gruesome reality

Department of Nephrology and Transplantation, Rehman Medical Institute, Peshawar, Pakistan

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Date of Submission07-Jan-2020
Date of Acceptance04-Mar-2020
Date of Web Publication09-May-2020


How to cite this article:
Toufeeq Khan TF, Mirza I, Rashid T, Anwar N. Unrelated donors in kidney transplantation: Myths and the gruesome reality. Saudi J Kidney Dis Transpl 2020;31:563-7

How to cite this URL:
Toufeeq Khan TF, Mirza I, Rashid T, Anwar N. Unrelated donors in kidney transplantation: Myths and the gruesome reality. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Jun 21];31:563-7. Available from: https://www.sjkdt.org/text.asp?2020/31/2/563/284041

To the Editor,

We read with interest the paper by Hamid and Khan in which they debate the legality and ethics of living-unrelated kidney donation.[1] The title questions legalization of unrelated kidney transplantation (KT) in exceptional circumstances? We ask what these exceptional circumstances are, if you are the patient and have no donor? The global burden of chronic renal failure (CRF) is frightening and the authors equate legalization of unrelated donors to winning a lottery? We have a vast experience with kidneys from unrelated donors in Saudi Arabia[2] and have sadly also watched the catastrophic deterioration of medical standards in Pakistan since the ban on KTs.

The 1920s alcohol prohibition in the US gave birth to organized crime; KT in Pakistan suffered the same fate, where organized crime, interested only in profits, and controlled by middle men. Interestingly, the idea of banning alcohol was to reduce criminal activity but in fact did the opposite. The debate over legalization of unrelated KT is not new; only that, no one had the conviction to challenge the conservative transplant fraternity, fearing reprisals, not realizing that their rigid stance would result in a tremendous, unnecessary, and preventable loss of life.[3]

The authors concede that KT is the best treatment modality for CRF, especially in those with comorbidities. We do not agree, we consider it to be the best option for all CRF patients who are considered fit. The authors state that only one in 10 of CRF patients in Pakistan has access to dialysis and only one in 20 to transplantation; in other words, CRF is a death sentence for these patients. The first world countries realized that dialysis was not sustainable, and KTs were the answer, but were opposed by the fraternity hawks who had decided it was ethically inconceivable to allow incentives for the donor. This inflexible attitude of withholding incentives for kidney donors in the US was a disaster for CRF patients and their families. The number of adults and children undergoing living donor KTs continued to fall because not enough kidneys were available, with nearly 9000 patients either dying or being unfit for KTs every year.[3] It has been estimated that with removal of donor disincentives, an extra 11,500 kidneys would become available each year in the US, which could theoretically have prevented this huge annual loss of life.[4] KT is a medical miracle indeed, not only significantly improving the length and quality of life of CRF patients, but also costing less than dialysis, saving $146,000 for the US taxpayer for each transplant.[4] This is a win-win situation, and there is now, finally, growing con-sensus in the transplant community that all disincentives to kidney donation should be removed.[5],[6],[7],[8] Even those who strongly opposed offering positive incentives to kidney donors now favor removal of the disincentives.[9] Fifteen thousand CRF patients die annually in Pakistan; this number could be reduced if more kidneys were available.[10] The government and vested interests did nothing to facilitate increasing donor kidney numbers, on the contrary, went out of their way to make sure that a ban was imposed and remained. This poorly thought out ban did the following:

  1. The vast majority of KTs were carried out in unaccredited centers
  2. Erosion of basic medical standards
  3. Absence of any data or patient records
  4. Lack of any accountability in workups, center facilities, graft loss, mortality, and morbidity
  5. Outcomes were considered irrelevant and not reported.

Unfortunately, legislation is carried out by politicians, who have no idea of the far- reaching effects of such legislation, and are misled by racketeers and vested interests. What the government should have done is:

  1. Establish a donor registry. A database with age, gender, ABO group, HLA typing, and place of residence
  2. Provide incentives for anyone who is willing to donate a kidney, including

    1. Lifelong health insurance
    2. Compensation for cost of travel and lost wages during the donation process/surgery
    3. Free hospitalization for donation surgery and recovery.

This donor incentive system is working successfully in Saudi Arabia and Iran; several incentives are given to all living donors and families of deceased donors to increase number of kidneys available for their patients with CRF. There is no middleman, all prospective donors are referred to a government regulator (Saudi Center for Organ Transplantation) for approval, and a similar organization is functional in Iran. On July 10, 2019, President Donald Trump issued an executive order to reimburse living donors for extra expenses associated with organ donation, such as lost wages and childcare, estimated at nearly $38,000.[4] Imagine the benefits of such an amount for a donor in Pakistan? The authors talk about an ethical backlash to living donors, converting a healthy person into a patient? Long-term studies have shown no difference in survival, cardiovascular, diabetes, and kidney disease.[11] Surprisingly, they feel that since an unrelated donor is not in“genetic coherence” with the recipient, they are immu- nologically incompatible but then surprisingly go on to promote paired exchange, where donor and recipient are usually also unrelated! Transplants can no longer be denied based on HLA mismatches, and we have shown that outcomes in related and unrelated donor kidneys are similar.[2] In addition, HLA mismatches are not considered critical in allocation of deceased donor kidneys in the US, if it saves cold ischemia time.[12]

The authors ask why there is remuneration for unrelated kidney donors. This does become an ethical issue, when donors are exploited by corrupt middlemen in this corrupt system. Several doctors have been repeatedly caught carrying out transplants in illegal medical centers, but instead of being punished with incarceration, they resurface and continue the illegal work because the corrupt system allows it. The law of 2010 permitting donation from close blood relatives only, was a travesty, promulgated by ill-informed politicians, at the behest of vested interests and penalized patients with hereditary kidney disease, those whose family members who either refused or could not donate, and those who were ABO incompatible or only had elderly relatives with comorbidities?!

There is talk that the remuneration of unrelated KTs demeans medical ethics, but does anyone stop to consider the sad plight of the CRF patients and their families. Dialysis keeps the patients alive but with no quality of life. The ethical objection is the financial remuneration of the donor, but no ethics are considered breached when the medical center, transplant team, or the pharmaceutical companies get their pound of flesh!? This is mind boggling, considering that the only person in this entire chain making a sacrifice, is the donor!

KT needs to be regulated by an incorruptible government agency (in reality an oxymoron), to compensate willing kidney donors. This is a win-win situation and will help patients get off dialysis, improve their quality of life, and also enable donors getting well-deserved and appropriate remuneration, health insurance, and other incentives. The first world countries have changed their thinking and now generously compensate their donors for this gift of life; the third world, however, lacks vision, compassion, and the will to change legislation. We, in Pakistan, are not first world, our system of dialysis is rudimentary and flawed, providing neither the desired clearance, nor protection from acquiring hepatitis and other infections.

The question that the authors should ask is, what does a patient with CRF do, if for whatever reason, no family donor is available, should he/she continue unsafe and expensive dialysis till their death sentence is carried out? Creation of a national donor database that guarantees donor compensation, and a seamless priority-based process of kidney allocation is the only way kidney donation can be increased so that all patients with CRF get an opportunity of transplantation.

Conflict of interest: None declared.

   References Top

Hamid RB, Khan MT. Living-unrelated kidney donor transplantation: Legalization in exceptional circumstances? Saudi J Kidney Dis Transpl 2019;30:1111-7  Back to cited text no. 1
Khan TF, Said MT, Kamal S, Akhter F, Salam Z. Prevention of poor early graft function using open nephrectomy, and minimizing the risk of procedure-related factors. Urotoday Int J 2013;6:art 30  Back to cited text no. 2
Hart A, Smith JM, Skeans MA, et al. OPTN/SRTR 2017 annual data report: Kidney. Am J Transplant 2019;19 Suppl 2:19-23  Back to cited text no. 3
McCormick F, Held PJ, Chertow GM, Peters TG, Roberts JP. Removing disincentives to kidney donation: A quantitative analysis. J Am Soc Nephrol 2019;30:1349-57  Back to cited text no. 4
Salomon DR, Langnas AN, Reed AI, et al. AST/ASTS workshop on increasing organ donation in the United States: Creating an“arc of change” from removing disincentives to testing incentives. Am J Transplant 2015;15: 1173-9  Back to cited text no. 5
Tushla L, Rudow DL, Milton J, et al. Living- donor kidney transplantation: Reducing financial barriers to live kidney donation - Recommendations from a consensus conference. Clin J Am Soc Nephro l2015;10: 1696-702  Back to cited text no. 6
Hays R, Rodrigue JR, Cohen D, et al. Financial neutrality for living organ donors: Reasoning, rationale, definitions, and imple-mentation strategies. Am J Transplant 2016; 16:1973-81  Back to cited text no. 7
OPTN/UNOS Public Comment Proposal: A White Paper Addressing Financial Incentives for Organ Donation; 2014. Available from: https://optn.transplant.hrsa.gov/media/2084/Et hics_PCProposal_Financial_Incentives_20170 1.pdf  Back to cited text no. 8
Delmonico FL, Martin D, Dominguez-Gil B, et al. Living and deceased organ donation should be financially neutral acts. Am J Transplant 2015;15:1187-91  Back to cited text no. 9
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. 10
O’Keeffe LM, Ramond A, Oliver-Williams C, et al. Mid- and long-term health risks in living kidney donors: A systematic review and meta- analysis. Ann Intern Med 2018;168:276-84  Back to cited text no. 11
Lee CM, Carter JT, Alfrey EJ, Ascher NL, Roberts JP, Freise CE. Prolonged cold ischemia time obviates the benefits of 0 HLA mismatches in renal transplantation. Arch Surg 2000;135:1016-9.  Back to cited text no. 12

Correspondence Address:
Taqi F Toufeeq Khan
Department of Nephrology and Transplantation, Rehman Medical Institute, Peshawar
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DOI: 10.4103/1319-2442.284041

PMID: 32394939

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