Some Interesting Stories from the Iranian Model of Kidney Transplantation

Organ shortage for transplantation is an important dilemma for end-stage renal disease (ESRD) patients worldwide.( 1) Several countries have developed different models of approach with respect to this issue. Iran has one of the most successful transplantation programs in the Middle East. Organ procurement in Iran includes allografts received from deceased donors, living genetically related, and living genetically unrelated donors. The latter group are either emotionally related (spouses, life partners, friends), or emotionally not related (incentivized donors or vendors).(2,3) In 1988, a government regulated and funded Living Unrelated Kidney Transplantation (LUKT) program was established in Iran that is generally referred to as the “Iranian model of kidney transplantation” (IMKT). (3-5) During the recent decades, organ transplantation and especially kidney transplantation has been developed and expanded in almost all regions of the country. At present kidney transplantation is performed in more than 30 centers in Iran with approximately 2500 kidney transplants being performed per year.(4,6) However, the IMKT has not been fully recognized and credited as a successful model in the world and has been challenged by other organ transplant schools. Ethical questions on the issue of organ selling are among the most challenging aspects of IMKT program.(7) While in the majority of cases of LUKT in Iran the motivation to donate (actually, to sell) is a financial need, however is some cases it could be a mixture of altruism and financial recovery, and there are still some kidney donors who wish to donate their kidneys as an altruistic humanitarian act. In this communication we would like to present the 3 interesting-stories of living unrelated kidney donation from the IMKT program that we have personally encountered. Case 1: Kidney donation leading to love and unio‎n in marriage A 25-year old Iranian woman (lady T) with ESRD of unknown cause was undergoing regular chronic hemodialysis (3 sessions per week) for nearly one year. She was in a very poor economic condition and could not afford obtaining a kidney transplant. During her regular visits for dialysis she met a 27-year old man (Mr. A) who was visiting his sick mother in the same hospital. The young man inquired about Lady T’s situation from hemodialysis personnel and found out that she does not have any potential living related donor, and that she did not have financial means to afford paying for a kidney in the IMKT. Mr. A asked from dialysis personnel how he could become a kidney donor to her. He was referred to the local Patient’s Kidney Foundation office (referred to as “anjoman”) as a volunteer living unrelated kidney donor (LUKD) to Lady T. After thorough evaluation of his health history, physical examination and the required para-clinical studies he was found to be a suitable kidney donor for Lady T. The kidney donation and transplantation were performed successfully after few months of their accidental encounter. Two months after transplantation Mr. A visited the holy city of Mashhad (Imam Reza shrine), where he expressed his wish to marry lady T asking for guidance and support. He subsequently proposed to her, which was well received by Lady T and her family, and a wedding ceremony was established at that time. They got married and have been happily living together. The allograft functioned for almost 14 years. She went back on hemodialysis after 14 years. Her husband (Mr. A) remains in good health, and continues supporting her. Lady T is currently being listed for a second kidney transplantation. Case 2: Kidney donation and continued financial support of allograft recipient by an altruistic unrelated donor A 23-year old patient with ESRD caused by neurogenic bladder with past history of a failed nonfunctioning allograft was listed for a second kidney transplantation in the local anjoman. However, he was from a family in poor economic condition that could not financially afford compensating (rewarding the gift of kidney) an unrelated live donor. At about the same time, a 30- year old gentleman decided to donate his kidney to a dialysis patient who is in poor economic condition. He had good education, had a stable job, and was in no economic distress. He visited the same local anjoman to find a suitable ESRD recipient. These two people were introduced together, and after checking the blood group compatibility, they were sent to the designated transplant physician for further evaluation. After full evaluation, including the required laboratory and imaging tests it was noticed that the donor had paid for all of the expense, i.e., costs related to the physician visits, laboratory and imaging studies. Subsequently, kidney transplantation was performed successfully without any complications, and with good allograft function. To date, sixteen years later, the recipient is doing very well with good allograft function. The truly altruistic kidney donor is also doing very well with good kidney function. The donor has also been supporting the allograft recipient during these years.