Worldwide organ shortage and death due to waiting lists have lead to several strategies to increase organ supply from deceased and living donors [1••,2•,3•]. In developing countries where deceased donor programs have not been established due to economic, cultural, social and religious impediments [4••,5], the focus has been on increasing supply of kidneys from living donors. Kidney transplantation in Pakistan and Iran started from living related altruistic donors. However, shortage of organs and absence of deceased donors lead to unrelated living donors transplants in both countries [4••,6••]. Pakistan took the route of commercial transplants, whereas Iran attempted to develop a system of regulated paid donor transplants. This article highlights the outcome of these strategies and their impact on transplant programs in these countries.
Transplantation in Pakistan
Pakistan has a population of 160 million with an estimated incidence of end-stage renal failure (ESRF) of 100 per million population (pmp). According to human development report of 2008, the per capita income of Pakistan is around US$800 and more than 50% of the people live below poverty line on less than US$1 a day . Currently, the cost of dialysis in private centers is US$4500–6000 year, transplant cost is $6000–10 000 and transplant rate is 8–10 pmp [4••]. Paucity of dialysis and transplant facilities in the public centers and high cost in private ones render more than 90% of the ESRF population disfranchised from treatment.
Renal transplantation started on a regular basis in 1979 from living related altruistic donors. Initially, the activity was low, that is, less than 50 per year but rose to more than 100 per year by the mid-1990s [4••]. Absence of a deceased donor program, growing shortage of organs and developed transplant expertise led to unrelated commercial transplants. These were done in private centers, and their numbers exceeded more than 1000 in the year 2000 [4••]. These constituted more than 70% of the total transplants as reported by Shah et al. . Initially, recipients were locals; however, the changing transplant scenario in the region led to transplant tourism in Pakistan , and over 1000 transplants per year were performed for tourists by the end of 2005 . First, the background to this tourism was regional when India prohibited organ trade . Secondly, absence of law that could prohibit sale of organ and trade [4••]. Thirdly, rich buyers from Europe, Middle East and India responded to advisements on the Web and traveled to Pakistan for transplants, paying between US$20 000–30 000 . In 2007, more then 1500 transplants were performed for foreigners.
Dynamics of commercial transplants
Commercial transplant are exclusively performed in private centers, which offer transplant packages of US$6000–10 000 for locals and US$20 000–30 000 for foreigners. The transplant package is for 7 days and includes hospital stay, immunosuppressive drugs and price of the kidney. These are offered through middle men, who provide the donors from villages around major cities of Punjab, the largest province of Pakistan. Donors are selected on ABO compatibility, although most centers claim human leukocyte antigen (HLA)-matched donors. Evaluation of donor is limited to blood group, renal function and screening for hepatitis B, hepatitis C and HIV. Majority of these centers have inadequate or no facilities for tissue matching, immunosuppressive drug monitoring, renal biopsy and imaging.
Induction by ATG or IL-2 antagonists is given to majority of recipients . Follow-up care is not offered to recipients by majority of centers. There is no follow-up of kidney vendors who are discharged within 3–4 days or earlier and are paid US$1200–1500.
Naqvi et al. [13••] have reported the socioeconomic status of the vendors in Pakistan. It showed that 34% of the vendors lived below poverty line on less than US$1 a day, 90% were illiterate and 69% were bonded laborers who were virtual slaves to the landlords [13••]. This modern-day slavery is practiced in a number of countries in south Asia where generation after generation of workers work long hours to repay debt of their fathers or grandfathers . Majority of the vendors (93%) sold kidneys to pay off debts; however, after vending, 88% had no economic benefits. Similar findings on vendors have come from India, where Goyal et al. [15••] reported no benefit to three-forth of vendors, and from Iran, where Zargooshi [16•] reported no benefit to 75% of vendors. In another study, to evaluate the health status and renal function of kidney vendors, Naqvi et al. [17••] showed that compared with carefully age-matched and sex-matched living related donors, vendors had poor selection, as 27% were hepatitis C positive and 7.7% hepatitis B positive. Hypertension was found in 17% and the mean glomerular filtration rate (GFR) after nephrectomy was 70 ml/min, with a third having GFR less than 60 ml/min. Therefore, donors selected were at higher risk of developing chronic kidney disease and hepatitis, putting their recipients at high risk of developing infectious complications [17••]. Vendors were the poor of the society who sold kidneys for financial gains, unfortunately this dream was never realized [13••,15••,16•].
There are no published reports in the literature on the outcome of local recipients of this kidney market. However, reports by Higgens et al. from UK  and Prasad et al. [19•] from Canada about tourists who were transplanted in Pakistan have shown poor outcome and higher infectious complications with hepatitis B, hepatitis C and tuberculosis, and reports by Canales et al. [20•] from United States and a review by Sajjad et al. [21••] of outcomes of recipients and donors have shown infectious and surgical complications. Many of these recipients had transplants against the advice of their physicians, as reported by Ben Hamida et al.  from Tunisia and Canales et al. [20•], due to presence of comorbidities. Inadequate evaluation and poor selection may contribute to the inferior graft outcomes and complications reported in the transplant tourists [20•,21••]. These observations suggest that the interest of commercial centers is in only finance without any regard of the suitability of the recipient for transplantation. Commercial transplantologists justified this practice on the grounds of benefit to their patients and alleviation of poverty and respect of their autonomy.
Transplant law in Pakistan
Reports on transplant tourism and exploitation of the kidney vendors led to judicial activation with so-motto notices from the Supreme Court of Pakistan . This event finally forced the government to agree to promulgate ‘The Transplantation of Human Tissues and Organ Ordinance 2007’ in September 2007. The ordinance has banned commercial transplants and has set up a monitoring authority. A national registry has been set up in which all transplants and outcomes are recorded. A year after the ordinance, the national monitoring authority has reported over 800 local renal transplants from living related altruistic donors and functional monitoring authorities in each province. The other positive impacts of the ordinance are that the number of commercial transplants of foreigners and locals has become negligible and those contravening the law are arrested .
Renal transplantation in Iran
Renal transplant activities in Iran have been described in detail by Ghods and Mahdavi [6••]. The first renal transplant in Iran was performed in 1967. Initially, the incidences were low (100 per year), all from living related altruistic donors, and many ESRF patients traveled abroad on the state expense for transplantation from living related donors. The great revolution in 1979 was followed by enormous challenges including war with Iraq and international economic sanctions. This isolation exerted tremendous pressure both on the economy and health facilities. It was not until 1985 that a coordinated successful transplant program was started using living related donors. The absence of a deceased donor program and increasing waiting lists led to a living unrelated paid donor transplant program, which was regularized and gained support of the government in 1988.
Dynamics of regulated transplant program
The details of this program have been published extensively by Ghods and Mahdavi [6••], Einollahi  and recently updated by Ghods and Savaj [26••]. A non-governmental organization (DATPA) receives referral of ESRF patients who have no willing or suitable donor. The same organization is also responsible for recruiting unrelated and presumed altruistic or emotionally related donors. According to the most recent report, there are now 80 branches of this organization through out Iran, and all are operated by patients with ESRF on a voluntary basis [26••]. After confirming their suitability, the recipient–donor pair is referred to state-run university hospitals for transplantation. However, it is not clear as to how the altruistic or emotional motive of an unrelated donor is assessed by DATPA. Transplants are performed in state-authorized hospitals funded by the government. Transplant physicians and surgeons have no nonmedical input in selecting the donor or influencing the organization and do not get extra benefit from the procedure. Due to directed nature of donation, HLA typing is not done and transplantation is performed on the basis of ABO blood group compatibility [26••].
The donor receives a fixed amount of US$1200 from the state directly after donation or via a state department in Tehran. The donors do not maintain anonymity and meet the recipient before donation to finalize other payments from the recipient under the auspices of DATPA. This amount is not fixed and can be negotiated. There is some provision for very poor recipients who are unable to pay the donor, and DATPA seeks help of charitable organization to pay the donors for such recipients [26••].
The Iranian program of compensated kidney donation has been successful in increasing the number of kidneys available for transplantation. Ghods and Mahdavi [6••] have shown that of the 20 185 living donor transplants performed in Iran till the end of 2006, 70% (16 544) were from living unrelated paid donors. They have claimed that waiting list for transplantation no longer exists in Iran. Unfortunately, it is not clear how many of the 370 pmp patients with end-stage renal disease have access to renal replacement therapy [25,26••].
It is difficult to analyze outcomes in the absence of a registry. Donors are provided 1-year free healthcare; however, there is no organized long-term follow-up. In the presence of well trained transplant teams in university hospitals, significant postoperative donor morbidity is unlikely. However, major issues are motivation, psychological well being and improvement in socioeconomic status of donors. In a study of 100 vendors, Zargooshi [16•] found financial incentive as the main reason for donation, but 75% were dissatisfied 2 years or more after donation. A recent cross-sectional study of 478 unrelated kidney donors by Malakoutian et al. [27••] showed that majority of the vendors were men and 70% belonged to first-income or second-income deciles and 60% were living below the poverty line by Iranian standards. In this study, although 91% were satisfied with their act of donation, period of evaluation after donation was not indicated. Majority donated for financial incentive and 56% used the payment to repay debts. In an earlier study of 1000 donors and recipient and using a much wider definition of poverty, Ghods and Mahdavi [6••] reported that 65% of donors were poor, a value that was slightly higher than the corresponding poverty prevalence of 50% among recipients.
In the absence of a transplant registry, the outcome of transplants is limited to single-center experiences. Single-center experiences of unrelated donor transplants have shown results similar to those of living related transplants [25,26••]. One of the largest series published to date by Ghods and Mahdavi [6••] of 1995 renal transplants of which 1499 (75%) were from living unrelated donors has shown graft survival rates of 90.5, 74.4 and 48.8% at 1, 5 and 10 years, respectively. These results were similar to one-haplotype-matched living related donor transplant from the same center [6••].
Ethical aspects of Iranian regulated systems
Iranian model has generated intense ethical debate in the transplant community [28,29••,30••]. Although Iran has achieved a relatively high transplant rate of 25–28 per million population per year (pmpy), but this figure is much lower compared with the best model of 70 pmpy in Spain [1••], where a very well coordinated deceased donor program is supplemented by a noncompensated living related altruistic donor program. The shrinkage of waiting list in Iran is partly due to rather low prevalence of 370 pmp in the country, a finding typical of developing countries where access to dialysis is limited [4••,5].
Removal of the middle men and other interest groups prevents overt commercialism, as seen in Pakistan. As the transplants are restricted to Iranian nationals, there are lesser chances of transplant tourism . However, the program in true sense of the word cannot be called regulated. The donation is almost always a directed donation to a recipient with variable monetary benefit depending on the ability of recipient to pay. Moreover, DATPA has no record of recipient donor transaction [29••]. Payment for organ is ethically unacceptable, as it comodifies the human body. It makes it more reprehensible when the data suggest that poorer vendors give kidneys to richer patients [29••]. Poverty makes the vendor vulnerable to exploitation [13••]. The program may also exclude very poor patients with ESRF who remain on dialysis waiting for a deceased donor. The amount paid to a donor by the state is not large by Iranian standard, people belonging to low socioeconomic class or the unemployed are likely to be exploited. There is little reason to believe that pure altruism is the driving force in any such donation.
Impact on deceased organ donation
The regulated model has hampered the development of a deceased donor transplant program, which currently accounts for only 10% of the total transplants, although brain death legislation was enacted in the year 2000. Bagheri [30••] has shown that the potential number of organs including kidneys available due to high rate of traffic accidents in Iran is not utilized due to its relative complexity compared with the easier option of living unrelated transplantation. Einollahi et al.  have estimated that deceased donor renal transplantation has significant potential of expansion in Iran.
Kidney transplantation from unrelated donors in Pakistan and Iran has failed to achieve a high transplant rate or fulfill the requirements of patients with ESRF. Unfortunately, as market forces prevailed, there was exploitation and coercion of poor and disadvantaged and the beneficiaries were the rich in both countries. Deceased donor programs have been delayed and forestalled and nonrenal solid-organ transplants have been ignored due to almost exclusive dependence on paid living donors. The way forward in both countries is to establish a fully integrated dialysis and transplantation program in public sector hospitals funded by the government or by model of public government partnership. Increased availability of dialysis and transplantation to all who need it irrespective of financial status is more likely to open the door to a viable deceased donor program in the future.
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 212).
1•• Matesanz R, Miranda B. A decade of continuous improvement in cadaveric organ donation: the Spanish model. J Nephrol 2002; 15:22–28. This paper is an update on the success of the Spanish model in which waiting lists have been abolished by a proactive deceased donor recruitment program run by Transplant Coordinator.
2• Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med 1995; 333:333–336. This paper has shown good outcome of spousal donor transplant from UNOS database. Such donors are a viable option for increasing donor pool.
3• Huh KH, Kim MS, Ju MK, et al
. Exchange living-donor kidney transplantation
: merits and limitations. Transplantation
2008; 86:430–435. This paper highlights the work of K. Park who initiated direct exchange donor (Swap) program in Korea with highly successful results.
4•• Rizvi SAH, Naqvi SAA, Zafar MN. Renal transplantation
in Pakistan. In: Cecka MJ, Terasaki PI, editors. Clinical transplants. Los Angeles: UCLA Immunogenetics Center; 2002. pp. 191–200.
This is a comprehensive report of history and transplant activities in Pakistan.
5 Sakhuja V, Kohli HS. End-stage renal disease in India and Pakistan: incidence, causes, and management. Ethn Dis 2006; 16(2 Suppl 2):S2-20–S2-23.
6•• Ghods AJ, Mahdavi M. Organ transplantation
in Iran. Saudi J Kidney Dis Transpl 2007; 18:648–655. This is a comprehensive report of history and renal transplant activities in Iran and the role a regulated system using unrelated paid
donors in increasing donor pool and reducing waiting lists.
8 Shah MH, Bokhari MZ, Bokhari MT, et al
. Safety and efficacy of basiliximab for the prevention of acute rejection in kidney transplant recipients. Transplant Proc 2003; 35:2737–2738.
11 Kishore RR. Organ donation: consanguinity vs universality – an analysis of Indian law. Transplant Proc 1996; 28:3603–3606.
13•• Naqvi SA, Ali B, Mazhar F, et al
. A socioeconomic survey of kidney vendors in Pakistan. Transplant Int 2007; 20:934–939. This report highlights the socioeconomic status of vendors in Pakistan and how the very poor of the society are coerced to sell kidneys.
15•• Goyal M, Mehta RL, Schneiderman LJ, Sehgal AR. Economic and health consequences of selling a kidney in India. JAMA 2002; 288:1589–1593. The paper was the first study to identify the economic and heath status of kidney vendors in India and their exploitation.
16• Zargooshi J. Iranian kidney donors: motivations and relations with recipients. J Urol 2001; 165:386–392. The first survey of its kind that analyzed motivation and degree of satisfaction after paid
17•• Naqvi SA, Rizvi SA, Zafar MN, et al
. Health status and renal function evaluation of kidney vendors: a report from Pakistan. Am J Transplant 2008; 8:1444–1450. This report is the first of its kind that has studied the postnephrectomy health status and renal function of kidney vendors.
18 Higgins R, West N, Fletcher S, et al
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: a Canadian experience. Transplantation
2006; 82:1130–1135. This paper shows poor outcome of commercial transplant donor in Pakistan and high rates of infections complications.
20• Canales MT, Kasiske BL, Rosenberg ME. Transplant tourism: outcomes of United States residents who undergo kidney transplantation
2006; 82:1658–1661. This paper shows high infectious complications in Americans traveling for commercial transplant to different countries including Pakistan.
21•• Sajjad I, Baines LS, Patel P, Salifu MO, et al
. Commercialization of kidney transplants: a systematic review of outcomes in recipients and donors. Am J Nephrol 2008; 28:744–754. This paper is a comprehensive combined report of several papers on transplant tourism. It highlights the outcome of recipients and donors. Overall outcome was poor in recipients with infectious complication.
22 Ben Hamida F, Ben Abdallah T, Goucha R, et al
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25 Einollahi B. Iranian experience with the nonrelated renal transplantation
. Saudi J Kidney Dis Transpl 2004; 15:421–428.
26•• Ghods AJ, Savaj S. Iranian model of paid
and regulated living-unrelated kidney donation. Clin J Am Soc Nephrol 2006; 1:1136–1145. This paper describes the Iranian model of regulated paid
donor kidney transplantation
in Iran and the role it has played in eliminatory waiting lists.
27•• Malakoutian T, Hakemi MS, Nassiri AA, et al
. Socioeconomic status of Iranian living unrelated kidney donors: a multicentre study. Transplant Proc 2007; 39:824–825. This paper is a detailed study of 478 vendors and identifies their socioeconomic status and reasons for vending.
28 Harmon W, Delmonico F. Payment for kidneys: a government-regulated system is not ethically achievable. Clin J Am Soc Nephrol 2006; 1:1146–1147.
29•• Griffin A. Kidneys on demand. BMJ 2007; 334:502–505. A viewpoint based on extensive personal investigation of the Iranian system of paid
30•• Bagheri A. Compensated kidney donation: an ethical review of the Iranian model. Kennedy Inst Ethics J 2006; 16:269–282. An in depth discussion on ethical aspects of paid
kidney donation in Iran.
31 Einollahi B, Nourbala MH, Bahaeloo-Horeh S, et al
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in Iran, trends, barriers and opportunities. Indian J Med Ethics 2007; 4:70–72.