The features of the Shiraz Program designed to enhance deceased organ donation include:
Transplant pioneers in Iran, led by Dr. Iraj Fazel, designed and implemented a unique model during the period of the Iranian revolution, subsequent war, and economic sanctions, which allowed thousands of patients to receive RTs throughout 3 decades. The Iranian Model was designed to assist patients with no living related donor, but in practice 81% of LURD recipients have a potential living related donor.22 The medical community subsequently guided religious approval and Brain Death Legislation in 2000 to provide an additional transplant opportunity beyond renal transplantation and for patients unable to access any form of LD.
Evidence indicates that in its current form, the Iranian Model is only partly regulated. The nonanonymous directed donation fosters a direct monetary relationship between donor and recipient with no safeguards against mutual exploitation. Although it was designed to be an organ broker-free process with no transplant tourism, in 2014, individual brokers and 12 organ broker teams have arranged transplantation of foreigners.23,24 The number of unauthorized transplants of foreigners is difficult to estimate,25,26 but citizens from neighboring countries have undergone broker-facilitated LURD transplants in Iran without oversight.12 In 2014, the Iranian MOH prevented an Iraqi with forged documents from undergoing LURD transplant from an Iranian in a private hospital in Tehran,27 but 2 Saudi citizens, using forged documents, were transplanted.28 Brokers in Azerbaijan have arranged for Azeri patients to receive kidneys from paid Azeri donors in Iran.29 Thus, the legal opportunity for LURD RTs for nonnationals facilitated a process in that patients from countries where LURD transplant is illegal, could receive commercial RT, mainly in private hospitals.12 Because of the concern about organ brokerage teams and foreigners receiving RTs from paid Iranian donors, in 2014, the MOH limited RTs to Iranian citizens.12
Advocates of the Iranian Model have identified academic standards and scrutiny as protective components of the regulated system; however, the websites of several private hospitals in Tehran30-33 indicate RT among services offered, and it is known that other private hospitals have been performing RTs (Broumand, B. nephrologist, Tehran, Iran, personal communication, November 4, 2015). Although recent regulations have been implemented to prohibit transplantation of foreigners and transplants in private hospitals, they have not prevented exploitation. Foreigners seeking transplant have been hospitalized with forged documents under pretenses, such as cholecystectomy; and according to officials of the MOH transplants have occurred in hospitals that lacked credentials.24
Due to inflation, the relative value of governmental reward has decreased to a small portion of total payment, and the recipient assumes the major burden.14 The Iranian Model was introduced during a period marked by altruism and monumental sacrifices in the early years after the revolution and during the Iran-Iraq war.34 War time altruism has been replaced by an economy marked by inflation rates ranging from 15% to 35% where the main motive for organ donation and transplantation has been financial gain,35 not only for the donor but also for brokers and others involved. There is no restriction on donors seeking a recipient who will pay more, and thus equitable access to LURD RT is distorted by recipient wealth. This is confirmed by Ghods and Savaj,5 identifying that 84% of the donors, but only 50.4% of the recipients, were from lower socioeconomic groups.
Donor follow-up and outcome studies of the Iranian Model have been limited to single centers, with small sample size, that are either cross-sectional or with very short follow-up.36-38 In 1 study, 500 donors were invited to participate and only 6 responded.14 In the largest available study of donors, the maximum follow-up was 4 years. Thus, long-term safety of donation in this donor population with a mean age of 30 remains a valid concern.39 Donor education is insufficient, as evidenced by a study showing that 80% of donors and donor candidates were unaware of complications of nephrectomy, and only 26% of the approved donor candidates were aware of the need for follow-up.40
Shiraz conducts the largest number of DD RTs in Iran and paid LURD RT has been eliminated. The question remains as to the role of the LURD program in inhibiting development of DD programs across the rest of the country that cannot be explained by cultural resistance to donation because of the cultural similarities between Shiraz and the rest of Iran.
The author is grateful to Dr. Behrooz Broumand, Dr. Ahad Ghods, Dr. Ali Nobakht Haghighi and Dr. S. Ali Malek-Hosseini for providing insightful mentorship, as well as updated data and information about transplant activities in Iran.
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