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Current Challenges of Kidney Transplantation in Iran: Moving Beyond The “Iranian Model”

Saidi, Reza F., MD1; Broumand, Behrooz, MD2

doi: 10.1097/TP.0000000000002212
In View: Around the World

Organ Transplantation in Iran has come a long way with many different policies and approaches addressing demand and supply. The first successfully kidney transplantation was performed at Namazi Hospital in Shiraz from a living donor in 1967. However, there had been only limited transplant activities in Iran until mid-1970. Previously, patients compensated the lack of organ transplants in Iran by travelling outside the country including the United Kingdom for living related transplants or to India, taking advantage of commercially available organs, usually with poor outcomes. There have also been attempts in the past to import allografts from Europe and the United States. After 1979 revolution, kidney transplantation was activated in Iran by using living donors which was know as Iranian model. Recently, there has been emphasis to expand deceased donor kidney transplantation. However, there are several challenges to expand transplant care in Iran.

1 Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.

2 Pars Advanced Minimally Invasive Medical Manner Research Center, Pars Hospital, Tehran, Iran University of Medical Sciences, Tehran, Iran.

Received 12 December 2017. Revision received 30 December 2017.

Accepted 6 January 2018.

The authors declare no funding or conflicts of interest.

Correspondence: Reza F. Saidi, MD, FICS, Department of Surgery, Shariati Hospital, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran. (srsaidi@tums.ac.ir).

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CHRONIC KIDNEY DISEASE IN IRAN

Mortality rates linked to ESRD have been increasing in Iran.1,2 Moreover, a large prospective cohort study showed low glomerular filtration rates as a critically important risk factors of mortality and morbidity in Iran.3 Indeed, 25% of study participants reflective of the general population had low glomerular filtration rate (<60 cc/min). Female sex, older age, urban residence, history of cardiovascular disease, hypertension, diabetes, and low low-density lipoprotein were all associated with chronic kidney disease (CKD).3 There is also an increasing trend of other CKD risk factors, including obesity, hypertension, diabetes, and cardiovascular disease in Iran.4

As in many other countries worldwide, demographics in Iran are dominated by the elderly. Therefore, the country is likely to face an increasing burden of CKD in near future.

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STATUS OF KIDNEY TRANSPLANTATION IN IRAN

After the 1979 revolution, living related and eventually living unrelated kidney transplant (LUKT) programs had been initiated in Tehran due to lack of infrastructure for deceased donor kidney transplantation (DDKT). In 1988, a governmental regulated and funded LUKT program has been established and approved by the government, frequently referred to as the “Iranian model of kidney transplantation.”1 This program facilitates access to kidney transplantation (KT) for patients with ESRD, predominantly through living donations. Although having been successful in increasing transplant volumes, the program has been discussed controversially on both a national and international level.4-6 Originally, the program allowed living donor KT for non-Iranian citizens if both donor and the recipients had the same nationality. With the adaption of the Istanbul declaration in 2008, there have been significant changes in the process of organ transplantation in Iran, including a commitment for a long-term medical care of donors. To abolish transplant tourism in Iran, transplantation of non-Iranian citizens is no longer legal since 2010.7

Since passing of the Donation after Brain Death Act in 2000, there has been an expansion of deceased donation and deceased donor KT in Iran (Figure 1) with current rates of 10.9/million population (Figure 2).

There are currently 30 transplant programs in the country with approximately 2500 kidney transplants being performed annually. The number of live donor KT has declined and the volume for DDKT has been on the rise (Figure 3).

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

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CHALLENGES AND OPPORTUNITIES

Although there has been significant progress, the country is facing several challenges:

  • (i) Lack of a national procurement organization and insufficient regulation and coordination on a national level.
  • Currently, each program works independently with a limited cooperation and collaboration among centers; there is no national registry system and database challenging quality and outcome assessments while preventing the coordination of care. Currently, lack of a national system also prevents the implementation of a paired kidney exchange program in Iran.
  • (ii) Lack of a Legal Platform:
  • The only national law regulating organ donation and transplantation has been passed 17 years ago, authorizing the utilization of organs from brain death donors for transplantation. There is a need to have a legal platform to develop a national transplant system. In the United States, the National Transplant Act of 1984 established the United Network for Organ Sharing expanding transplantation activities.8 A comparable platform is expected to make transplantation in Iran more efficient with an improved quality of care and access for all the patients to transplantation.
  • (iii) Lack of national organ procurement and transplantation registry:
  • A high-quality database appears necessary for a nationwide quality assessment/process improvement, assessment of needs and resource plan.
  • (iv) Improving public awareness for organ donation:
  • There has been a significant progress in increasing organ donation rates. Iran has approximately 5000 brain death donors/year. However, conversion rates remain low and only 1500 (30%) brain dead donors proceed to organ donation because of low public awareness.9,10 Several provinces in Iran remain to lack deceased donor procurement programs and, consequently, rely on LDKT only.
  • (v) Financial and insurance issues:
  • Almost 100% of perioperative costs of KT are covered by government insurance. However, posttransplant care, especially costs of lifelong immunosuppression remain only partly covered. There should be a national effort to support patients in need of KT financially with adequate insurance coverage.

In summary, KT has seen a significant progress during the recent decades. Most notably, rates of LUKT have been decreasing and more DDKTs are being performed in Iran. However, several challenges remain. Implementing a legal platform for a national organ procurement and transplant network in addition to a scientific registry are expected to improve quality of care and access to KT in Iran.

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