20 Years Iranian Experience of Organ Donation: Shifting From Compensated Living Unrelated Kidney Transplantation

Kidney transplantation is the treatment of choice for patients with end-stage kidney disease and is associated with a reduced risk of death, fewer cardiovascular events, and a better quality of life than with chronic dialysis. However, the increasing prevalence of end-stage kidney disease, together with relatively stable or declining rates of organ donation, has led to a critical shortage of kidneys available for transplantation worldwide.¹

The living unrelated kidney transplantation program was adopted in Iran in part because of lack of infrastructure for kidney transplantation from deceased donors; however, over the past 20 years, the ratio of transplantation from deceased donors (brain-dead) to transplantation from living donors has been steadily increasing from 1% in 1999 to 72% in 2021.² In this brief report, we highlight the key steps taken to create the infrastructure needed for increasing the deceased-donor kidney transplantation and moving away from compensated living unrelated kidney transplantation in Iran.

Historical Background

The first successful kidney transplantation in Iran was performed by Dr. Mohammad Sanadi Zadeh at Shiraz University Hospital in 1968 from a living related donor.³ The Iranian Blood Transfusion Organization performed necessary tests for kidney transplantation, including the histocompatibility tests under the guidance of Dr. Freidoon Ala in collaboration with Dr. Behrooz Nikbin, who created a registry of the patients with kidney failure. With support from the European Organ Transplantation Bank, a total of 14 kidneys from deceased donors were imported to Iran without payment and transplanted in Behavar Hospital and Dariush Kabir Hospital.⁴ In 1976, the hemodialysis division of the Ministry of Health was established in Behavar Hospital. The number of patients with end-stage kidney disease on maintenance hemodialysis has grown rapidly.^5,6 Transplantation efforts were suspended for almost a decade because of the political instability of the 1979 revolution in Iran with unique conditions, including a lack of transplant experts in the country. The transplantation program was reestablished in 1983.⁶ However, because of a lack of infrastructure and proper legislation, organ transplantation from brain-dead donors was not pursued at that time.

Living Unrelated Kidney Transplantation

A rapidly growing number of patients with end-stage kidney disease and an increased awareness about the benefits of kidney transplantation resulted in an increasing demand for kidney transplantation in Iran.⁶ Until 1988, kidney transplantation was performed only through living-related transplantation; however, based on the suggestion of some transplant experts, the government-regulated and compensated living unrelated kidney transplantation program was adopted in 1988 to address organ shortage.⁵ Ethical considerations about exchanging money between recipients and donors, particularly with the involvement of the brokers, prompted the Iranian Association of Kidney Patients Advocacy, organized by dialysis patients and transplant recipients, to supervise the process of living unrelated kidney transplantation to remove the brokers from the process.

Hemodialysis is the most common dialysis therapy in Iran. Home-based dialysis, including peritoneal dialysis, is less commonly performed. All expenses related to dialysis care is paid by the government in Iran. All hospitalization costs for organ transplants, both living and deceased, are also covered by the government, including the expenses of surgery and full hospitalization.

Regarding compensation for living kidney donors, in 2000, the government ordered the Special Diseases Foundation to pay 10 million IRR (US $1500) as compensation to living kidney donors. As inflation increased, the government gradually increased the amount. Currently, donors receive 2 different payments: one is an official payment provided by the government in the amount of 800 million IRR (US $1400), and the other is an unofficial amount paid by the recipient to the donor through negotiation. The unofficial amount is typically several times higher than the official government-approved payments. The Iranian Association of Kidney Patients Advocacy may help recipients who cannot afford the unofficial payments.S1

In 2024, the government’s compensation amount increased to 800 million IRR (US $1400). The median cost of living for a family of 4 is approximately 190 million IRR (US $333) per month. The consumer price index was 3 in 2000, which has increased to 187 in 2023, according to the Statistical Center of Iran.⁷ Therefore, the consumer price index has increased 60 times over the past 20 years while the compensation amount has increased by 80 times.

Despite efforts to eliminate middlemen, compensation for living unrelated kidney transplantation remains controversial, with concerns about the potential exploitation of vulnerable populations.S2

Bolstering the infrastructure for deceased-donor kidney transplantation has emerged as a practical solution for moving away from compensated living unrelated kidney transplantation.

Removal of Barriers for Deceased-Donor Kidney Transplantation in Iran

Organ transplantation from brain-dead individuals has been a controversial issue among Islamic religious authorities, with concerns such as burying a body intact; however, a religious decree (FATWA) permitting organ transplantation from brain-dead patients was issued by Iran’s supreme religious leader on May 21, 1989. This was a major step forward in supporting deceased-donor kidney transplantation in an Islamic country. On this occasion, May 21 was named the National Day of Organ Donations in Iran. At the next step, formal legislation on organ donation from deceased donors became necessary to ensure consistency in judicial practices across the country. In 2000, the Brain Death and Organ Transplantation Act was passed in Iran’s parliament, legalizing deceased-donor organ transplantation.^5,8

In addition, the Ministry of Health prepared a guideline for transparency in the process of matching donors and recipients and communicated it to all medical science universities in Iran. According to these guidelines, organ procurement units identify potential donors, procure organs, and ensure transparency in the organ donation process and arrival of organs to the destination hospitals. In academic hospitals, each case of brain death is determined and confirmed by 5 physicians, including neurologists, neurosurgeons, internists, and anesthesiologists, none of whom are members of the transplant team or licensed by the Minister of Health for this purpose. In addition, a forensic pathologist is involved in the process of determining brain death. No money is exchanged between donor families and recipients of the deceased donation program.

Establishment of Iranian Society of Organ Donation

In addition to addressing the religious and legal aspects of deceased-donor organ transplantation, building a culture of organ donation in Iranian society was crucial. Although the establishment of relevant nonprofit organizations, such as the Iranian Society of Nephrology and Iranian Society of Organ Transplantation, dates back decades, their focus was on scientific advancements. There was a need for an independent organization to promote and create a culture of organ donation and to manage the organ transplantation system. Inspired by the United Network for Organ Sharing, a nonprofit organization that manages the United States’ organ transplantation system under contract with the federal government, the Iranian Society of Organ Donation (ISOD) was established in 2015. Iranian celebrities, movie stars, artists, famous athletes, physicians, patients, and family of deceased donors, all came together to raise public awareness and encourage organ donation in Iran. Approximately 8 million Iranians (10% of the Iranian population) opted to become deceased organ donors (ehdacenter.ir). Furthermore, the Ministry of Health delegated some of its authority to ISOD, such as the education of procurement teams, in addition to organizing cultural and social events to promote organ donation. In collaboration with the authorities, ISOD launched an organ aviation transport service. ISOD has created a national waitlist for transplantation, which is now managed by the Ministry of Health.

The multidisciplinary approach to encourage deceased-donor organ transplantation resulted in a significant change in the organ donation index (Figure 1), which increased 70-fold over the past 2 decades in Iran from 0.2 per million population in 2000 to 14.3 per million population in late 2019. In 2020, there was a decline because of the Covid-19 pandemic. Subsequently, the organ donation rate increased and reached 12.6 per million population in 2023. The ratio of kidney and liver transplantations from brain-dead donors to kidney and liver transplantations from living donors has steadily increased from 1% in 1999 (14/1395 transplants) to 72% in 2021 (1849/2569 transplants) and 66% (2224/3413 transplants) in 2023.²

Figure 1.

The milestones and the trend of organ donation after brain death in Iran 2000–2023.

There has been a shift from living-donor kidney transplantation, which was more than 95% unrelated,⁹ to deceased-donor kidney transplantation (Figure 2).

Figure 2.

The percentage of kidney and liver transplant from living donors compared to brain-dead donors in Iran from 1999 to 2023.

The following 4 types of kidney transplantations are performed in Iran: living related transplantation, living unrelated transplantation, donation after brain death, and donations after circulatory death, which have begun recently. Swaps and altruistic nondirected donors do not occur in Iran. Regarding prevention of transplant rejection, the country's integrated system of human leukocyte antigen– matching is used, and to confirm the matching, at least 3 human leukocyte antigens of the donor and the recipient must be matched.

Currently, 32,000 patients are undergoing dialysis in Iran, and about 2500 of them are receiving kidney transplant every year, of which 60% are from deceased donors and the rest are from living donors. The annual need for kidney transplantations in Iran is at least 10,000.

In addition to kidney transplantation, the number of transplantations of other organs, including the liver, heart, lung, pancreas, and small bowel has rapidly progressed.²

Conclusion

Organ shortage is a complex challenge that affects individuals in need of transplantation, their caregivers, healthcare professionals, and policymakers worldwide. Compensated living unrelated kidney transplantation was adopted in Iran in the 1980s because there was no deceased-donor program at that time, and living related donors were limited. By removing religious, legal, and cultural barriers and bolstering the infrastructure for deceased-donor kidney transplantation, Iran has changed from compensated living unrelated kidney transplantation to increased deceased-donor kidney transplantation.

Disclosure

All the authors are members of Iranian Society of Organ Donation.

Supplementary Material

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