Iranian model of paid and regulated living-unrelated kidney donation

Dilemma of commercial organ transplant in the Middle East

In recent years, the Middle East has witnessed a significant rise in commercial transplantation activities. This practice is driven by a multitude of factors including economic disparities, inadequate healthcare infrastructure, and cultural attitudes towards organ donation. In this article, we try to explore the complex landscape of commercial transplantation within the Middle East, shedding light on the ethical, legal, and socio-economic dimensions of this contentious issue.

Are Differences in Living Kidney Donation Rates a Sex or a Gender Disparity?

Sex-disaggregated data reveal significant disparities in living kidney donation, with more female than male living kidney donors in most countries and proportions over 60% in some countries. We summarize the present state of knowledge with respect to the potential drivers of this disparity and argue that it is primarily driven by gender-related factors. First, we present the differences between sex and gender and then proceed to summarize the potential medical reasons that have been proposed to explain why males are less likely to be living kidney donors than females, such as the higher prevalence of kidney failure in males. We then present counterarguments as to why biological sex differences are not enough to explain lower living kidney donation among males, such as a higher prevalence of chronic kidney disease among females, which could affect donation rates. We argue that gender differences likely provide a better explanation as to why there are more women than men living kidney donors and explore the role of economic and social factors, as well as gender roles and expectations, in affecting living kidney donation among both men and women. We conclude with the need for a gender analysis to explain this complex psychosocial phenomenon in living kidney donation.

Awareness, Attitudes, and Willingness: A Cross-Sectional Study of Organ Donation in Saudi Arabia

BACKGROUND

Organ transplantation is inherently dependent on the availability of organ donors. There is a noticeable paucity of literature addressing the rates of organ donation registration and the awareness of Islamic regulations (Fatwa) regarding organ donation within Saudi Arabia. Our study aimed to evaluate the level of organ donation registration, awareness of Islamic regulations, and knowledge of the Saudi Center for Organ Transplantation (SCOT) within the Saudi society.

METHODS

We conducted a cross-sectional survey from 30 March to 9 April 2023. This survey aimed to assess the awareness of Islamic (Fatwa) guidance on organ donation, the role of SCOT, and the rate of organ donation registration facilitated through the Tawakkalna app, the official health passport application in Saudi Arabia.

RESULTS

Out of 2329 respondents, 21% had registered as potential deceased organ donors, despite 87% acknowledging the importance of organ donation. Awareness of the Islamic Fatwa regarding organ donation was reported by 54.7% of respondents, and 37% recognized the Fatwa's acceptance of brain death criteria. The likelihood of registration as organ donors was higher among Saudi citizens under 45 years of age, females, healthcare workers (HCWs), individuals with higher education, relatives of patients awaiting organ donations, those informed about the Islamic Fatwas, and those willing to donate organs to friends. Conversely, being over the age of 25, Saudi nationality, employment as an HCW, awareness of SCOT, and prior organ donation registration were predictive of a heightened awareness of Islamic Fatwas. However, perceiving the importance of organ donation correlated with a lower awareness of the Fatwas. Significant positive correlations were found between awareness of SCOT, awareness of Fatwas, and registration for organ donation.

CONCLUSIONS

While the Saudi population exhibits a high regard for the importance of organ donation, this recognition is not adequately translated into registration rates. The discrepancy may be attributable to limited awareness of SCOT and the relevant Islamic Fatwas. It is imperative to initiate organ donation awareness campaigns that focus on religious authorization to boost organ donation rates and rectify prevalent misconceptions.

Renal allograft procurement from living unrelated donors in Iran: What falls under the eclipse

Renal transplantation is the treatment of choice for end stage kidney disease. However, despite all the efforts to expand the donor pool, the shortage of donors is increasing and as a consequence, there has been a significant increase in the number of patients on transplant waiting lists globally. Societies worldwide have employed different methods to address this, each with specific ethical concerns surrounding them. Over three decades ago, a governmentally regulated program of kidney transplantation from living unrelated donors was introduced in Iran and since practiced which has been the subject of hot debate in the literature. Nevertheless, despite all these extensive discussions and publications, several key aspects of the program have still not been properly elucidated and addressed. In this article, the author aims to illuminate some dark corners related to this issue that have largely escaped the notice of ethicists.

A Survey Study to Examine Willingness to Travel for Transplantation and Consider Commercial Transplantation Among a Multi-Ethnic Cohort of Canadians

Introduction

Travel for transplantation is the movement of organs, donors, recipients, or transplant professionals across jurisdictional borders for transplantation purposes and is considered transplant tourism if transplant commercialism is involved. Little is known about the willingness of patients at risk for transplant tourism to engage in this practice.

Methods

A cross-sectional survey of patients with end-stage renal disease was conducted in Canada to determine interest in travel for transplantation and transplant tourism, characterize patients according to their willingness to consider transplant tourism, and identify factors to deter willingness to consider transplant tourism. Surveys were conducted face-to-face and in multiple languages.

Results

Among the 708 patients surveyed, 418 (59%) reported a willingness to travel outside of Canada for transplantation, with 24% reporting a strong willingness. One hundred sixty-one (23%) reported a willingness to travel and purchase a kidney overseas. On multivariate analysis, male sex, younger age, and Pacific Islander ethnicity were associated with higher odds of willingness to travel for transplant, whereas male sex, annual income greater than $100,000, and Asian and Middle Eastern ethnicity were associated with higher odds of willing to travel to purchase a kidney. Willingness reduced when respondents were informed of medical risks and legal implications related to travel for transplantation. Financial and ethical considerations were less effective at reducing willingness to travel for transplantation.

Conclusion

There was a high level of interest in travel for transplantation and transplant tourism. Legal consequences and education on medical risks of transplant tourism may be effective deterrent strategies.

Trends in organ donation and transplantation over the past eighteen years in Iran

BACKGROUND

This article will review the trends in organ donation over the past 18 years in Iran.

MATERIAL AND METHODS

All donation and transplantation statistics were extracted by reviewing the Organ Procurement and Transplantation database of the Ministry of Health of Iran from 2002 to 2019.

RESULTS

Iran's national deceased donation rate from 2002 to 2019 increased 19.06-fold from .75 to 14.3 per million population (PMP). After the beginning of the COVID-19 pandemic, the rate of organ donation in Iran decreased significantly. Although 1 year after the onset of the pandemic, due to the widespread adoption of COVID19 vaccination, the rate of organ donation began to increase again, this system is still under performing. During the years under examination, the rate of deceased kidney donation increased significantly compared to living kidney donation and reached up to 2001 kidney transplantations in 2021. From 2002 to 2019, the rate of liver transplants increased to 12.8. Likewise, the rate of heart transplants increased 8.4-fold, from 15 to 126 cases during the same time.

CONCLUSSION

Although a personal choice, the process of organ donation involves medical, legal, ethical, organizational, and social aspects. The trend in increasing donation rates over the past years can be attributed to multiple influences, which include rigorous team efforts in the organ donation and transplantation systems, in addition to creating a donation culture and promoting donation through media platforms. Moreover, we can say that the rising rates of deceased donor transplantation also can drive down rates of commercial living donor transplantation.

Payment systems for dialysis and their effects: a scoping review

BACKGROUND

End stage renal disease (ESRD) is a major health concern and a large drain on healthcare resources. A wide range of payment methods are used for management of ESRD. The main aim of this study is to identify current payment methods for dialysis and their effects.

METHOD

In this scoping review Pubmed, Scopus, and Google Scholar were searched from 2000 until 2021 using appropriate search strategies. Retrieved articles were screened according to predefined inclusion criteria. Data about the study characteristics and study results were extracted by a pre-structured data extraction form; and were analyzed by a thematic analysis approach.

RESULTS

Fifty-nine articles were included, the majority of them were published after 2011 (66%); all of them were from high and upper middle-income countries, especially USA (64% of papers). Fee for services, global budget, capitation (bundled) payments, and pay for performance (P4P) were the main reimbursement methods for dialysis centers; and FFS, salary, and capitation were the main methods to reimburse the nephrologists. Countries have usually used a combination of methods depending on their situations; and their methods have been further developed over time specially from the retrospective payment systems (RPS) towards the prospective payment systems (PPS) and pay for performance methods. The main effects of the RPS were undertreatment of unpaid and inexpensive services, and over treatment of payable services. The main effects of the PPS were cost saving, shifting the service cost outside the bundle, change in quality of care, risk of provider, and modality choice.

CONCLUSION

This study provides useful insights about the current payment systems for dialysis and the effects of each payment system; that might be helpful for improving the quality and efficiency of healthcare.

Challenges and Opportunities in the Supply of Living Kidney Donation in the UK National Health Service: An Economic Perspective

End-stage kidney disease is a significant burden on the healthcare systems of many countries, and this is likely to continue because of an increasingly aging and comorbid population. Multiple studies have demonstrated a significant clinical benefit in transplantation when compared with dialysis, however, there continues to be a shortage of donor kidneys available. This article provides an economic perspective on issues pertinent to living kidney donation and transplantation. Although ethics, equity, and cultural considerations often seem at odds with economic concepts around resource allocation, this article explains the situation around supply and demand for living kidneys and illustrates how this has been addressed in the economic literature. The article discusses different policy recommendations for resolving the imbalance between supply and demand in kidney donation, through policies under 3 main approaches: increasing supply, decreasing demand, and improving the allocation of kidney supply.

Ethical and medical dilemmas in paid living kidney donor transplantation

Due to the shortage of deceased and genetically- or emotionally-related living donors, living unrelated paid donor (LURpD) kidney transplantation has been considered; however, this practice may result in medical, ethical and social dilemmas, induce organ trading (commodification), and even criminal activities. Commodification also risks undermining public trust in the transplant system and impeding the development of proper altruistic or deceased donor programs by ignoring altruism, volunteerism, and dignity. However, despite many objections by authoritative organizations, black market practices are involved in up to 10% of all transplants worldwide. The authors strongly discourage any payment or rewards for organ donation, and instead urge the governments of all countries to provide adequate and accessible kidney health care. However, it is an undeniable fact that paid-living donor transplantation is increasing despite all objections, disapprovals and regulations. We feel it as our responsibility not to ignore this uncertain and undesirable practice, but rather to underline the necessity for strict rules and prohibitions to minimize unacceptable medical, social and ethical risks as long as it exists. Furthermore, economic profit, be it direct or indirect, must not be the goal of those involved, and the employment of intermediaries must be avoided entirely. Additionally, the donor should be in a position where not donating has no detrimental effect on his/her future in any way (free agency). In our view, every country has the obligation and responsibility to provide adaequate kidney health care and to make kidney transplantation accessible to those in need. This provision is key to stop transplant tourism and commercialization of kidney transplantation. The nephrology community has a duty to establish structures that optimize organ availability within strict ethical limits. The legal position of LURpD varies considerably worldwide. Strictly respecting each country's legislation and local values is mandatory to minimize medical and ethical risks and controversies.

How a compensated kidney donation program facilitates the sale of human organs in a regulated market: the implications of Islam on organ donation and sale

BACKGROUND

Advocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales.

METHODS

This study reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation.

RESULTS AND DISCUSSION

According to Islamic law, organ donation is an act of sadaqatul jariyah, and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim eethaar, undermining donors of 'selfless' or 'altruistic' motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran's unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran's unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of 'buyer and seller', ensuring the philosophy of 'donor and recipient' is maintained.

CONCLUSIONS

Offering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors' health and reducing human suffering without legalizing the human organ trade.

Kidneys for Sale: Empirical Evidence From Iran

The kidney market in Iran is the only legal market of this sort globally. Yet, it has not been empirically studied based on real data. For the first time, we obtained data on donors and recipients from the Kidney Foundation in Mashhad, April 2011 up to March 2018, and assessed which individualistic characteristics contribute to a kidney’s price. Our findings indicate that each year of education for both donors and recipients increases the kidney price. Moreover, old patients are willing to make a higher payment to young vendors. We have also provided some policy implications to improve the efficiency of kidney allocations.

Polish attitudes towards unspecified kidney donation: a cross-sectional study

BACKGROUND

Chronic kidney disease effects about 4.2 million people in Poland, yet Polish organ donation research is rare. In addition, compared to other countries in the world, Poland has a relatively low living donation rate. Still, little is known about how Poles would react to the possibility of living kidney donation to strangers. A study was conducted to examine public opinion about living kidney donation, as well as their knowledge about it, willingness to donate to a stranger, and support for a possible expansion of existing Polish organ donation legislation to include living donation to strangers.

METHODS

A self-report questionnaire, which included a socio-demographic datasheet (9 questions), 16 questions about attitudes towards living donation, and 1 question about knowledge concerning transplantation law was sent to the respondents from December 2020 - February 2021. Logistic regression was used to assess factors affecting the support of the legalization of unspecified kidney donation amongst the participants.

RESULTS

More than sixty percent (62.1) of respondents supported legalization of unspecified living kidney donation. Such legalization would be accepted by people who accept a choice of a family member to donate a kidney to a stranger (OR = 3.50; Cl 95%: 1.49 to 4.85), who think bone-marrow transplant is safe (OR = 2.65; Cl 95%: 1.80 to 3.91), recognize the benefit of carrying out tests before donating a kidney (OR = 2.56; Cl 95%: 1.79 to 3.69), would agree to receive a kidney from another person (OR = 2.24; Cl 95%: 2.53 to 3.13), or would agree to donate organs after death (OR = 2.06; Cl 95%: 1.45 to 2.95). However, support for unspecified living kidney donation would not be given by respondents fearing the risk of organ trafficking (OR = 0.54; Cl 95%: 0.38 to 0.79).

CONCLUSIONS

In Poland there is strong support for legalization of unspecified living kidney donation. It is vital that future legislation define organ trafficking as a crime with serious punishment so that legal unspecified living kidney donation is not hindered.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov (ID: NCT04789122 ) on 08/03/2021.

Equity or Equality? Which Approach Brings More Satisfaction in a Kidney-Exchange Chain?

In United States (U.S.), government-funded organizations, such as NLDAC, reimburse travel and subsistence expenses incurred during living-organ donation process. However, in Iran, there is a non-governmental organization called Iranian Kidney Foundation (IKF) that funds the direct and indirect costs of donors through charitable donations and contributions from participants in the exchange program. In this article, for countries outside the U.S. that currently use an equality approach, we propose a potential new compensation-apportionment approach (equitable approach) for kidney-exchange chains and compare it with the currently available system (equality approach) in terms of the apportionment of compensation in a kidney-exchange chain to cover the expenses incurred by the initiating living donor of the chain in the act of donation. To this end, we propose a mechanism to apportion compensation among all participating pairs based on the equity approach by utilizing a prediction model to calculate the probability of graft survival in each transplant operation. These probabilities are then used to define the utility of any transplantation, considering the quality of each pair’s donated and received kidney in the chain. Afterward, the corresponding cost is apportioned by a mechanism based on the normalized differences between the utility of donated and received kidneys for each incompatible pair of the chain. In summary, we demonstrate that by utilizing the equitable approach, there is more fairness and equity in the allocation of resources in organ-procurement systems, which results in more satisfaction among incompatible pairs. Additional future prospective studies are needed to assess this proposed equitable approach for kidney-exchange chains in countries outside the U.S., such as Iran, that currently use an equality approach.

Can Living Donor Liver Transplantation in the United States Reach Its Potential?

Living donor liver transplantation (LDLT) is a vital tool to address the growing organ shortage in the United States caused by increasing numbers of patients diagnosed with end-stage liver disease. LDLT still only makes up a very small proportion of all liver transplantations performed each year, but there are many innovations taking place in the field that may increase its acceptance among both transplant programs and patients. These innovations include ways to improve access to LDLT, such as through nondirected donation, paired exchange, transplant chains, transplant of ABO-incompatible donors, and transplants in patients with high Model for End-Stage Liver Disease scores. Surgical innovations, such as laparoscopic donor hepatectomy, robotic hepatectomy, and portal flow modulation, are also increasingly being implemented. Policy changes, including decreasing the financial burden associated with LDLT, may make it a more feasible option for a wider range of patients. Lastly, center-level behavior, such as ensuring surgical expertise and providing culturally competent education, will help toward LDLT expansion. Although it is challenging to know which of these innovations will take hold, we are already seeing LDLT numbers improve within the past 2 years.

Ethical Challenges in Dialysis and Transplantation: Perspectives From the Developing World

Renal replacement therapies including dialysis and transplantation for patients with end-stage kidney failure are treatment options beyond the reach of a large segment of the population, particularly in resource-constrained settings. Health care professionals practicing within developing countries face unique ethical issues in the provision of these treatment options despite the existence of free treatment at different centers. Apart from issues of accessibility of dialysis services, initiation of treatment can have disastrous consequences for the entire family unit, which is magnified in collectivist societies. Several cost-cutting measures also may have to be used that raise moral dilemmas for physicians. Although transplantation is considered the most cost-effective solution in developing countries, leading to significantly better quality of life, issues of consent from biologically related living donors and the use of marginal donors may place physicians in a quandary. Policy making in developing countries must consider the socioeconomic implications of treatment choices that extend far beyond the treatment cost.

What makes a market transaction morally repugnant?

Many people find it morally impermissible to put kidneys, jury duty exemptions, or permits for having children on the free market. All of these are examples of repugnant transactions-market transactions that third parties want to prevent. In two studies (N = 1,554), using respondents' judgments of 51 different market transactions across 21 characteristics, we show that repugnance can be decomposed into five higher-order dimensions: moral outrage, need for regulation, incommensurability, exploitation, and unknown risk. Repugnance toward the 51 market transactions was highly consistent across two samples. Our results can help identify mismatches between public sentiments and current regulations (selling carbon emissions is currently legal but considered repugnant), anticipate responses to novel markets that have not been publicly scrutinized (often arising from technological advances, such as markets for "designer babies"), and help design less repugnant markets (e.g., by making the risks involved in a transaction known to sellers).

An evaluation of the current status of kidney transplant in terms of the type of receipt among Iranian patients

Introduction

With the increasing prevalence and incidence of chronic renal failure leading to advanced kidney disease (ESRD), the use of renal transplant therapy is increasing globally. The aim of this study was to determine the status of kidney transplant in patients during a period of 4–5 years.

Materials and methods

In this retrospective, analytical study, patients undergoing renal transplant at one of the hospitals in northern Iran were studied. The data was collected using a checklist assessing the required information, including the age, sex, place of residence, source of the kidney for transplant (living related, living non-related, deceased), kidney receiving method (donated, purchased), and wait time for a kidney transplant.

Results

A total of 228 patients were included in the study, of which 73.7% were male and 26.3% were female. The average wait time for kidney transplant was 386.22 days. The mean age of patients was 32.7 ± 10.7 years. In addition, living non-related (66.2%) and deceased (14%) were the most and least frequent sources of kidney transplant, respectively. Moreover, 51.8% of all transplanted kidneys were purchased.

Conclusion

Over the past 5 years, there has been a decrease in wait time for kidney transplant in Rasht, Iran. Factors, such as being female, lower age, and living in urban areas, are related to a shorter wait time for kidney transplant. The most common types of kidney transplant are from non-related donors and purchased.

If the Price is Right: The Ethics and Efficiency of Market Solutions to the Organ Shortage

Due to the shortage of organs, it has been proposed that the ban on organ sales is lifted and a market-based procurement system introduced. This paper assesses four prominent proposals for how such a market could be arranged: unregulated current market, regulated current market, payment-for-consent futures market, and the family-reward futures market. These are assessed in terms of how applicable prominent concerns with organ sales are for each model. The concerns evaluated are that organ markets will crowd out altruistic donation, that consent to sell organs is invalid, that sellers will be harmed, and that commodification of organs will affect human relationships in a negative way. The paper concludes that the family-reward futures market fares best in this comparison but also that it provides the weakest incentive to potential buyers. There is an inverse relationship between how applicable prominent critiques are to organ market models and the increase in available organs they can be expected to provide.

The impact of country reimbursement programmes on living kidney donations

INTRODUCTION

Living-donor kidney transplantation is the gold standard treatment for patients with end-stage kidney disease. However, potential donors ubiquitously face financial as well as logistical barriers. To remove these disincentives from living kidney donations, the governments of 23 countries have implemented reimbursement programmes that shift the burdens of non-medical costs from donors to the governments or private entities. However, scientific evidence for the effectiveness of these programmes is scarce. The present study investigates whether these reimbursement programmes designed to ease the financial and logistical barriers succeeded in increasing the number of living kidney donations at the country level. The study examined within-country variations in the timing of such reimbursement programmes.

METHOD

The study applied the difference-in-difference (two-way panel fixed-effect) technique on the Poisson distribution to estimate the effects of these reimbursement programmes on a 17 year long (2000-2016) dataset covering 109 countries where living donor kidney transplants were performed.

RESULTS

The results indicated that reimbursement programmes have a statistically significant positive effect. Overall, the model predicted that reimbursement programmes increased country-level donation numbers by a factor of 1.12-1.16.

CONCLUSION

Reimbursement programmes may be an effective approach to alleviate the kidney shortage worldwide. Further analysis is warranted on the type of reimbursement programmes and the ethical dimension of each type of such programmes.

Exploring the motives of Israeli Jews who were living kidney donors to strangers

Non-directed living donors are individuals who donate a kidney to a recipient with whom they have neither a genetic nor emotional relationship. Israel legalized this type of donation in 2008. After this law was implemented, living donations significantly expanded. The aim of this article was to determine the motivations, characteristics, and perioperative experiences of non-directed living donors in Israel. Three online questionnaires (own questionnaire, Rosenberg Self-Esteem Scale (RSES), Rushton Self-Report Altruism Scale) were distributed to 180 Jewish kidney donors with the help of Matnat Chaim organization. One hundred and fifteen responses were received (69.3% response rate). The motivation for most donors (60%) was a strong willingness to help and a desire to do good. The majority of donors (78.3%) reported their health status as unchanged after donation; however, 16.5% experienced clinical problems (eg, wound infection, more pain than expected), and 5.2% experienced psychological complications. About 18% reported their health to improve after donation. Most (80%) inspired someone else to also become a kidney donor. This study breaks the myth that Jews do not support organ donation. In fact, their high level of altruism and their positive experience with donation has propelled the practice of non-directed donation in Israel.

Organ Procurement in Poland: Legal and Medical Aspects

Transplantology is one of the fastest growing specialties of medicine. However, data on actual students' knowledge in this field is lacking.

AIM

Assessing the education of medical students; level of current basic knowledge in the field of medicine, law, and statistics on transplantology in Poland.

METHODS

Survey (with 48 questions) conducted among 165 medical students (1st-6th year). The average age was 22 years; 62.0% women.

RESULTS

Only 29.7% of the respondents are blood donors, 36.4% are registered as a potential bone marrow donor, and 11.8% have the donor card. None of these factors had a clear impact on transplantology knowledge. The respondents obtained a result of 54.9% correct answers (medicine, 58.2%; law, 55.8%; statistic, 39.9%). An increase in the level of knowledge in subsequent years of education can be seen. Students in the first year marked 49.4% correct answers compared to people in the sixth year who marked 62.9% correct. Students base their knowledge about transplantation mainly on messages obtained in class (89.1%). The survey showed that 18.8% of respondents consider the family's consent for organ procurement from their deceased member as legally valid; 27.9% do not treat brain death as synonymous with death; and 9.1% believed that organ trafficking is allowed. Nobody is registered in the Central Register of Objections.

CONCLUSIONS

Despite the increase in the level of knowledge about transplantation during the study, it does not reach a satisfactory level. The number of sources of knowledge does not correlate with the quality of acquired knowledge.

Deceased donor organ transplantation potential: A peep into an untapped gold mine

Organ transplantation is the gold standard for treating end-stage organ diseases, many of whom are on waiting lists. The reasons for this include the nonavailability of suitable organs to be transplanted. In many nations, most of these challenges have been surmounted by the adoption of deceased donor program, which is not so in sub-Saharan countries such as Nigeria. This study is to audit the potentially transplantable organs available from potential deceased donors from a Nigerian tertiary hospital. This is a study of deaths in the intensive care unit (ICU) and the accident and emergency units of the University of Ilorin Teaching Hospital, Nigeria. Data included the biodata, social history, diagnosis or indications for admission, time of arrival and death, causes of death, associated comorbidities, potential organs available, social history, and availability of relations at the time of death. There were 104 deaths in the ICU and 10 patients in the accident and emergency unit. There were 66 males (57.9%) and 48 females (42.1%). Eighty patients were Muslims (70.2%) and 34 were Christians (19.8%). A total of 33 participants were unmarried (28.9%),whereas 81 (71.1%) were married. The tribes of the patients were Yoruba (105, 92.1%), Igbo (7, 6.1%), Hausa (1, 0.9%), and Nupe (1, 0.9%). The age range was 0.08-85 years. Twenty-two (19.3%) had primary and the remaining had at least secondary education. The causes of death were myriad, and there were relatives available at the times of all deaths. The Maastricht classification of the deaths were Class I - 1 (0.9%), Class II - 37 (32.2%), Class III - 9 (7.8%), Class IV - 20 (17.4%), and Class V - 47(40.9%). There were no transplantable organs in 42 (36.5%), one organ in eight (7%), two organs in two (7%), three organs in one (0.9%), four organs in 13 (11.3%), five organs in six (5.2%), six organs in 11 (9.6%), seven organs in 11 (9.6%), eight organs in five (13%), and nine organs in five (4.3%). Deceased donor sources of organs are worthy of being exploited to improve organ transplantation in Nigeria.

Relationship between spiritual health and hope by dietary adherence in haemodialysis patients in 2018

Aim

The present study aimed to determine the relationship between spiritual well-being and hope through adherence to diet in haemodialysis patients referred to the dialysis centre.

Design

This research was a cross-sectional study of a descriptive-analytical type conducted on 120 patients undergoing haemodialysis in a haemodialysis centre of a hospital affiliated to Dezful University of Medical Sciences using the census method.

Method

The data were collected using a questionnaire and through the laboratory information included in the patient's records. The data collection tools were a demographic information questionnaire, the Ellison and Paloutzian spiritual well-being scale (SWBS), the Hope-Herth questionnaire and the objective laboratory criteria (phosphorus, potassium). This included the weight difference between the two dialysis sessions from the record to examine the adherence to the diet.

Results

The results indicate there to be a significant relationship between hope and spiritual well-being with the objective criteria of the adherence to the diet in dialysis patients (p = .001).

Cadaveric Organ Donation in Lebanon: Proposed Suggestions for Improvement

Organ transplantation is the treatment of choice for most end-stage diseases, despite the continuous advancements in the medical and surgical field. The dilemma of the shortage between supply and demand of organs for transplantation has been an ongoing debate and concern. The well-known "Spanish Model" was established in 1989 and adopted by the National Transplant Organization. The main commitment of the National Transplant Organization is to increase organ donation and transplantation rates. The program was also successfully adopted in countries such as Australia and Great Britain as well as Latin-American countries. The system is based on recruitment of cadaveric organs by a specialized team in hospitals at the regional and national level. Lebanon hopes to initialize a model similar to the Spanish Model but faces several obstacles. Adopting such a model could help increase cadaveric organ donation in Lebanon.

Radical actions to address UK organ shortage, enacting Iran’s paid donation programme: A discussion paper

Globally there is a shortage of organs available for transplant resulting in thousands of lives lost as a result. Recently in the United Kingdom 457 people died as a result of organ shortage in just 1 year. 1 NHS Blood and Transplant suggest national debates to test public attitudes to radical actions to increase organ donation should be considered in addressing organ shortage. The selling of organs for transplant in the United Kingdom is prohibited under the Human Tissue Act 2004. This discussion paper considers five ethical objections raised in the United Kingdom to paid donation and discusses how these objections are addressed within the only legal and regulated paid living unrelated renal donation programme in the world in Iran, where its kidney transplant list was eliminated within 2 years of its commencement. This article discusses whether paid living unrelated donation in Iran increases riskier donations and reduced altruistic donation as opponents of paid donation claim. The paper debates whether objections to paid donation based upon commodification arguments only oppose enabling financial ends, even if these ends enable beneficent acts. Discussions in relation to whether valid consent can be given by the donor will take place and will also debate the objection that donors will be coerced and exploited by a paid model. This article suggests that exploitation of the paid donor within the Iranian model exists within the legally permitted framework. However, paid living kidney donation should be discussed further and other models of paid donation considered in the United Kingdom as a radical means of increasing donation.

Psychosocial Needs of the Families With Hospitalized Organ Transplant Patients in an Educational Hospital in Iran

Nurses are required to understand and meet the physiological needs of the family members of the patients hospitalized in transplant wards of the hospitals. Considering the importance of this issue, this study aimed to investigate the psychosocial needs of the families with an organ transplant patient. The study employed a cross-sectional design and was conducted in Afzalipour Educational Hospital affiliated to the Kerman University of Medical Sciences in 2018. The 45-item questionnaire of the psychosocial needs was applied to assess the psychosocial needs of the families with an organ transplant patient, including kidney, liver, and bone marrow. The quota sampling method was used and 230 participants completed the survey. Data were analyzed using descriptive mean and SD and analytical statistics independent t-test, anova, and Pearson's correlation coefficient tests by SPSS 22 (version 22, SPSS, Chicago Inc., IL). The results indicated that the mean scores of psychological needs of families with transplanted patients hospitalized in three wards of bone marrow, kidney, and liver were at a high level (143/16 ± 12/29). The mean scores of psychosocial needs in the bone marrow transplantation ward (148/60 ± 8/18) were significantly higher than those of the patients hospitalized in the liver (141/24 ± 16/41) and kidney (141/25 ± 11/30) wards. A significant difference was observed among the three wards of the liver, kidney, and bone marrow transplantation with regard to the provided support, information, and proximity. To improve the psychological needs of the family members with patients hospitalized in transplant wards and reduce their mental reactions, they should be provided with more precise information about the patient's treatment procedure.

The present and future of transplant organ shortage: some potential remedies

Transplantation remains the modality of choice for patients with end stage renal disease (ESRD). However, while there has been a steady rise in the number of patients with ESRD the supply of donors (combine living and deceased) has fallen far behind the need, resulting in an increasing number of qualified patients remaining on the wait-list, and thousands being removed from the list every year because of death or becoming too sick for transplantation. This has also fed to transplant tourism around the world. Several countries have implemented a variety of policies to overcome their organ shortage that are presented in this article. There is an urgent need for developing policies geared to the cultural norms of different societies and universally accepted ethical principles to remedy this public health issue.

Sometimes Merely as a Means: Why Kantian Philosophy Requires the Legalization of Kidney Sales

Several commentators have tried to ground legal prohibitions of kidney sales in some form of Kant's moral arguments against such sales. This paper reconsiders this approach to justifying laws and policies in light of Kant's approach to law in his political philosophy. The author argues that Kant's political philosophy requires that kidney sales be legally permitted, although contracts for such sales must remain unenforceable. The author further argues that Kant's approach to laws, such as those governing kidney distribution, was formed in part by considering and rejecting an assumption frequently employed in the bioethics literature, namely, that legal duties can be grounded directly in moral duties. The author explains some of Kant's reasons for rejecting this assumption and concludes that arguments pertaining to the legality of kidney sales developed on the basis of Kant's moral philosophy should no longer be considered tenable.

A review of the possibility of adopting financially driven live donor kidney transplantation

Kidney transplantation for end-stage renal disease remains the preferred solution due to its survival advantage, enhanced quality of life and cost-effectiveness. The main obstacle worldwide with this modality of treatment is the scarcity of organs. The demand has always exceeded the supply resulting in different types of donations. Kidney donation includes pure living related donors, deceased donors, living unrelated donors (altruistic), paired kidney donation and more recently compensated kidney donation. Ethical considerations in live donor kidney transplantation have always created a debate especially when rewarding unrelated donors. In this paper, we examine the problems of financially driven kidney transplantation, the ethical legitimacy of this practice, and propose some innovative methods and policies that could be adopted to ensure a better practice with accepted ethical guidelines.

Living Unrelated Kidney Transplantation: Does It Prevent Deceased-Donor Kidney Transplantation Growth?

OBJECTIVES

It is usually assumed that an active livingdonor transplant program inhibits the growth of a deceased-donor kidney transplant program. In our 33-year experience, we found the contrary to be true.

MATERIALS AND METHODS

From 1984 until 2017, we performed a total of 4966 kidney transplant procedures. All cases were registered through the Collaborating Transplant Study (Heidelberg, Germany).

RESULTS

During the first 16 years, only living-donor kidney transplant procedures were done. Our first unrelated living-donor kidney transplant procedure was in 1986 and involved a wife to husband donation. This breakthrough in our country was the first in our unrelated living-donor kidney transplant program. In 2000, the Iranian Parliament passed the deceased-donor transplant act, and we have started deceased-donor kidney transplants since then. Despite a jam-packed living-donor kidney transplant program, our deceased-donor kidney transplant program has grown steadily since then and now comprises more than 50% of our kidney transplant procedures. When we compared the outcome of these programs, the 5-year survival from Collaborating Transplant Study report of 3527 cases of 114 living-related donor procedures was 90%. The 5-year survival rates for living unrelated-donor (n = 2689) and deceased-donor (n = 724) transplant procedures were 88% and 83%, respectively (P = .001).

CONCLUSIONS

Our data showed that deceased-donor kidney transplant procedures have steadily increased despite an active unrelated living-donor kidney transplant program. Wait lists for kidney transplant can be significantly reduced by following our model, both in developed and in developing countries.

Ethically Acceptable Compensation for Living Donations of Organs, Tissues, and Cells: An Unexploited Potential?

The number of living donations of human organs, tissues, and cells falls far short of the need. Market-like arrangements to increase donation rates have been proposed, but they are broadly considered unacceptable due to ethical concerns and are therefore not policy relevant in most countries. The purpose of this paper is to explore a different approach to increasing living donations, namely through the use of ethically acceptable compensation of donors. We review the compensation practices in Europe and find a lack of reimbursement of incurred costs and lack of compensation for non-monetary losses, which create disincentives for donation. We draw on a well-known philosophical theory to explain why donors are rarely fully compensated and why many existing proposals to raise donation rates are seen as controversial or even unethical. We present and discuss three categories of compensation with the potential to increase donation rates in an ethically acceptable way.

An ethical appraisal of living-anonymous kidney donation using Adam Smith's Theory of Moral Sentiments

Ethical debates continue to shape organ transplant policies, particularly for kidneys. Facing organ shortages, governments have created incentives targeting prospective living-anonymous donors - socially and biologically unrelated to the recipient. However, these policies may transform altruistic exchanges of tissues into trades of commodities. We use Adam Smith's concept of sympathy to outline a new approach to transplantation ethics. This is accomplished using a case study analysis of six countries with established living-anonymous kidney donation practices - Iran, Israel, the Netherlands, Saudi Arabia, the United Kingdom, and the United States. An ethical test was also developed from ethnographies of donors and Smith's Theory of Moral Sentiments. The case study analysis considered the role of religious and historic norms, media campaigns, adherence to the 2008 Declaration of Istanbul guidelines for each case, and how each factor related to Smith's sympathy, categorizing the countries into four tiers of altruism. Iran occupied the least altruistic tier, followed by the Netherlands, the UK and the US, and Saudi Arabia and Israel. The ethical test identified a similar ranking. Our findings suggest that a highly-selected cohort of states with established living-anonymous kidney donation programs may already utilize a Smithian approach for recruiting donors, and that socially-valued government incentives can preserve altruism. The ethical test could become a useful instrument to assess the altruism of emerging incentive policies.

Coercion, dissatisfaction, and social stigma: an ethnographic study of compensated living kidney donation in Iran

This article updates the qualitative research on Iran reported in the 2012 article by Tong et al. "The experiences of commercial kidney donors: thematic synthesis of qualitative research" (Tong et al. in Transpl Int 25:1138-1149, 2012). The basic approach used in the Tong et al. article is applied to a more recent and more comprehensive study of Iranian living organ donors, providing a clearer picture of what compensated organ donation is like in Iran since the national government began regulating compensated donation. Iran is the only country in the world where kidney selling is legal, regulated, and subsidized by the national government. This article focuses on three themes: (1) coercion and other pressures to donate, (2) donor satisfaction with their donation experience, and (3) whether donors fear social stigma. We found no evidence of coercion, but 68% of the paid living organ donors interviewed felt pressure to donate due to extreme poverty or other family pressures. Even though 27% of the living kidney donors interviewed said they were satisfied with their donation experience, 74% had complaints about the donation process or its results, including some of the donors who said they were satisfied. In addition, 84% of donors indicated they feared experiencing social stigma because of their kidney donation.

Altruism and Religion: A New Paradigm for Organ Donation

Activity of NGO's supporting living donor kidney donations can affect the shortage of kidneys. Matnat Chaim is a Jewish orthodox organization active in Israel since 2009. This is a voluntary organization with aims to shorten and eliminate the waiting list for kidneys. Since the beginning of its activity, it has said to play a key role in 379 kidney transplantations. In 2015, out of 174 live donor kidney transplantations that took place in Israel, Matnat Chaim had a key role in 88 of them (50.6%). We found some ethical issues concerning the organization's activity. The donor can restrict his or her donation to specific characteristics of recipient which can result in organs transplanted in a homogeneous group of the population. Another issue is the question of whether nudging people to kidney donation takes place and whether it is valid to do so. We found that Matnat Chaim does a great deal for promotion and intermediation of kidney donations in Israel. This form of promotion can be implemented by other organizations and countries.

Transplant tourism among kidney transplant patients in Eastern Nigeria

Background

Transplant tourism entails movement of recipient, donor or both to a transplant centre outside their country of residence. This has been reported in many countries; and has variously been associated with organ trade.

The objective of this study is to determine the frequency and pattern of transplant tourism among transplant patients in Eastern Nigeria.

Methods

This is a non randomized cross sectional study. All kidney transplant patients who presented at Enugu State University Teaching Hospital Parklane Enugu and Hilton Clinics Port Harcourt in Nigeria were recruited. The clinical parameters including the transplant details of all the patients were documented. The data obtained was analysed using SPSS package.

Results

A total of one hundred and twenty six patients were studied, 76.2% were males with M:F ratio of 3.2:1 and mean age of 46.9 ± 13.3 years. Fifty four and 58.7% of the patients were managed in a tertiary hospital and by a nephrologist respectively before referral for kidney transplant. Only 15.8% of the patients had their kidney transplant without delay: finance, lack of donor, logistics including delay in obtaining travelling documents were the common causes of the delay.

Ninety percent of the patients had their transplant in India with majority of them using commercial donors. India was also the country with cheapest cost ($18,000.00). 69.8% were unrelated donors, 68.2% were commercial donors and 1.6% of the donors were spouse. All the commercial donors received financial incentives and each commercial donor received mean of 7580 ± 1280 dollars. Also 30.2% of the related donors demanded financial incentive.

Conclusion

Transplant tourism is prevalent in eastern Nigeria.

Living related and living unrelated kidney transplantations: A systematic review and meta-analysis

AIM

To compare the outcomes between related and unrelated kidney transplantations.

METHODS

Literature searches were performed following the Cochrane guidelines. We conducted a systematic review and a meta-analysis, which included 12 trials that investigated outcomes including the long-term (ten years), mid-term (one to five years), and short-term (one year) graft survival rate as well as the acute rejection rate. Meta-analyses were performed using fixed and random-effects models, which included tests for publication bias and heterogeneity.

RESULTS

No difference in graft survival rate was detected in patients who underwent living related kidney transplantations compared to unrelated (P = 0.44) transplantations after ten years. There were no significant differences between the graft survival rate in living related and unrelated kidney transplantations after a short- and mid-term follow-up (P = 0.35, P = 0.46). There were no significant differences between the acute rejection rate in living related and unrelated kidney transplantations (P = 0.06).

CONCLUSION

The long, mid and short term follow-up of living related and unrelated kidney transplantation showed no significant difference in graft survival rate. Also, acute rejection rate was not significantly different between groups.

Policy options for increasing the supply of transplantable kidneys in Singapore

Kidney transplantation is the preferred treatment for eligible end-stage renal disease patients. However, the supply of donated kidneys has been consistently insufficient to meet the transplantation requirements of the population. In this paper, I discuss the feasibility of several policy options that engage potential donors or key individuals in a Singapore context, including financial and non-financial incentives for deceased/living organ donors and their families, improving actualisation rates of both donation after brain death, donation after cardiac death through quality improvement programmes and remuneration schemes, and a media platform for directed organ donation. I conclude by highlighting the most feasible policies to be considered.