The Alternative Iranian model of living renal transplantation
Authors: Francis L. Delmonico
Journal: Kidney International (2012)

The experience of the Iranian model should be carefully considered by those who suggest a pilot trial of a regulated market in organ sales. Mahdavi-Mazdeh's candid report makes clear that a fixed price as the basis of regulation is not possible. Iran is proceeding with an independent program of deceased organ donation in cities such as Shiraz. Mahdavi-Mazdeh's report is encouraging for the prospect of a revitalized expansion of deceased donation. The experience of the Iranian model should be carefully considered by those who suggest a pilot trial of a regulated market in organ sales. Mahdavi-Mazdeh's candid report makes clear that a fixed price as the basis of regulation is not possible. Iran is proceeding with an independent program of deceased organ donation in cities such as Shiraz. Mahdavi-Mazdeh's report is encouraging for the prospect of a revitalized expansion of deceased donation. Mitra Mahdavi-Mazdeh is a highly regarded physician internationally who represents the best of Iranian medicine. In this issue of Kidney International,1.Mahdavi-Mazdeh M. The Iranian model of living renal transplantation.Kidney Int. 2012; 82: 627-634Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Dr Mahdavi-Mazdeh presents a candid and comprehensive review of the Iranian model of living renal transplantation. The Iranian living-donor program has spanned two decades, with more than 20,000 vendors participating.1.Mahdavi-Mazdeh M. The Iranian model of living renal transplantation.Kidney Int. 2012; 82: 627-634Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Dr Mahdavi-Mazdeh's conclusions are poignant and sobering. The process of identifying an Iranian vendor for a potential kidney transplant recipient ultimately occasions a tense financial bargaining between the donor and the recipient that escapes regulatory control. The vendor wants to be paid more; the recipient wants to pay less. The vendors want more because they are poor; the recipients want to pay less because they may not have the money. The experience of the Iranian model should be carefully considered by those who suggest a pilot trial of a regulated market in organ sales. This candid report makes clear that a fixed price as the basis of regulation is not possible. The vendor demands more money than is allotted by the government's fixed price, in what Mahdavi-Mazdeh describes as a ‘confrontation.’ And although the final interaction may be perceived as broker free, the introduction of the recipient to the unrelated donor is not, with shopping at the 137 kidney-foundation outlets throughout the country. Mahdavi-Mazdeh, like other Iranian colleagues, rationalizes these realities by asserting that the model ‘has enabled most of the Iranian kidney transplant candidates, irrespective of socioeconomic class, to have access to kidney transplantation.’ But the program is not just about recipients. The experience of Iran and the rest of the world has clearly shown that vendors are poor, hapless, jobless, indebted, and largely destitute. It is this social condition that compels the vendor to sell a kidney. The male–female ratio of 1.6 among Iranian vendors is in keeping with the published vendor demographics. It is exploitation of the poor that has enabled most Iranian kidney transplantations over the past two decades. Whether a vendor resides in Iran or is Pakistani or a Sudanese refugee or a Filipino, the fundamental unethical aspect is the same—it is a victimization of the poor. Mahdavi-Mazdeh acknowledges that the Iranian model has, regrettably, provided little information about such a large nephrectomized patient population. She has carefully reviewed the literature to cite studies showing a less than 1% risk of kidney donors’ developing end-stage renal disease, but none of these references is from an Iranian experience. Not cited is the reported health status of vendors from neighboring Pakistan. Many of these Pakistani vendors were bonded laborers, some jaundiced, some with inadequate kidney function, and some with stone disease or a history of urinary tract symptoms. Naqvi et al. concluded that vendors had insufficient renal function and thus were at risk themselves for end-stage renal failure in the long term.2.Naqvi S.A. Rizvi S.A. Zafar M.N. et al.Health status and renal function evaluation of kidney vendors: a report from Pakistan.Am J Transplant. 2008; 8: 1444-1450Crossref PubMed Scopus (49) Google Scholar Importantly, Iran is proceeding with an independent program of deceased organ donation, and in certain parts of the country, such as Shiraz, the program is exemplary in fostering that approach. It is also commendable and encouraging that the Iranian government is now diverting funds from the unrelated-donation program to deceased donation after brain death. The World Health Organization is now calling upon all governments to address the donation and transplantation needs of their people.3.Nejatisafa A.A. Mortaz-Hedjri S. Malakoutian T. et al.Quality of life and life events of living unrelated kidney donors in Iran: a multicenter study.Transplantation. 2008; 86: 937-940Crossref PubMed Scopus (36) Google Scholar Another assessment of the Iranian model (characteristic again of Iranian physicians) has been published by Fazel and colleagues4.Delmonico F.L. Domínguez-Gil B. Matesanz R. et al.A call for government accountability to achieve national self-sufficiency in organ donation and transplantation.Lancet. 2011; 378: 1414-1418Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar suggesting that the Iranian vendor has a low quality of life and is vulnerable to stressful events. Fazel and colleagues have also concluded that aspects of the Iranian living unrelated renal donation program should be reappraised for needed changes before it is presented as a successful model to the rest of the world.3.Nejatisafa A.A. Mortaz-Hedjri S. Malakoutian T. et al.Quality of life and life events of living unrelated kidney donors in Iran: a multicenter study.Transplantation. 2008; 86: 937-940Crossref PubMed Scopus (36) Google Scholar Mahdavi-Mazdeh's report1.Mahdavi-Mazdeh M. The Iranian model of living renal transplantation.Kidney Int. 2012; 82: 627-634Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar is encouraging for the prospect of an alternative focus—a revitalized expansion of deceased donation.