Running Head: Can Cadaveric Transplant Alone Eradicate the Kidney WL?

Can Deceased Donor Transplantation Alone Eradicate the Kidney Waiting List?

Mohsen Khakzad Kelarijani1,2*

1 Shahid Labbafinejad Medical Center, The Center of Excellence in Urology and Kidney

Transplantation, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Deputy for Public Health, Mazandaran University of Medical Sciences, Sari, Iran

Corresponding Author:

Mohsen Khakzad Kelarijani, M.D.

Department of Kidney Transplantation and Urology, Shahid Labbafinejad Hospital, 9th

Boostan Street, Pasdaran Ave, Tehran, Iran.

Tel: +98 21 22588016

E-mail: mohsenkh1010@yahoo.com

ORCID ID: https://orcid.org/0009-0009-0439-1700

Keywords: rewarded gifting; paid donation; living donation; unrelated paid transplantation;

kidney donation; renal transplantation; living donor; living unrelated donor.

The prevalence of end-stage kidney disease (ESKD) could greatly increase in the upcoming

decades, caused by population aging and rising diabetes and hypertension cases. An estimation

of 3.9 million individuals globally undergoing renal replacement therapy for ESKD in 2017 is

expected to climb to 5.4 million by 2030. Chronic kidney disease was the 13th most common

cause of death all around the world in 2016, and it is predicted to be the 5th leading cause of

years of life lost by 2040(1).

Kidney transplantation is the gold standard treatment for ESKD patients. However, the shortage

of transplant kidneys is a global crisis. It is well understood that post-transplant outcomes of

living donor kidney transplants are better than those of deceased donor transplants. Living donor

kidney transplants from unrelated donors resulted in longer graft survival compared to related

donors, according to a large cohort study on more than 70,000 kidney transplants in the US(2).

Nevertheless, some authors believe that living unrelated donor kidney transplantation should be

stopped(3); the experience of Shiraz Transplant Center (STC) with the exclusively deceased organ

donation program may apply to the city or province, but it cannot be extended to larger regions

like Iran or the Middle East. Some patients on the waiting list of the STC, especially those

requiring second or third re-transplantation, have gone to other centers in the country to have a

living unrelated kidney transplant, as they could not wait any longer for a deceased donor in

Shiraz.

Even in developed countries with the most successful deceased organ procurement and

transplantation networks, the entire demand for kidney transplants cannot be met (Figure 1),

resulting in many deaths for patients on long waiting lists. For example, in the United States,

over 90,000 patients are currently wait-listed for a kidney transplant with an average waiting

time of five years. Tragically, 4-5 thousand of these patients lose their lives each year before

receiving the kidney they need. Spain, which has approximately 90% of kidney transplants

coming from deceased donors, had the most deceased-donor kidney transplants per population in

the world from 2017 to 2019 and was ranked second after the United States in 2020 and 2021,

but the waiting list did not decrease significantly. At the end of 2017 and 2021, the number of

people awaiting a kidney transplant in Spain was 3942 and 3945, respectively(4).

In Iran and the Middle East, even if the number of kidney transplants from deceased donors

reaches the highest possible level, it will still not be enough to meet the needs of those on the

waiting list. Health systems officials should therefore consider supporting all types of kidney

transplants, including living related and unrelated donors, as they are directly responsible for the

lives and well-being of patients. More than twenty countries have implemented some types of

reimbursement programs to remove disincentives for living kidney donors(5). Anyone who

donates a kidney, even if they receive a financial reward, should be celebrated as a hero since

they are saving a human life.

The Iranian model of government regulated paid living-unrelated kidney donation (rewarded

gifting) started in the 1980s has proven its usefulness and success in shortening the waitlist(6) and

now requires more support from the government and the public. In this direction, in November

2022, the Iranian government substantially increased the financial compensation by forty times.

With this cost-effective approach, compared to dialysis, more lives can be saved, patients can

experience a higher quality of life, and the burden on taxpayers can be reduced(7).

Rewarded or paid living kidney donation has been endorsed by Islamic religious-ethical leaders.

Nonetheless, some opponents find this practice unethical. They do not feel accountable for the

lives of dialysis patients, and they strive to propagate their critical views in society, but this will

only lead to more deaths. Deceased and living kidney donations must be used together, like two

wings of a bird (Upgraded Iranian Model of Kidney Transplantation), and weakening either will

cause irreparable damage. Once the waiting list is eliminated, living-donor kidney

transplantation can be reconsidered. Until that time, which does not appear to be soon, the

transplant community should unite in the pursuit of saving human lives.

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https://www.transplant-observatory.org/
https://www.transplant-observatory.org/

Figure 1. Despite the growth in kidney transplants, the gap between demand and supply has

expanded.