Organ Donation in Syria.

The first living donor kidney transplant in Syria was performed 44 years ago; by the end of 2022, 6265 renal transplants had been performed in Syria. Kidney, bone marrow, cornea, and stem cells are the only organs or tissues that can be transplanted in Syria. Although 3 heart transplants from deceased donors were performed in the late 1980s, cardiac transplant activities have since discontinued. In 2003, national Syrian legislation was enacted authorizing the use of organs from living unrelated and deceased donors. This important law was preceded by another big stride: the acceptance by the higher Islamic religious authorities in Syria in 2001 of the principle of procurement of organs from deceased donors, provided that consent is given by a first- or second-degree relative. After the law was enacted, kidney transplant rates increased from 7 per million population in 2002 to 17 per million population in 2007. Kidney transplants performed abroad for Syrian patients declined from 25% in 2002 to <2% in 2007. Rates plateaued through 2010, before the political crisis started in 2011. Forty-four years after the first successful kidney transplant in Syria, patients needing an organ transplant rely on living donors only. Moreover, 20 years after the law authorizing use of organs from deceased donors, a program is still not in place in Syria. The war, limited resources, and lack of public awareness about the importance of organ donation and transplant appear to be factors inhibiting initiation of a deceased donor program in Syria. A concerted and ongoing education campaign is needed to increase awareness of organ donation, change negative public attitudes, and gain societal acceptance. Every effort must be made to initiate a deceased donor program to lessen the burden on living donors and to enable national self-sufficiency in organs for transplant.

Monitoramento de tecnologias incorporadas no SUS: Monitoramento do transplante renal no Brasil: 2000 a 2015 / Monitoring of technologies incorporated into the SUS: Incorporation monitoring of kidney transplantation in Brazil: 2000 to 2015 / Monitoreo de tecnologías incorporadas al SUS: Monitoreo de la incorporación del trasplante de riñón en Brasil: 2000 a 2015

TECNOLOGIA: Neste documento discute-se o transplante renal (TxR) e as terapias imunossupressoras utilizadas na manutenção do enxerto. INDICAÇÃO: O TxR está indicado para pacientes com insuficiência renal crônica terminal (IRCT), doença caracterizada pela perda gradual da função renal. Algumas doenças estão associadas ao surgimento da IRCT, em especial a diabetes mellitus e hipertensão. CARACTERIZAÇÃO DA TECNOLOGIA: O transplante renal é uma terapia substitutiva para pacientes que apresentam perda elevada da função renal. É um dos tratamentos de escolha por ser mais custo-efetivo e oferecer melhor qualidade de vida aos pacientes. OBJETIVO: Analisar as características individuais, a sobrevida do enxerto e seus fatores associados em pacientes submetidos ao TxR atendidos pelo SUS. Além disso, avaliar a utilização da primeira linha dos esquemas de manutenção imunossupressora no Brasil, dispensados pelo Componente Especializado da Assistência Farmacêutica (CEAF). MÉTODOS: Foi construída uma coorte retrospectiva com todos os pacientes submetidos ao TxR no período entre 01/01/2000 e 31/12/2014 por meio do SUS. Os indivíduos foram acompanhados por pelo menos um ano, até 31/12/2015. Considerou-se como perda de enxerto o retorno às diálises, casos de óbito e retransplantes. RESUMO DOS RESULTADOS: Foram incluídos 47.876 indivíduos, dos quais a maioria (60,1%) era do sexo masculino. A sobrevida do enxerto após 16 anos de acompanhamento da coorte foi de 42%. Transplantes realizados em indivíduos de etnia amarela e com órgãos provenientes de doadores vivos apresentaram maior probabilidade de sobrevida. Em contrapartida, transplantes realizados em indivíduos idosos (maiores de 65 anos) apresentaram piores resultados. CONCLUSÃO: Os resultados aqui apresentados são de grande relevância para que se discuta a imunossupressão na manutenção dos enxertos do transplante renal e possibilitam uma visão do panorama atual dos procedimentos realizados no SUS

TECHNOLOGY: Kidney transplantation (TxR) and immunosuppression therapy used in posttransplant period. USE: TxR is indicated for patients with end-stage renal disease (IRCT), a disease characterized by gradual loss of renal function. Among the diseases associated with the onset of IRCT, it is worth mentioning hypertension and diabetes mellitus. CHARACTERISTICS OF TECHNOLOGY: TxR is a substitutive therapy for patients who experience high loss of renal function. It is one of the treatments of choice due to its cost-effectiveness and better outcomes in quality of life. OBJECTIVE: To assess the characteristics and survival of the individuals undergoing TxR treated by SUS, as well as data on effectiveness and use of drugs provided by the Componente Especializado da Assistência Farmacêutica (CEAF). METHODS: A retrospective cohort was performed with all patients who underwent a TxR in the period between 01/01/2000 and 31/12/2014 through SUS. The individuals were followed up for at least one year, until 31/12/2015. All cases of death and retransplantation were considered as graft loss. SUMMARY OF THE RESULTS: A total of 47,876 individuals were included, of whom the majority (60.1%) were male. The graft survival probability after 15 years of follow-up was 42%. Transplants performed in individuals of yellow ethnicity and with organs from living donors were more likely to survive. In contrast, transplants performed in elderly individuals (older than 65 years) showed worse results. CONCLUSION: The results presented here are of great relevance for discussing immunosuppression in the maintenance of kidney transplant grafts and provide an overview of the current panorama of procedures performed at SUS.

TECNOLOGÍA: trasplante de riñón y terapia de inmunosupresión utilizada en pós-trasplante. Uso: TxR está indicado para pacientes con enfermedad renal en etapa terminal (IRCT), una enfermedad caracterizada por la pérdida gradual de la función renal. Entre las enfermedades asociadas con la aparición de IRCT, cabe mencionar la hipertensión y la diabetes mellitus. CARACTERÍSTICAS DE LA TECNOLOGÍA: TxR es una terapia sustitutiva para pacientes que experimentan una alta pérdida de la función renal. Es uno de los tratamientos de elección debido a su rentabilidad y mejores resultados en calidad de vida. OBJETIVO: Evaluar las características y la supervivencia de los individuos sometidos a TxR tratados por SUS, así como los datos sobre la efectividad y el uso de medicamentos proporcionados por el Componente Especializado da Assistência Farmacêutica (CEAF). MÉTODOS: se realizó una cohorte retrospectiva con todos los pacientes que se sometieron a una TxR en el período comprendido entre el 01/01/2000 y el 31/12/2014 a través del SUS. Los individuos fueron seguidos durante al menos un año, hasta el 31/12/2015. Todos los casos de muerte y trasplante se consideraron como pérdida del injerto. RESUMEN DE LOS RESULTADOS: se incluyeron un total de 47.876 individuos, de los cuales la mayoría (60,1%) eran hombres. La probabilidad de supervivencia del injerto después de 15 años de seguimiento fue del 42%. Los trasplantes realizados en individuos de etnia amarilla y con órganos de donantes vivos tenían más probabilidades de sobrevivir. En contraste, los trasplantes realizados en personas de edad avanzada (mayores de 65 años) mostraron peores resultados. CONCLUSIÓN: Los resultados presentados aquí son de gran relevancia para analizar la inmunosupresión en el mantenimiento de los injertos de trasplante de riñón y proporcionar una visión general del panorama actual de los procedimientos realizados en el SUS.

Living-unrelated kidney donor transplantation: Legalization in exceptional circumstances?

The prevalence of end-stage renal disease (ESRD) morbidity and mortality is mounting. Kidney transplantation offers a good means of survival and improves longevity of patients with ESRD. However, not everyone is fortunate to benefit from this lifesaving renal replacement therapy due to the lack of available kidneys, one of the many reasons. It eventually expands the number of patients on waiting list of kidney transplantation. At present, deceased and living-related kidney donor transplantation models are widely used, but with limited success to keep up with the pace of burgeoning ESRD. A debate over the legalization of unrelated living kidney donor transplantation has erupted lately. This short review articles focuses on issues surrounding kidney transplantation in Pakistan and draws an informed conclusion regarding pragmatic legalization of unrelated living kidney donor transplantation in exceptional circumstances. Finally, this article also offers a food for thought for countries facing analogous picture in the field of kidney transplantation.

The future of HIV Organ Policy Equity Act is now: the state of HIV+ to HIV+ kidney transplantation in the United States.

PURPOSE OF REVIEW: We report the current state of HIV+ to HIV+ kidney transplantation in the United States and remaining challenges in implementing this practice nationally. RECENT FINDINGS: The HIV Organ Policy Equity (HOPE) Act, which was the first step in unlocking the potential of HIV+ organ donors, mandates clinical research on HIV+ to HIV+ transplantation. As of March 2019, there have been 57 HOPE donors, including both true and false positive HOPE donors resulting in more than 120 transplants. SUMMARY: The HOPE Act, signed in 2013, reversed the federal ban on the transplantation of organs from HIV+ donors into HIV+ recipients. Ongoing national studies are exploring the safety, feasibility, and efficacy of both kidney and liver transplantation in this population. If successfully and fully implemented, HIV+ to HIV+ transplantation could attenuate the organ shortage for everyone waiting, resulting in a far-reaching public health impact.

Dramatic secular changes in prognosis for kidney transplant candidates in the United States.

Over recent decades, numerous clinical advances and policy changes have affected outcomes for candidates of kidney transplantation in the United States. We examined the national Scientific Registry for Transplant Recipients for adult (18+) solitary kidney transplant candidates placed on the waiting list for primary listing from 2001 to 2015. We evaluated rates of mortality, transplantation, and waitlist removal. Among 340 115 candidates there were significant declines in mortality (52 deaths/1000 patient years in 2001-04 vs 38 deaths/1000 patient years in 2012-15) and transplant rates (304 transplants/1000 patient years in 2001-04 vs 212 transplants/1000 patient years in 2012-15) and increases in waitlist removals (15 removals/1000 patient years in 2001-04 vs 25/1000 patient years in 2012-15) within the first year after listing. At 5 years an estimated 37% of candidates listed in 2012-15 were alive without transplant as compared to 22% in 2001-04. Declines in mortality over time were significantly more pronounced among African Americans, candidates with longer dialysis duration, and those with diabetes (P < .001). Cumulatively, results indicate dramatic changes in prognoses for adult kidney transplant candidates, likely impacted by selection criteria, donor availability, regulatory oversight, and clinical care. These trends are important considerations for prospective policy development and research, clinical and patient decision-making, and evaluating the impact on access to care.

Changes in Simultaneous Liver-kidney Transplant Allocation Policy May Impact Postliver Transplant Outcomes.

BACKGROUND: Previous simultaneous liver-kidney (SLK) transplant allocation was based on serum creatinine, a metric that disadvantaged women relative to men. A recent SLK transplant policy change uses estimated glomerular filtration rate (eGFR), which accounts for sex-based differences in creatinine. METHODS: To understand the impact of this new policy, we analyzed nonstatus 1 adults listed for liver transplantation (LT) from May 2007 to July 2014, excluding those with exceptions. We defined patients who met the new SLK policy as having an eGFR <60 mL/min for 90 days, with a final eGFR <30 mL/min. RESULTS: Of 40979 candidates, 1683 would have met only the new criteria (N-SLK), 2452 would have met only the old criteria (O-SLK), and 1878 would have met both criteria (B-SLK). Compared to those in the B-SLK or O-SLK groups, those in the N-SLK group were significantly more likely to be female (52% versus 36% versus 39%, P < 0.001). Cox-regression analysis demonstrated that in adjusted analysis those in the N-SLK group were significantly less likely to die postliver transplant (hazard ratio [HR], 0.0; P < 0.001). Further, in Cox regression subgroup analyses, both in women (HR 0.04; P < 0.001) and in men (HR, 0.02, P < 0.001) those in the N-SLK group who underwent liver transplant were significantly less likely to die postliver transplant, even after adjustment for confounders. CONCLUSIONS: We anticipate that implementation of the new SLK policy will increase the proportion of women and decrease the proportion of men who are listed for SLK but may not improve posttransplant survival. Our data highlight the need for monitoring of SLK outcomes after implementation of the new policy.

Expanding renal transplantation organ donor pool in Nigeria.

Kidney transplantation is the gold standard for end-stage renal disease. All over the world there are several challenges preventing sufficient organ donation to meet the growing needs of patients on the waiting list. One major challenge which is common to most countries is the shortage of organs from willing living donors. Many countries, especially, the developed countries, have devised several models of expanding their donor pools to meet the growing needs of patients on the waiting list. Nigeria, a developing country has very low kidney transplantation rate even though some progress have been made in making the procedure feasible in about a dozen hospitals in Nigeria. One very major challenge has been the shortage of donor organ supply. This paper intends to proffer suggestions on how to expand the organ donor pool in Nigeria.

Understanding the sex disparity in living kidney donation.

Living donors are the preferred source of organs for kidney transplantation, which is the treatment modality of choice for end-stage kidney disease. Health care systems widely promote living kidney donation. However, women are consistently overrepresented among living donors. The reasons behind the sex-based disparity in living kidney donation remain poorly understood. Compared to women, men possess a greater amount of kidney function, and the higher deceased donation rate among men reflects their higher overall kidney quality. A plausible medical explanation for the sex-based disparity in living kidney donation includes an uncompromising emphasis on preserving donor health, with less emphasis placed on organ quality, which is the main criterion in deceased donor selection. On the other hand, consent to deceased donation is also greater in women, indicating their greater desire to donate even though fewer women actually become deceased donors. Therefore, nonmedical reasons for the sex disparity in living donation must be sought. Increased empathic distress or emotional memory; a greater sense of responsibility, urgency, and impulsiveness with increased reaction to empathy; a different body image; and a different social status may all contribute to greater living kidney donation in women. Economic inequity may be the singular explanation when personal worth links to economic worth. To better understand the sex disparity in living kidney donation, we need better data on the reasons behind both nondonation and donor rejection after evaluation in clinical practice. Nondirected living kidney donation provides unique opportunities to minimize factors such as emotional distress, empathy, and impulsiveness. More liberal acceptance criteria for donors with isolated medical abnormalities and testing legitimate donor reimbursement strategies based on actual income levels rather than a fixed amount can assist in both ascertaining the reasons behind the sex disparity in living kidney donation and increasing overall living kidney donation rates.

Current Challenges of Kidney Transplantation in Iran: Moving Beyond The "Iranian Model".

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.

Swaps and Chains and Vouchers, Oh My!: Evaluating How Saving More Lives Impacts the Equitable Allocation of Live Donor Kidneys.

Live kidney donation involves a delicate balance between saving the most lives possible and maintaining a transplant system that is fair to the many thousands of patients on the transplant waiting list. Federal law and regulations require that kidney allocation be equitable, but the pressure to save patients subject to ever-lengthening waiting times for a transplant has been swinging the balance toward optimizing utility at the expense of justice. This article traces the progression of innovations created to make optimum use of a patient's own live donors. It starts with the simplest - direct donation by family members - and ends with voucher donations, a very recent and unique innovation because the donor can donate 20 or more years before the intended recipient is expected to need a kidney. In return for the donation, the intended recipient receives a voucher that can be redeemed for a live kidney when it is needed. Other innovations that are discussed include kidney exchanges and list paired donation, which are used to facilitate donor swaps when donor/recipient pairs have incompatible blood types. The discussion of each new innovation shows how the equity issues build on each other and how, with each new innovation, it becomes progressively harder to find an acceptable balance between utility and justice. The article culminates with an analysis of two recent allocation methods that have the potential to save many additional lives, but also affirmatively harm some patients on the deceased donor waiting list by increasing their waiting time for a life-saving kidney. The article concludes that saving additional lives does not justify harming patients on the waiting list unless that harm can be minimized. It also proposes solutions to minimize the harm so these new innovations can equitably perform their intended function of stimulating additional transplants and extending the lives of many transplant patients.

Improvements in Outcomes for Ethnic Minorities During the Share 35 Era Are Not Due to Decreased Rates of Early Graft Loss.

OBJECTIVES: Our aim was to investigate the effects of the Share 35 policy on outcomes in ethnic minorities and recipients who experienced early graft failure. MATERIALS AND METHODS: We analyzed donor and recipient data from the United Network for Organ Sharing database before (June 6, 2011 to June 18, 2013) and after (June 18, 2013 to June 30, 2015) implementation of Share 35. Graft and patient survival outcomes were compared. RESULTS: There were significant differences in 1- and 2-year graft and patient survival rates between ethnicities pre-Share 35 (P = .03, P < .001, P = .01, P < .001, respectively). There were no significant differences in 1- and 2-year graft and patient survival between ethnicities post-Share 35 (P = .268, P = .09, P = .343, P = .087, respectively). There were no differences in early graft failure rates pre- and post-Share 35 at 7 days (2.1% vs 2.0; P = .71) and 30 days (4.0% vs 3.8%; P = .47) after transplant, with a decreased early graft failure rate shown at 90 days after transplant (6.8% vs 5.8%; P = .003). When analyzed separately, the low Model for End-Stage Liver Disease (score of < 35) and the high Model for End-Stage Liver Disease recipients (score of ≥ 35) both exhibited reduced early graft failure rates post-Share 35 (6.1% vs 5.3% and 10.8% vs 7.8%, respectively; P < .05). CONCLUIONS: Share 35 was associated with a short-term reduction in ethnic disparities. Most ethnic groups experienced improved survival in the Share 35 era. Share 35 was not associated with an increase in early graft failure and is an efficacious policy with regard to short-term outcomes.

Transplant tourism following the declaration of Istanbul: Poor outcomes and nephrologist dilemma.

AIM: Transplant tourism (TT) violates many international laws and documents. Despite all efforts, TT seems to be increasing. The aim of this study is to review outcomes of recipients of commercially transplanted kidneys since the Declaration of Istanbul. METHODS: All recipients of kidney transplantation done abroad and then returning to our centre, from September 2008 to December 2015, were included (tourists). Demographics and outcomes were collected from patients' charts. All data were compared with all recipients of living donor kidney transplants done at our centre (locals). RESULTS: A total of 86 tourists and 365 locals were included. Both groups had similar age and gender. Re-grafting rates were the same, however, more pre-emptive transplants were done abroad. TT increased over time. Tourists presented early after TT, median 17.5 (IQR 7-30) days, and 47.7% were encountered initially in the emergency department. One-year graft and patient survivals were significantly lower among tourists compared with locals (87.2% vs. 98.0%, P < 0.001 and 90.7% vs. 98.0%, P < 0.001, respectively). Tourists had a significantly higher rate of acute cellular rejection (19.8% vs. 7.1%, P < 0.001), and they sustained significantly higher rates of serious viral, bacterial and fungal infections compared with the locals. CONCLUSION: Transplant tourism seems to be increasing despite international condemnation and efforts to stop it. Outcomes are significantly worse when compared to local transplant recipients. Concerted effort is needed to better inform patients about the ethical and physical harms related to TT, and to point them towards ethically sound and medically safer alternatives.

Choice, pressure and markets in kidneys.

We do not always benefit from the expansion of our choice sets. This is because some options change the context in which we must make decisions in ways that render us worse off than we would have been otherwise. One promising argument against paid living kidney donation holds that having the option of selling a 'spare' kidney would impact people facing financial pressures in precisely this way. I defend this argument from two related criticisms: first, that having the option to sell one's kidney would only be harmful if one is pressured or coerced to take this specific course of action; and second, that such forms of pressure are unlikely to feature in a legal market.