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INTRODUCTION Organ transplantation in Iran started in 1967 with the first successful live donor kidney transplant performed at Namazi Hospital in Shiraz.1 Subsequently, transplantation progressed, although at a slow pace with only a handful of procedures done until mid-1970. Some patients who could afford the expenses went abroad, mainly to the United Kingdom, to receive living-related transplants; outcomes were usually poor. The Iranian Revolution in 1979 and the Iran-Iraq war halted further progress and only few attempted to move transplantation forward until the field received the attention it deserved in 1986 in Tehran and 1987 in Shiraz. The paid-donation model was initiated in Tehran in 1988 and gained acceptance by almost all kidney transplant centers in the country; the transplant center in Shiraz, at the same time, emphasized on deceased donation, although establishing a deceased donor transplantation program appeared as a Herculean task. THE INFRASTRUCTURE Organ transplantation from living donors does not involve complex legal and religious challenges. However, deceased donation requires extensive structural and organizational efforts. One of the main obstacles early on was the ambiguity in the definition of death.2 Neither Judeo-Christianity nor Islam, the prevailing religion in Iran and the Middle East, provides criteria indicating the time point that separates the soul from the body. Thus, a carefully orchestrated approach including legal approval on the time of death in addition to the acceptance and approval by medical professionals and clergy had to be implemented. Saving a life is highly respected in Islam, and it was expected that the religious authorities could be supportive by edicts if the importance of organ donation and transplantation was communicated convincingly.2 After long efforts and negotiations, supportive decrees on brain death were issued by the clergy in 1989, and legislation on brain death and organ transplantation was finally passed by the Iranian parliament in 2000. Moreover, there was a knowledge gap about brain death, even among well-educated people. Public awareness was raised through meetings at universities, hospitals, and high schools and by reaching out to eminent scholars and celebrities. Since 2000, rates of organ donation have increased exponentially, from 0.2 donations per million people (pmp) to >11 donations pmp in 2017, representing an average annual growth rate of 21%. In parallel with the increasing rates in organ donation from deceased patients, we have witnessed an exponential increase in the number of liver transplantations performed at the Shiraz Transplant Center (Figure 1). Almost all transplants at our center have been procured from deceased donors with the contribution of living liver transplant donors declining from 25% in 2000 to almost 8% in 2017.FIGURE 1.: Trends of organ donation (red circles) and liver transplantations performed at the Shiraz Organ Transplant Center (blue triangles) from 2000 to 2017. Trends are exponential (red solid and blue dashed curves) with average annual growth rates of 21% and 26%, respectively. Note that organ donation and liver transplant rates increase in parallel, reflecting the dependency of transplantations on deceased donor availability.Organ donation is unevenly distributed in Iran ranging from zero in Hormozgan province to 35 donations pmp in the Kohgiluyeh-va-Boyr-Ahmad province (Figure 2). Generally, Shiraz and its neighboring cities have the highest average donation rate of 20 donations pmp. Increasing donation rates has been a team effort in which the determination of transplant coordinators in these provinces has been the key in identifying brain-dead donors and convincing families to agree to organ donation. As a matter of fact, most families grant permission for the donation of organs taken from their dying loved ones based on altruistic grounds as long as the body is treated respectfully.FIGURE 2.: Iran and geographic regions are shown in a 3-dimensional perspective. Cities coordinating organ donations and donations per million population (pmp) are listed. The height of each region reflects the donation rate. Donation rates may vary substantially among regions (not shown). Rates in Shiraz zone (the green region), for example, vary from zero (Hormozgan province) to 35 donations pmp (Kohgiluyeh-va-Boyr-Ahmad province). (Map designed by Nima Owji).We have also witnessed an increasing trend in the number of kidney transplantations performed in Shiraz (Figure 3). Since 2000, we have also observed increasing numbers of deceased donor kidney transplants, while numbers of living donors declined. In fact, there has not been a kidney transplant from an unrelated living donor since 2008; live donor-related transplants have become rare since 2016.FIGURE 3.: The trend of kidney transplantations performed from 2000 to 2017 stratified by type of donation. Although the trend is increasing, the number of living-unrelated and living-related donors had decreased, with no living-unrelated donation since 2008; living-related donations have become a rarity since 2016. In clear contrast to what is practiced in many other centers in the region, we only rely on deceased donors.With increasing deceased donor procurements, reliable transport system had to be established to quickly ship organs from any hospital in the country to the Shiraz Transplant Center. To achieve this goal, we divided the country into 7 zones (Figure 2). Procured organs are transported by ambulance within each zone; domestic flights (both commercial and chartered depending on timing and availability) are used. We believe that having an efficient transport system is of paramount importance in establishing a successful deceased donor transplantation program. OUTCOME Despite increasing numbers of transplantations performed in our center, liver transplant outcomes compare favorably to international standards with current 1-, 5-, and 10-year survival rates of adult liver transplant recipients of 87%, 77%, and 70%, respectively; survival rates of pediatric liver transplant recipients are 77%, 67%, and 58% by 1, 2, and 5 years.3,4 The graft survival rates for adult kidney transplants are 98%, 95%, 90%, and 89%, after 1, 3, 5, and 7 years, respectively.5 FELLOWSHIP TRAINING PROGRAMS We have shared our experience with other centers in Iran and abroad to achieve an expansion of transplantation at those centers. With the start of our work at the Shiraz Organ Transplant Center, we have started to train local and national fellows in organ transplantation. In a close collaboration with the Middle East Society for Organ Transplantation, we have extended our fellowship training program into the regional countries. To date, we have trained 65 fellows and 130 transplant nurses and coordinators from Iran in addition to 31 fellows and 40 transplant nurses from Afghanistan, Iraq, Lebanon, Pakistan, Sudan, Syria, and Tajikistan, not mentioning those who participated in our short courses. Our center is considered the go-to and consulting place for the region. FUTURE On the basis of volume, Shiraz Organ Transplant Center is considered one of the largest of its kind. Even with this success, there is still room for improvements. For example, the rate of organ donation is still low in many parts of Iran (Figure 2). Moreover, approximately only one-third of approved brain-dead donors move forward to donation.6 In fact, the transplant team approaches only approximately one-third of families from identified brain-dead donors; out of those, most grant permission for organ procurement. Thus, there is a substantial amount of unrealized deceased donor potential. Further education efforts targeting an effective communication of our transplant coordinators and further research into identifying the motivation of families to donate are expected to increase donation and transplantation numbers further. Moreover, we have plans to strengthen our cooperation with other scientific centers and to further expand our activities particularly into transplant research. We believe that these are not just dreams. Our main goal is to be steadfast in our campaign against paid donation, which we see as unethical. Moreover, Iran has a great potential of young elite scientists. Involving those in our efforts may help us furthermore to show the world that self-sufficiency through deceased donor organ transplants can be achieved.
Malek‐Hosseini et al. (Thu,) studied this question.