Trends in unrelated-donor kidney transplantation in the developing world

Living unrelated donors (LUDs) constitute an incremental source of kidneys for transplantation at a global level. Excellent outcomes are reported, superior to those of deceased-donor transplantation and comparable to related donor transplantation. LUD include six categories: spouses, distant relatives, paired-exchange, living-deceased exchange, and non-directed and directed donors. Although a financial reward may be involved in any of these categories, it is in the declared selling of organs that ethical concerns have intensified. There are three patterns of paid LUDs in the developing world: organized, erratic and commercial. The only model of organized LUDs is in Iran, where a central agency assigns and compensates the donors. Erratic LUD transplantation has been experienced, and subsequently banned, in the development of transplant programmes in most developing countries. However, the tightness and enforcement of the official ban are geographically different, providing variable room for uncontrolled trafficking. Commercial transplantation has, thus, become phenomenal in a few countries, gradually evolving into an organized business that follows market dynamics, including advertisement, brokerage, commissions, auctions and tourism. While most international organizations and activist groups condemn commercial transplantation, it is often perceived, in certain cultures and under particular socioeconomic standards, as a human right that meets the demands of all stakeholders, and should be organized rather than declined just for the purpose of meeting the values of a third party.