World Kidney Forum
Organ Trafficking: Global Solutions for a Global Problem

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The organ trafficking market is on the rise worldwide. Numerous unfortunate stories of networks of brokers, physicians, and hospitals engaged in illegal trade have been featured in high-profile media. The profitable enterprises facilitating these unregulated services exploit the poor in underresourced countries and offer substandard medical care with unacceptable outcomes to the rich recipients. Despite efforts to boost altruistic organ donation and resolutions to curb transplant tourism, their implementation has been compromised. At the same time, the worldwide escalation in the number of patients with kidney failure coupled with a shortage in the supply of organs continues to fuel this trade. Thus, measures to enhance the donor pool in well-resourced countries to meet their own needs will act as a strong deterrent to the proliferation of transplant tourism in impoverished nations. Regulated schemes that include reimbursement for removing potential disincentives to organ donation and ensure the long-term safety of donors and their families are likely to increase living donations. Such socially responsible programs should be tested in both developed and developing countries for their own populations. It also is vital that developing countries establish a regulated, standardized, and ethical system of organ procurement; create awareness in physicians and the public; upgrade facilities and standardize medical care; and enforce legislation for transplantation. The World Health Organization, National Kidney Foundation, and international transplant and nephrology societies can have an instrumental role in facilitating initiatives in these critical areas. There should be clearly defined codes of conduct for health care facilities and professionals' roles in unregulated paid organ donations and transplants. Ultimately, physicians and transplant surgeons have the responsibility to ensure to the best of their ability that the organs they transplant were obtained upholding the highest standards of ethics.

Section snippets

Background

With an increase in cardiometabolic diseases and aging populations worldwide, the burden of kidney disease also is increasing, posing unique social and ethical challenges in a rapidly globalizing world.7, 8, 9, 10 The number of patients with ESKF, ie, those requiring maintenance dialysis therapy or transplant, in the United States nearly doubled during the 1990s, increasing from 196,000 in 1991 to 382,000 in 2000. A recent US Renal Data System projection of the growth of the ESKF population

Legislation and Regulations

Major steps toward establishing a sound and ethical system of availability of organs were initiated by enactment of the Uniform Anatomical Gift Act in 1968 in the United States.24 This law details the rights of individuals to designate their organs for donation after their death and also the conditions under which living donor transplant is permissible. Further advances were made in 1984 by the National Organ Transplant Act, which established the nationwide computer registry operated by the

Unregulated Kidney Trade and Transplant Tourism

Based on a survey of 98 countries that represent more than 5.4 billion people (82% of the world's population), the WHO estimated that 10% of all global kidney transplants in 2004 were in patients from developed countries who traveled to economically challenged nations to buy organs (Fig 2).40

The ease of access to such services advertised in package deals of $15,000-$150,000 has been particularly attractive, and countries such as Pakistan, India, and Turkey have acquired the unsavory reputation

Regulated Compensated Kidney Transplantation

To address the concern of the short supply of kidneys to meet the national demand of patients with ESKF, a regulated system of living unrelated paid donor kidney transplantation was legally adopted in Iran in 1988.57 In this system, all potential donors are registered by the government and undergo a rigorous process of informed consent and donor evaluation. No brokers are involved in the state-run program, which offers a fixed amount of US $1,200 to the donor, along with posttransplant care.

Efforts to Curb Transplant Tourism

Because of deep concerns with the gross exploitation of the vulnerable associated with profit-driven organ trade, the World Health Assembly issued a resolution in 2004 for all WHO member states to prohibit transplant tourism.71 It also called for international cooperation in the formulation of organ procurement guidelines on suitability, safety, and ethics and the establishment of national oversight committees to ensure implementation.

Although countries have attempted to adhere to the

Declaration of Istanbul on Organ Trafficking and Transplant Tourism

The most recent Declaration of Istanbul on Organ Trafficking and Transplant Tourism strictly condemns all forms of organ trade that exploit the poor, regardless of whether from within their own countries or abroad.81 This declaration, which builds on the principles of the Universal Declaration of Human Rights, was passed in April 2008 at the Summit in Istanbul, Turkey, convened by the Transplantation Society and International Society of Nephrology. The declaration states that all forms of

Other Successful Efforts to Enhance the Kidney Donor Pool

The nexus that supports kidney trade is powerful, fueled by the lure created by the limited supply of kidneys in the face of increasing demands in rich countries. Therefore, measures to enhance the donor pool in well-resourced countries to meet their own needs will act as a strong deterrent to the proliferation of unregulated transplant enterprise in impoverished nations. Results of initiatives to increase the legal donor pool, such as the Organ Donation Breakthrough Collaborative, which

The Way Forward

It is obvious that in addition to guidelines and declarations, multipronged concerted efforts are needed at the national, regional, and global levels to address illegal kidney trade and transplant tourism within and across borders. For a global approach, there are lessons to be learned from countries that have shown success with innovative models and initiatives of regulated cadaveric and living donations. The following efforts are likely to yield fruitful results.

Acknowledgements

I would like to thank my distinguished colleagues who encouraged me to write on the subject and shared their valuable thoughts on it with me.

Financial Disclosure: None.

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      The kidney waiting list has been eliminated in Iran, 1 of the several nations, including Australia and Singapore, that have instituted some levels of state-sponsored structures for compensating for organ donation [37,38]. The present report and many others [7,8,39–41] have indicated that the current laws and the prevalent system are insufficient to meet the donor organ demand and unable to prevent the illegal and immoral activities related to organ transplantation. Many developing nations may not have the resources to combat transplantation-related crimes [9].

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    Originally published online as doi:10.1053/j.ajkd.2009.08.014 on November 2, 2009.

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