Life in Death: an Overview of Solid Organ Transplant

in Shiraz, Iran
Alireza Mehdizadeh,1,2 Afsoon Fazelzadeh1,3

Achaemenidae (the Achaemenian dynasty), as

evidenced by engravings in Persepolis (an ancient
Advances in organ preservation, immuno-

city located near Shiraz) (Figure 1) of mythologic

suppression, and surgical procedures have resulted in

chimeras with a human head, the body of a lion, and

improved outcomes and survival rates. However,

the wings of an eagle (1). This chimera represents a

regarding organ transplant in different communities,
these advances raise major ethical, policy, and
religious issues.
Transplant progress in Iran, in relation to the rest
of the world, has been slow at times and quick during
others. Between 1988 and 1993, there was a rapid
surge in experiments with tissue transplant in Iran,
and the Shiraz Organ Transplantation Center,
superhuman creature with the intelligence of a
human being, the power of a lion, and the freedom of
the eagle.
Professor Mohammad Sanadizadeh performed
the first kidney transplant in Iran from a living-
related donor in 1967 in Shiraz (2). The Shiraz Organ
Transplantation Center, established by Professor
Seyed Ali Malek-Hosseini in 1988, uses the Iran

transplant model of renal transplant (3). The first

established in 1988, rose to become a pioneer of the

successful heart transplant was performed in Shiraz

most significant improvements, a leading center for

in 1993 by Professor Mohammad Ali Sanjarian at

organ transplant, and the only center for liver
Saa’di Hospital in Shiraz (personal communication).
transplant in Iran.
Professor Malek-Hosseini performed the first liver
In this article, we review milestones in the
development of a successful organ transplant transplant from a deceased donor at the Shiraz Organ
program and implementation of legislation in Iran. Transplantation Center in 1993 (4).
The Shiraz model of transplant is a new program that The reduced-size liver transplant and the split-
attempts to overcome the problems of organ liver transplant paved the way for the living-donor
shortage. We provide a description of the Iranian
model of transplant and its restrictions and examine
the most promising future trends in this exciting field.

Key words: Transplantation, Kidney, Liver, Donation,

Xenograft

History of Transplant in Shiraz

Regarding the history of transplant in Iran, Shiraz is

the most important city. Ideas of implanting organs
from animals into human, known as xeno-
transplantation, date back to the sixth century BC, to

From the 1Shiraz Organ Transplant Research Center, Nemazee Hospital, Shiraz University of
Medical Sciences, and the 2Persian Network for Organ Transplantation, Shiraz, Iran, and the
3
School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
Address reprint requests to: Alireza Mehdizadeh, PO Box: 91375-1471, Mashad, Iran
Phone: +98-915-510 31 08 +98-511-840 95 97 Fax: +98-511-851 75 05 Figure 1. Mythologic chimeras, creatures with a human head, a lion’s
E-mail: Alireza.mehdizadeh@gmail.com body, and an eagle’s wings. Carvings of these chimeras, which date
back to the sixth century BC to Achaemenidae, remain to this day, in
Experimental and Clinical Transplantation (2007) 2: 701-707 Persepolis, an ancient city near Shiraz.

Copyright © Başkent University 2007

Printed in Turkey. All Rights Reserved.
702 Alireza Mehdizadeh, Afsoon Fazelzadeh / Experimental and Clinical Transplantation (2007) 2: 701-707
liver transplant, the most viable alternative to the
significant shortage of organs for liver transplant
(5,6). In Iran, first attempts were made in pediatric
recipients beginning in 1998 at the Shiraz Organ
Transplantation Center (7).
Because of the difficulty in finding size-matched
hepatic grafts, the donor shortage has been even
worse for children (8). Prior to instituting the living-
donor liver transplant procedure for infants at the
Shiraz Organ Transplantation Center, morality rates
for infants awaiting liver transplants approached
61%. With the rapid acceptance of the living-donor
liver transplant procedure, mortality decreased to less
than 31% in 2006 (9). Although the first living-donor
liver transplant was performed in 1993, owing to
technical problems leading to graft loss, the
procedure has only recently emerged as a clinical
liver transplant alternative at the Shiraz Organ
Transplantation Center. By November 2006, the
Shiraz Organ Transplantation Center had performed
19 living-related liver transplants (17 left lobes and 2
right lobes) (10).
The first split liver transplant in Iran was
performed at the Shiraz Organ Transplantation
Center in January 2004. By 2006, the Shiraz Organ
Transplantation Center had performed 10 split liver
transplants, demonstrating that patient survival after
split liver transplant is not significantly different from
that of whole-organ orthotopic liver transplant (10).
For the first time in Iran, between April 2006 and
August 2006, the Shiraz Organ Transplantation
Center performed a simultaneous kidney-pancreas
transplant in 5 patients with type 1 diabetes mellitus
and end-stage renal disease (11).
Iranian Model of Renal Transplant
Until 1975, transplanted kidneys were all from living-
related donors. The Dialysis and Transplant
Committee at the Blood Transfusion Organization,
under the Ministry of Health and Medical Education
of Iran, established an agreement with Eurotransplant
to transfer deceased-donor kidneys to Iran and
because of this, 10 kidney transplants were performed
(12). By 1980, 112 renal transplants had been
performed. Unfortunately, because a deceased organ
donation program had not been established, this
rapid success in organ transplant was not matched by
a parallel increase in the supply of organs available
for transplant (13). Since 1980, because of the limited
renal transplant activity in Iran, the Ministry of
Health, using government funds, began to allow
dialysis patients to be transplanted abroad. Any
dialysis patient who had a letter of acceptance from a
transplant unit abroad was accepted, and all travel
Exp Clin Transplant
and transplant expenses were paid by the
government. As a result, the many dialysis patients
awaiting transplant created a long transplant waiting
list at the Ministry of Health. Between 1980 and 1985,
more than 400 of these patients traveled to Europe
and the United States to receive their renal
transplants. The majority of these transplants were
performed in the United Kingdom from living-
related donors (14). In 1985, the high cost of renal
transplant abroad and the increasing number of
patients on the renal transplant waiting list prompted
health authorities to establish renal transplant in Iran
(13).
Since 1980, Iran has been involved in the imposed
war with Iraq, and because of unilateral sanctions
against Iran and also the costs of the war, acquiring
supplies and equipments for dialysis has become
increasingly difficult. Dialysis patients have been
dying because of the burdens imposed by the war’s
expenses and the sanctions imposed on Iran.
Although the imposed war was a restricting event, it
had some valuable benefits too because it trained
skilled surgeons and taught them independence.
Owing to strong cultural and religious barriers to
deceased-donor transplant, the only solution for
this lack of organs was to establish living-unrelated
donations, which would enhance organ availability
and reduce the number of problems associated with
dialysis. Therefore, a controlled, living-
unrelated–donor renal transplant program called
the Iranian Model of Kidney Transplant was
adopted in 1988 by Professor Iraj Fazel (15). Since
that time, however, there have been fears about
unethical organ trade in Iran.
Historically, money has been the driving force in
purchasing healthcare worldwide. Even so, there are
many who do not agree that healthy individuals
should be allowed to pay for organs or that they
should be allowed to sell one of their kidneys while
alive. Despite ethical dilemmas and discussions,
organ sales in Third World countries occur all the
time, and all attempts to rely solely on altruism to
meet the demand for transplantable donor organs
have failed and will continue to fail because the
dilemma regarding organ availability will always be:
to buy or to die (16-18).
Kidneys are the subject of a quietly growing global
drama. In the United States, ailing, rich patients are
buying kidneys from the poor and desperate in
burgeoning black markets. Clandestine kidney sellers
get little medical follow-up, buyers often catch
hepatitis or HIV, and both endure the consequences of
slapdash surgery. As long as some people are
determined to obtain kidneys and others are
 Alireza Mehdizadeh, Afsoon Fazelzadeh / Experimental and Clinical Transplantation (2007) 2: 701-707
desperate enough to sell them, the trade will be
impossible to stop. It makes better sense to regulate
the business than to drive it underground (19).
In the face of all this, most countries are staying
with the worst of all possible policy options.
Governments place the onus on their citizens to
volunteer organs. A few European countries,
including Spain, increase the supply slightly by
presuming citizens' consent to have their organs
transplanted when they die unless specified
otherwise. Whether or not such presumed consent is
morally right, it does not solve the supply problem, in
Spain or elsewhere (19). On the other hand, if just
0.06% of healthy Americans aged between 19 and 65
years donated 1 kidney, the country would have no
waiting list (19), which is now about 74 128 patients
(20). The only way to encourage this is to legalize the
sale of kidneys. Although organ donors are currently
deprived of legitimate compensation in many places
worldwide, there is an international push toward
acceptance of a regulated market for human organs.
Providing incentives to increase people’s willingness
to donate organs and compensating living-unrelated
donors are receiving increased global attention (21).
This is already occurring in the United States: the
State of Pennsylvania will pay $300 to families of
deceased organ donors to help cover funeral expenses
(22).
In Iran, the initiative to provide compensation to
living-unrelated kidney donors began in 1997. The so-
called “sacrifice gift” is given as a reward from the
Society and Charity Foundation to compensate the
donor’s altruistic donation for saving a life. The
acceptance and regulation of living-unrelated kidney
donation in 1988 provided the foundation for this
initiative. Under the living-unrelated donor program,
the Charity Foundation of Special Diseases, a
nongovernmental organization, is responsible for
providing financial compensation as a social gift to
unrelated kidney donors in a fixed amount of ten
million rials (USD $1090) (23).
It was hoped that a living-unrelated kidney
transplant program would decrease waiting list
mortality rates and improve the quality of life for
patients undergoing dialysis. Before implementing
living-unrelated donation, only 30% of patients on the
waiting list for a transplant received kidneys from
living-related donors. As a result of procuring
kidneys from living-unrelated donors, the waiting list
for a kidney transplant in Iran was eliminated in 1999
(13).
According to the program protocol, a complete
medical examination of the potential donor
(including screening for serious contagious diseases
703
such as hepatitis B and HIV infection, as well as a
psychosocial evaluation and donor-recipient tissue
matching) is performed prior to the procurement
operation in all cases. The screening program and
health check protocols have been set up to ensure the
donors’ safety. The practice also rules out the
possibility that persons with poor organs may try to
cover up medical problems to participate in the
program (21). While the risk of dying from renting
out a womb is 6 times higher than that from selling a
kidney, some countries still allow people to buy
babies from surrogate mothers (19). To decrease the
complication rate of kidney donation and make this
procedure more acceptable for all persons, Professor
Naser Simfroush developed a laparoscopic living-
donor nephrectomy that has been used for more than
750 living kidney donors (24). The total cost of living-
unrelated donor kidney transplant in Iran is USD
$2047 (USD $374 for the donor and USD $1673 for the
recipient). Compared with other countries, kidney
transplants today are less expensive in Iran (25).
There is no fee for a renal transplant incurred by the
patient; the government pays all hospital charges (1).
This program has removed the disparities for
different socioeconomic classes in their access to
organ transplants. In 1 study, 50.4% of recipients were
poor, 36.2% were middle class, and 13.4% were
wealthy (26).
In this model, many, but not all, of the ethical
problems related to living-unrelated donor renal
transplants have been prevented. For example,
poorer persons who, prior to the model’s
introduction, had been unable to afford transplants
can now afford transplants (27). According to the
available results, more men than women are living-
unrelated donors. In studies from different cities in
Iran, the male-to-female ratio in the donor group has
varied from 3:1 to 9:1, and it is about 1.7:1 among
recipients. Most living-unrelated donors are in their
30s or 40s, with a mean age of 28.8 ± 6.5 years. These
data negate the possible violation and coercion of
women or children to donate organs in Iran (27). In
the Iranian model, if recipients have no living-related
donors, they are referred to the Dialysis and
Transplant Patients Association to find a suitable
unrelated donor. All members of the Dialysis and
Transplant Patients Association are themselves
patients who are maintained on some sort of renal
replacement therapy, either maintenance hemo-
dialysis, or continuous ambulatory peritoneal
dialysis, or they have undergone renal transplant.
After the work-up, if the donor is found to be suitable,
they will be referred to one of the transplant units
(13).
704 Alireza Mehdizadeh, Afsoon Fazelzadeh / Experimental and Clinical Transplantation (2007) 2: 701-707
By implementing various control measures, the
Iranian model has officially banned trade in organs;
the procurement system and the model work to
prevent the development of organized organ trade
such as exists in other countries. Iran, with its well-
equipped transplant centers and qualified transplant
surgeons, is attractive to patients from neighboring
countries as a regional transplant hub (21). A
thoughtful and effective regulation that states that the
“organ donor and recipient must be of the same
nationality” (28) has helped prevent Iran from being
seen as a haven for international organ traders. The
regulation prohibits non-Iranian citizens from
participating in the country’s living-unrelated
transplant system and associated compensated
donation program. In all cases, organ procurement
takes place from a well-documented source through
the official registration process. Organ transplant
from an unknown origin is never performed (29,30).
Shiraz Model of Transplant
Despite positive results and opinions favoring the
Iranian model, some criticisms have arisen as well.
Owing to cultural reasons, the program has decreased
the willingness of transplant candidates to get organs
from their loved ones. One study showed that the
living-unrelated donor program had an adverse effect
on the number of living-related donors. In that study,
81% of recipients who received a graft from living-
unrelated donors had a potential living-related donor,
but owing to cultural reasons, it was not used (31).
Most recipients are reluctant to impose any emotional
or physical pressure on their families. Although a
reward is given to living-related renal transplant
donors as well as most recipients, even poor persons
prefer to obtain an organ from unrelated donors (31).
The Shiraz Model of Organ Transplant attempts to
remove these problems by making structural
revisions to the program. In April 1993, the Shiraz
Organ Transplantation Center created the Southern
Iran Network for Deceased Donor Organ
Transplantation, which is an original, integrated
approach to improving and emphasizing deceased
organ donation over living-unrelated donation. This
network monitors all patients listed for organ
transplant across the country and is responsible for
overseeing the procurement, allocation, and
transplant of solid organs. This network covers 9 of
most important provinces of Iran to offer the option of
organ donation and coordinates deceased organ
recovery and placement; it provides public education
with the hope that every resident will become a donor
(32). Consequently, the annual rate of organ
transplant from deceased donors has increased from
Exp Clin Transplant
0.3 per million of population in 2000 to 1.7 per million
of population in 2004; living donations in 2004 were
22.9 per million (33). Since 2000, less than 1% of all
kidney transplants in Iran have been from deceased
donors. This percentage has increased to 10%
currently (34). After training a liver transplant team in
1999 at King’s College in London, the Shiraz Organ
Transplantation Center extended its work (35).
Patients from Iran and other Persian Gulf countries
requiring liver transplants are now referred to this
center.
The strategy to increase deceased-organ donation
is to have a recipient’s first-degree relatives evaluated,
and then, if none is suitable for living-related
donation, a living-unrelated donor candidate is
selected. Transplant candidates should wait 6 months
for a deceased-donor organ; if no deceased donor
organ is found during this time, then a living-
unrelated organ should be transplanted. This strategy
has 3 benefits: it increases the number of deceased-
donor and living-related donations; it decreases
organ trafficking by decreasing the number of living-
unrelated donors; and it increases compliance by
requiring organ recipients to undergo a 6-month
period of dialysis while waiting for the organ.
Problems facing transplant candidates, prior to
transplant, make the transplanted organ more
valuable for them.
Studies at the Shiraz Organ Transplantation
Center have shown that the most common cause of
rejection in kidney transplant recipients is
nonadherence to the immunosuppressive medication
regimen (36). The Shiraz model has been used since
2003, and the preliminary results support the benefits
of this program (3). To make the Shiraz model more
ethically defensible, the Shiraz Organ Transplantation
Center has adopted a policy of nondirected living-
unrelated donation to prevent any direct monetary
relationship between donors and recipients.
According to this policy, individuals donate their
kidneys to unknown recipients altruistically and
receive compensation. To expand the donor pool,
modifications have been made to the living-related
donor/recipient relationship including using swap
donation between incompatible living-related
recipient/donor pairs and another pair who are
compatible the donor and the recipient.
Between 1988 and 2004 there were 1200 renal
transplants performed at the Shiraz Organ
Transplantation Center, which included 168
deceased-donor (14% of donors) kidney transplants
(3). The Shiraz Organ Transplantation Center is
responsible for training the transplant coordinators
for all centers. These coordinators are taught to
 Alireza Mehdizadeh, Afsoon Fazelzadeh / Experimental and Clinical Transplantation (2007) 2: 701-707 705

advertise for deceased-donor donations by
encouraging people to sign organ donation cards and
urge families to consent to a donation if a family
member dies (37). With 27 000 deaths per year related
to motor vehicle accidents, Iran has a tragically
plentiful supply of young corpses, and a deceased-
donor program could alleviate the costs involved
with a living-unrelated donation program and
waiting lists (38). During just the first year after
establishing this program, 55 000 organ donation
cards were filled out. Today, more than 10% of the
people living in Shiraz have filled out organ donation
cards. The deceased organ donation consent number
increased from 7 cases in 1998 to 12 cases in 1999.
However, between 2000 and 2005, approximately 40
consents per year (or 243 consents) were granted (39).
This itself is a reflection of excellent public awareness
and humanistic motives, which undoubtedly are the
result of having skilled transplant coordinators who
can modify the attitudes of families, allowing well-
informed families to make a decision and get on with
the process of grieving. Our results show that
activities to improve deceased-donor and living-
related donations in Shiraz have been surprisingly
effective in recent years (Figure 2). The 1- and 3-year
patient survival rates for deceased-donor kidney
transplants in Shiraz are 93% and 90.5%, respectively;
while graft survival rates are 88% and 84% at 1 and 3
years, respectively. Although the success rate for
transplant surgeries when clinicians in Iran first
began performing them was not high, current data
reflect a greater-than-90% survival rate, which is
comparable to that of major centers throughout the
world (3).
Barriers facing organ transplant
The economics of live kidney donations from the
perspectives of the recipient and the healthcare
provider have been well described: 1 kidney
transplant is estimated to result in a net increase of 2
to 3.5 quality-adjusted life-years and a net healthcare
savings of USD $100 000 (40). In many countries, there
are economic barriers to donors that, in addition to
being unfair, may limit rates of organ donation; these
barriers must be addressed with a national policy
(41). Eliminating barriers to donations is one way of
increasing donations. It is the moral responsibility of
those administering the procurement system to
ensure that donors incur no economic detriment from
donating (21).

200

190
Deceased donor
180

170
Living-related donor
160

150
Living-unrelated donor
140

130

120

110
Number

100

90

80

70

60

50

40

30

20

10

0
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Figure 2. Number of renal transplants performed at the Shiraz Organ Transplantation Center between 1988 and 2005.
706 Alireza Mehdizadeh, Afsoon Fazelzadeh / Experimental and Clinical Transplantation (2007) 2: 701-707
The cost of a liver transplant in the United States is
about USD $350 000 (20), but at the Shiraz Organ
Transplantation Center this same cost is
approximately USD $38 000, and health insurance
does not cover all of it. Therefore, charity
organizations such as the Fars Liver Foundation and
the Ministry of Health pay some of the charges (about
USD $32 000). Patients are left with the remainder of
the charges (USD $6000).
Since 1980, owing to limited renal transplant
activity in the country, the Ministry of Health began
to allow dialysis patients to receive transplants
abroad using governmental funds. All travel and
transplant expenses are paid (14). However, this
program developed 3 problems: first, the cost of
organ transplants in Western countries was higher
than it was in Iran. Second, it caused an outflux of
financial resources from Iran. Third, and most
important, were sociocultural problems. Patients
were forced to go to another country with a different
language, diet, and culture; they had the same
problems regarding medical follow-up also. A
portion of the funds from the Ministry of Health is
now given to any active Iranian liver transplant
center to cover some of the expenses of the transplant
procedures (USD $6000 for each patient).
Dramatic improvements in organ transplant
mean that patients must take expensive immuno-
suppressive medications for the rest of their lives.
Health insurances currently cover most transplant
procedures in Iran, but most insurance companies do
not pay for outpatient immunosuppressive
medications (42). Although the annual per capita
income of most persons in Iran is approximately
USD $2300 (43), the costs of mandatory immuno-
suppressive drugs such as mycophenolate mofetil
and tacrolimus are USD $1700 and USD $8500,
respectively, per year. Evidence suggests that poverty
has become a major cause of noncompliance and
allograft dysfunction among transplant recipients
(44). A solution is needed. We believe that health
insurance should cover the cost of all immuno-
suppressive therapies for all solid-organ transplant
recipients who cannot afford to pay. Something must
be done to ensure that transplants do not fail because
people cannot afford to pay for their immuno-
suppressive medications.
Unilateral sanctions by the United States against
Iran, which began after the takeover of the US
embassy in Tehran (November 1979) (45), have
limited the availability of vital medicines and
medical devices for organ transplants in Iran.
Especially, the availability of new immuno-
suppressive drugs, which are unquestionably more
Exp Clin Transplant
effective in controlling acute rejection and have
potentially huge economic advantages regarding the
costs of hospitalization and treatment of acute
rejection episodes. Transplant in Iran has been
slowed by political and financial obstacles, and
patients are the casualties of these struggles.
However, there are certain sociocultural beliefs and
customs too that have slowed the process of
transplant development in Iran. Important
misconceptions and fears include fear of death, the
belief that removing organs from a dead person
violates the sanctity of the deceased, concerns about
being dissected after death, the desire to be buried
intact, a distain for the concept of organs inside
another person, and inaccurate information
regarding brain death.
Areas for improvement
The final goal of the Shiraz model to eliminate
disparities in organ transplant between Iran and
other developed countries, is not too far off. Since
2005, the Shiraz Organ Transplantation Center has
been training liver transplant surgeons in an effort to
increase the number of liver transplant centers and
promote liver transplant in Iran. The Shiraz Organ
Transplantation Center also began an integrated
program for heart and lung transplant in 2006.
Another large step in expanding the transplant
program is the construction of the Avi-Cenna (Abou
Ali Sina) Transplant Hospital in Sadra, a new town
near Shiraz. This hospital hopefully will begin
operating in 2009. It will offer the opportunity for
transplant teams all over the Middle East to transfer
graft organs between themselves and to increase
cooperation. The hospital offers great promise for
transplant medicine in Iran and other Persian Gulf
countries (1).
References
1. Broumand B. Transplantation activities in Iran. Exp Clin
Transplant. 2005;3(1):333-337.
2. Ghods AJ, Abdi E. Dialysis and renal transplantation in Iran. In:
Haberal MA, ed. Chronic Renal Failure and Transplantation.
Ankara: Semith Offset; 1987:103-108.
3. Malek-Hosseini S, Razmkon A, Mehdizadeh A, et al. Long-term
results of renal transplantation: A single-center analysis of 1200
transplants. Transplant Proc. 2006;38(2):454-456.
4. Malek Hosseini SA, Lahsaee M, Zare S, et al. Report of the first
liver transplants in Iran. Transplant Proc. 1995;27(5):2618.
5. Broelsch CE, Emond JC, Whitington PF, Thistlethwaite JR, Baker
AL, Lichtor JL. Application of reduced-size liver transplants as split
grafts, auxiliary orthotopic grafts, and living related segmental
transplants. Ann Surg. 1990;212(3):368-375; discussion 375-377.
6. Raia S, Nery JR, Mies S. Liver transplantation from live donors.
Lancet. 1989;2(8661):497.
7. Nezakatgoo N, Malek-Hosseini SA, Salahi H, et al. Lessons
learned from the first successful living-related liver
transplantation. Transplant Proc. 1999;31(8):3171.
 Alireza Mehdizadeh, Afsoon Fazelzadeh / Experimental and Clinical Transplantation (2007) 2: 701-707
8. Baltz AC, Trotter JF. Living donor liver transplantation and
hepatitis C. Clin Liver Dis. 2003;7(3):651-665.
9. Dehghani SM, Gholami S, Bahdor A, et al. Morbidity and
mortality of children with chronic liver disease who listed for liver
transplant in Iran. Exp Clin Transplant. 2006;4(2 suppl):174.
10. Malek-Hosseini SA, Nikeghbalian S, Salahi H, et al. Liver
transplantation: Shiraz experience with 253 cases. Exp Clin
Transplant. 2006;4(2 suppl):63-64.
11. Nikeghbalian S, et al. The first Iranian experience: Simultaneous
kidney-pancreas transplantation in Shiraz Organ Transplant
Center. Exp Clin Transplant. 2006;4(2 suppl):69.
12. Pourmand G. Country reports (Iran). Exp Clin Transplant.
2006;4(2 suppl):21.
13. Ghods AJ. Renal transplantation in Iran. Nephrol Dial Transplant.
2002;17(2):222-228.
14. Ghods AJ. Long-term results of renal transplantation in 104
Iranian patients transplanted in abroad. Acta Med Iran.
1994;32:51-59.
15. Fazel I. Renal transplantation from living related and unrelated
donors. Transplant Proc. 1995;27(5):2586-2587.
16. Bignall J. Kidneys: buy or die. Lancet. 1993 Jul 3;342(8862):45.
17. Friedlaender MM. The right to sell or buy a kidney: are we failing
our patients? Lancet. 2002;359(9310):971-973.
18. Kevorkian J. A controlled auction market is a practical solution to the
shortage of transplantable organs. Med Law. 1992;11(1-2):47-55.
19. Organ transplants. Economist.com Web site. http://www.
economist.com/opinion/displaystory.cfm?story_id=8173039.
Accessed Nov 30, 2007.
20. The organ Procurement and Transplant Network (OPTN) Web
site. Data. http://www.optn.org/data/. Accessed Dec 15, 2007
21. Bagheri A. Compensated kidney donation: an ethical review of
the Iranian model. Kennedy Inst Ethics J. 2006;16(3):269-282.
22. Veatch RM. Transplantation Ethics. Washington, DC:
Georgetown University Press; 2000:158.
23. Zargooshi J. Iranian kidney donors: motivations and relations
with recipients. J Urol. 2001;165(2):386-392.
24. Simforoosh N. Technical modifications in laparoscopic donor
nephrectomy-7 years experience with 750 cases. Exp Clin
Transplant. 2006;4(2 suppl):10.
25. Noorbala MH, Einollahi B, Kardavani B, et al. The cost of kidney
transplantation in Iran. Exp Clin Transplant. 2006;4(2 suppl):142.
26. Ghods AJ, Ossareh S, Khosravani P. Comparison of some
socioeconomic characteristics of donors and recipients in a
controlled living unrelated donor renal transplantation program.
Transplant Proc. 2001;33(5):2626-2627.
27. Larijani B, Zahedi F, Taheri E. Ethical and legal aspects of organ
transplantation in Iran. Transplant Proc. 2004;36(5):1241-1244.
28. Ministry of Health. Regulation No. K/ 21278. With respect to
organ transplantation of foreign citizens in Iran. Ministry of
Health and Medical Education, Iran. December 16, 1998.
29. Larijani B. Organ Transplantation: Medical, Legal and Religious
Aspects [in Persian]. Tehran: Entesharat Baraye Farda: 2005.
707
30. Ghods AJ, Nasrollahzadeh D. Transplant tourism and the Iranian
model of renal transplantation program: ethical considerations.
Exp Clin Transplant. 2005;3(2):351-354.
31. Ghods AJ, Savaj S, Khosravani P. Adverse effect of a controlled
living unrelated donor renal transplant program on living related
and cadaveric kidney donation. Transplant Proc 2000;32:541.
32. Gholami S, Janghorban P, Mehdizadeh A, et al. Cadaveric
donation in Iran: problems and solutions. Transpl Int.
2005;18(suppl 1):269.
33. Larijani B, Zahedi F, Taheri E. Deceased and living organ donation
in Iran. Am J Transplant. 2006;6(6):1493.
34. Einollahi B, Noorbala MH, Horeh SB, et al. Cadaveric kidney
transplantation in Iran model: opportunities, trends, and needs.
Exp Clin Transplant. 2006;4(2 suppl):141.
35. Malek-hosseini SA, Salahi H, Lahsaee M, et al. Initial experience
with liver transplantation in Iran. Transplant Proc. 2003;35(1):
375-376.
36. Salahi H, Mehdizadeh AR, Derakhshan A, et al. Evaluation of the
causes of graft loss in kidney transplant patients: a single center
study. Iranian J Med Sci. 2004;29(4):198.
37. Gholami SP, Mehdizadeh A, et al. The role of the transplant coordinator
on tissue donation in Iran. Transpl Int. 2005;18(suppl 1):270.
38. Iran's market in human organs 2006; http://www.
economist.com/world/international/displaystory.cfm?story_id=8
173393. Accessed Nov 30, 2007.
39. Bahador A, Yazdani M, Gholami S, et al. Foundation of local
network for increasing organ donation in southern Iran.
Transplant Proc. 2007;39(4):801-802.
40. Whiting JF, Kiberd B, Kalo Z, Keown P, Roels L, Kjerulf M. Cost-
effectiveness of organ donation: evaluating investment into
donor action and other donor initiatives. Am J Transplant.
2004;4(4):569-573.
41. Klarenbach S, Garg AX, Vlaicu S. Living organ donors face
financial barriers: a national reimbursement policy is needed.
CMAJ. 2006;174(6):797-798.
42. Ghods AJ, Ossareh S, Abedi Azar S, Savaj S, Shahroukh M.
Characteristics of patients remaining on chronic dialysis after
elimination of renal transplant waiting list in Iran. Transplant
Proc. 2002;34(6):2037-2038.
43. The World Bank. Annual Report 2005. Organ Transplants
Country Eligibility for Borrowing from the World Bank 2005.
http://web.worldbank.org/WBSITE/EXTERNAL/EXTABOUTUS/E
XTANNREP/EXTANNREP2K5/0,,contentMDK:20647778~menuP
K:1578499~pagePK:64168445~piPK:64168309~theSitePK:1397
343,00.html. Accessed Nov 30, 2007.
44. Butkus DE, Dottes AL, Meydrech EF, Barber WH. Effect of poverty
and other socioeconomic variables on renal allograft survival.
Transplantation. 2001;72(2):261-266.
45. Franssen H, Morton E. The Middle East economic survey. A
Review of US Unilateral Sanctions Against Iran. XLV (34)
http://www.mafhoum.com/press3/108E16.htm. Accessed in
Nov 30, 2007.