Global Epidemiology of Living Organ Donation
Living organ donation represents approximately 30% of all kidney transplantations performed annually in the United States, with significant global variation in rates and practices across the 83 countries that have established transplant programs. 1, 2
Geographic Distribution and Program Availability
- Of the 195 independent countries worldwide, only 83 have established transplant programs, meaning the majority of nations lack any formal living donation infrastructure 2
- Living donation rates vary widely between geographic regions and even between countries within the same geographic area, reflecting differences in cultural acceptance, regulatory frameworks, and healthcare infrastructure 2
- Some countries have emphasized and expanded living donation programs, while others have decreased or restricted this practice based on ethical, religious, or resource considerations 2
Volume and Trends
- In the United States specifically, living donor kidney transplantation has been a critical component of kidney failure treatment for over 7 decades, currently accounting for approximately 30% of all kidney transplants performed annually 1
- The annual count of repeat living donors (individuals donating a second time) has increased dramatically from 5 donors in 2018 to 25 donors in 2019, representing a significant emerging trend 3
- The percentage of nondirected (altruistic) donations has increased substantially, rising from 30.5% at first donation to 53.2% at second donation among repeat donors 3
Global Challenges and Disparities
- A major global problem is the severe shortage of organs for transplantation, which has led to the development of illegal or quasi-legal unregulated markets in some regions 1, 2
- The Declaration of Istanbul (2008) specifically addressed urgent problems of organ sales, transplant tourism, and trafficking in organ donors, noting reports of patient-tourists from wealthy countries traveling abroad to purchase organs from impoverished populations 1
- These underground unregulated markets have failed to provide adequate protection for either donors or recipients 2
International Variation in Practice Standards
- There remains considerable variation between countries—and even between programs within the same country—in donor evaluation protocols and acceptance criteria 1, 2
- US-based transplant centers differ significantly from non-US centers in their informed consent practices: US centers are more likely to use written materials and visual aids, mandate psychosocial evaluations, provide access to donor support groups, and discuss financial implications including travel expenses and lost income 4
- Conversely, non-US centers are more likely to offer long-term follow-up and utilize nephrologists to obtain written donor consent 4
- The heterogeneity in evaluation practices across professional associations and countries underscores the need for comprehensive international guidelines 1
Regulatory Framework Disparities
- In the United States, the United Network for Organ Sharing (UNOS) provides specific policies stipulating minimum required evaluation processes and follow-up of living kidney donors, with oversight of transplantation center compliance 1
- Most other countries lack similar regulatory oversight systems, creating significant gaps in donor protection and standardization of care 1
Critical Pitfalls in Global Context
- The transplant community has taken a unified stand against underground unregulated markets through international consensus statements like the Declaration of Istanbul 1, 2
- Each country should strive to provide organs to meet transplant needs from donors within its own population or through regional cooperation, rather than relying on exploitative international markets 1
- Educational programs are essential to address barriers, misconceptions, and mistrust that impede development of sufficient deceased donor transplantation programs, which would minimize the burden on living donors 1