Newsletters

Newsletter - December 2020


Welcome Message

Welcome to the first issue of the DICG newsletter. This is brought to you on behalf of the executive council of the Declaration of Istanbul Custodian Group (www.declarationofistanbul.org) which works to protect and promote the principles enunciated in the Declaration of Istanbul(DOI), a landmark document in the history of global transplantation.

In the extraordinary times that we are passing through and the impact of Covid 19 on global transplant activity, the DOI becomes even more relevant.

We are excited to start regularly communicating with our members, endorsing organizations and the global transplantation community. We would like to extend an opportunity for members to contribute articles or news for consideration in our forthcoming newsletter. Please email This email address is being protected from spambots. You need JavaScript enabled to view it.. We would also appreciate other feedback on the newsletter,

We start the first newsletter with a letter from Alejandro Nino Murcia, a transplant surgeon from Colombia & one of the co-chairs of the DICG who will be finishing his term in December.

Message From Alejandro Niño Murcia, Co-Chair of the DICG:

Just before ending my two-year term as Declaration of Istanbul Custodian Group (DICG) co-chair, I would like to share what this experience has meant to me. 

My journey with the DICG started in 2004, when a group led by Dr. Francis Delmonico helped us to handle a very difficult situation in Colombia. At that time, 16.5% of the transplant recipients done in Colombia were foreigners.

With the help of what would become the DICG, the transplantation laws in Colombia were modified in order to prevent transplant tourism and protect transplantation resources for Colombian recipients.  The result of this intervention was gratifying. Colombia changed from being a stigmatized country to an example for other countries as to how to deal of transplant tourism effectively. Today, less than 0.37% of the organ transplants performed in Colombia involve foreign nationals. We have set up systems to ensure that all transplantation of foreign nationals performed in Colombia have the necessary authorization from both the Columbian National Health Institute, as well as similar regulatory institutes in the patients’ country of origin. Working with the authorities and healthcare teams from patients’ home countries do not only save guard against fraud and deception, but also increase the long-term graft and survival outcome for patients returning home. 

After witnessing the changes in Colombia, I understood the importance of the Declaration of Istanbul and the Custodial Group encouraging countries to uphold the principles. This propelled me to become a member of the DICG and I had the privilege to serve as Co-Chair of the group, since the 2018 Madrid International Transplantation Congress. Every month, the DICG receives notifications about organ trafficking irregularities and transplant tourism occurring in different nations worldwide. As leaders of the DICG, we are able to interact with the respective authorities and local transplantation communities around the world and provide assistance to those countries who still have centers involved in illegal and unethical transplant practices.

With a global decrease in transplants as a consequence of the Covid-19 pandemics, new difficulties are arising in transplant access across the globe. Patients will unequivocally search for a solution for their needs in other countries where the economic crisis can signify ethical lability. Now more than ever, the scientific community must be strong in order to identify those centers and their members, where irregularities are being committed to guide and support them to ethical transplantation practices. This implies a need for a stronger DICG.

While I will be stepping down as Co-Chair at the end of 2020, I am happy to have had the opportunity to be part of such a dedicated group of individuals. I wish to thank my co-chair Eric Rondeau, the DICG executive and council, as well as all those who are dedicated to furthering the principles of the DOI.

In The News

In this section we carry links to recent news articles related to the DOI’s concerns. We are aware that it is not always possible for us to verify the contents of all the news being highlighted in popular media across the globe. However, we feel that since the media is talking about these issues, it may be important for us to know what the global population is seeing. Distrust in the transplant process amongst the general population is one of the barriers to setting up successful donation programs. Therefore, we need to engage with what impacts public perception in a responsible manner. If you would like to offer comments on an article posted by us, we request you to email This email address is being protected from spambots. You need JavaScript enabled to view it.. Our executive will consider your submission and if found suitable will carry it. We are clear that the intention behind this section is not to discredit the work of colleagues or further rumours. Therefore, we will try and stick to reputed and reliable news sources.

  • 'Leaked files, organ removal and irrepressible anger': What's behind the Kosovo war crimes probe?

    A recent report on an old conflict from Europe uncovers involuntary organ removal after death by killing

    Read the article

  • COVID-19 a ‘perfect storm’ for organ trafficking victims

    How Covid-19 serves as a 'perfect Storm' for organ trafficking

    Read the article

  • Meet this man who has put his kidney ‘on sale’

    A classic story from one of the poorest countries in the world

    Read the article

  • Kerala police open probe into organ transplant racket

    A large organ trafficking ring exposed from of India's most developed states

    Read the article

  • Organ harvesting industry booms in Lagos as probe deepens

    A ground investigation from Africa on 'life givers'

    Read the article

Recent Publications

In this section we highlight recent publications in literature that are related to the DOI. The selection and summaries have been prepared by Maryn Reyneke.
  • Assessing the Potential Impact of the Declaration of Istanbul 2008 on Internet Reporting of Human Organ Transplantation-Related Crimes Using Interrupted Time Series Analysis and Meta-Analysis Approaches

    Link: https://pubmed.ncbi.nlm.nih.gov/31917000/  

    Summary: Illegal activities, alleged crimes and injustices are often first reported in the news and other media platforms. While this reporting cannot always be taken as an accurate reflection of reality, it can give us insight into trends and possible geographical hotspots. In this article, the authors examined the impact of the Declaration of Istanbul on the reporting of transplantation related crimes on the internet.

    To do so, they made use of advanced google searches and interrupted time series analysis methodology. They collected data on “kidney trade,” “kidney sale,” “organ trafficking,” and “transplant tourism” reporting in 25 different countries with time points well before and after the 2008 promulgation of the DoI. They found that the DOI has a positive impact on the reporting of “organ trafficking” and “transplant tourism” but not on the reporting of “kidney sale” and “kidney trade.” They conclude to say that the increased reporting of “kidney sale” and “kidney trade” can be indicative of an impact of DOI on public awareness and increased reporting of the residual transplantation related crimes. 

    The authors then provide commentary, seemingly unrelated to the study conducted, and advocate for the legalization of organ trade. While this commentary is in direct conflict with the principles of the DoI, the results ofthe research could still provide valuable insight into the impact of the DoI.

  • Organ Trafficking and Migration: A Bibliometric Analysis of an Untold Story

    Link: https://www.mdpi.com/1660-4601/17/9/3204 

    Summary: It is estimated that the global refugee population in 2018 were 25.9 million, the number of internally displaced persons due to violence and conflict around 41.3 million and the number of stateless persons around 3.9 million (International Organization for Migration: World Migration Report 2020). Faced with poor socioeconomic and political conditions in their countries of origin, they often also fell prey to situations of vulnerability, abuse and exploitation while en-route or in host countries. These people are among the most vulnerable for the trafficking of humans for the purpose of organ removal (THBOR). Yet, this crime remains severely under detected and reported on, and as Gondzalez, Garijo and Sanchez’s (2020) article shows, sparsely researched. 

    Through a bibliometric analysis, the authors found that the 2008 Declaration of Istanbul has resulted in a significant increase in publications on the topic of human trafficking for the purpose of organ removal. However, the momentum has slowed down in recent years and has yet to catch up with literature on other types of human trafficking. The authors also found a significant gap in the literature focused on the relation between THBOR and migrants. This study provides a renewed focus on a specific vulnerable group which should not be neglected in the quest to prevent organ trafficking.

Thematic Discussion

Approximately, every other month, the DICG council hosts thematic discussions around topics relating to the DOI’s concerns including emerging issues in ethics and equity in global transplantation.

Summary provided by, Thomas Mueller, MD, PD Co-director, Lead Attending, Clinic of Nephrology, University Spital Zürich, Zürich, Switzerland

Organs from Living Donors – Transplantation of the super affluent traveling recipient accompanied by their donor

The DIGC concerns itself with trafficking of organs and humans for transplantation. Thus far most emphasis has been on the sale of organs and exploitation of vulnerable populations for transplantation in lower income settings. A potentially relevant, but thus far less discussed area is that of affluent non-resident recipients who travel, frequently with non-resident, often genetically un-related donors, to other countries for transplantation because of purported high medical standards. The frequency of this situation varies from country to country, but it generally lacks transparency.

In the typical scenario, the transplant center is contacted via an agency or an intermediary with the wish of their affluent client to be transplanted. Usually the medical information provided is incomplete, often from multiple private centers all over the world. In general transplantability has already been determined and the recipient has a potential donor. The relationship between recipient and donor is often a family or business “friend”, not genetically related or family member, there are clear socio-economic asymmetries, and the depth of the altruistic motivation is not clear. The medical work-up is complicated by multiple parties are involved. It is very time intensive for the transplant team, exceptions are the rule, and the usual processes of donor and recipient work-up are often not followed. Hospitals may add further pressure as these transplants are viewed as a source of revenue and reputation.

Fundamental to this process are ensuring transparency, assessing voluntariness and ruling out coercion. In addition, issues regarding impact on social justice and equity (impact on local patients), loyalty to the institution and protection of the health care staff, who frequently experience moral distress in these cases, are of importance. 

  To achieve transparency and to prevent organ trafficking a defined multi-step process for living kidney donation and transplantation between self-paying non-resident living donor and recipient has been developed at the University Hospital in Zurich, which was presented to the DIGC as a possible template for the individual centers (Figure 1). 

Figure 1. Overview of process for living kidney donation and transplantation between self-paying non-resident living donor (D) and recipient (R)

Key elements of this algorithm include: provision of documents outlining the ethics of organ transplantation (DOI, WHO guiding principles); information on requirements of payments; process of legal and medical assessment; written statements confirming the voluntariness and motives of donation; lack of financial incentives; proof of life-long health care insurance for the donor; agreement to reporting and data collection. 

DICG members agreed such a document and process is needed, and the participants supported the use of the presented algorithm as a template for other countries. The discussion made it clear that significant local and national differences exist regarding the problem of the non-resident recipient and donor. All participants agreed on the significance of this topic as a potential form of organ trafficking and that the establishment of clear rules by the DICG is required.

New Endorsing Organizations:

The DOI has been endorsed by numerous organizations. This list and the procedure for endorsement is available on our website. In this section we will carry names of new organisation who endorse the DOI.

  • Centro Nazionali de Trapianti, Italy

    Visit the website

  • Instituto Portugês de Sangue e da Transplatção, Portugal

    Visit the website

  • Iraqi Society of Nephrology and Renal Transplantation

  • China National Organ Donation and Transplantation Committee

View Past Newsletters

The newsletter is brought to you on behalf of the executive council of the Declaration of Istanbul Custodian Group which works to protect and promote the principles enunciated in the Declaration of Istanbul(DOI), a landmark document in the history of global transplantation.

Newsletter - February 2021


Welcome Message

Welcome to the second issue of the DICG newsletter.

Covid 19 has proven to be a tumultuous experience for everyone across the globe. We hope that once the Covid 19 "curtain" has lifted, we will not discover significant unethical transplant activities being conducted "behind the scenes."

Our community remains strong throughout the turmoil, we look to our endorsing organizations and the global transplantation community to continue promoting ethical transplant practices world-wide.

We would like to extend an opportunity for members to contribute articles or news for consideration in our forthcoming newsletter. We furthermore welcome any feedback or comments. To do so, please email This email address is being protected from spambots. You need JavaScript enabled to view it..

We start the second newsletter with a letter from Sanjay Nagral, a transplant surgeon from India and one of the co-chairs of the DICG who just started his term in January, 2021.

Message From Sanjay Nagral, Co-Chair of the DICG:

A few years ago, I was introduced to the DICG, a remarkable group of transplant professionals and ethicists who have strived for more than a decade to highlight and combat organ trafficking and unethical practices in global organ transplantation. This group had originated from a meeting held in Istanbul in 2008 where the Declaration of Istanbul, a significant document on organ trafficking and transplant tourism, was put together by individuals from many countries. I found its focus and work particularly relevant as I come from a region that has seen this modern form of slavery in its history. Also where with notable exceptions, professionals and their associations have sometimes been complicit and often not been very vocal about these issues. 

South Asia in general and India, in particular, went through a phase of significant trafficking and commercialism in kidney transplantation. With many countries in the region promulgating laws outlawing the organ trade, there is now a semblance of regulation and control on this activity. However, the potential for the trade remains alive and, in fact, does rear up its head periodically. The background of severe social inequality and the fact that deceased donation has still not taken root in the region provides the backdrop.

During my work with the DICG, I have had the opportunity to interact with courageous professionals who have devoted significant time to the issue, even at the risk of being isolated amongst their peers. I have had the honour of being nominated as the co-chair of the DICG starting in 2021. Along with my co-chair Eric Rondeau, colleagues on the DICG council as well our mother organizations TTS and ISN, we hope to carry forward the agenda of the DOI.

I am aware that given the severe demand for organs, the task set out before us is humungous. We are also passing through one of humankind's toughest existential challenges in the form of the Covid pandemic, which has exacerbated the demand supply gap in transplantation. However, it is clear that we cannot progress without active participation and sustained pressure from the global transplantation community. This newsletter is one small step towards this.

In The News

In this section we carry links to recent news articles related to the DOI’s concerns.

As mentioned in our first newsletter, we are aware that it is not always possible for us to verify the contents of all the news being highlighted in popular media across the globe. However, we feel that since the media is talking about these issues, it may be important for us to know what the global population is seeing. Distrust in the transplant process amongst the general population is one of the barriers to setting up successful donation programs. Therefore, we need to engage with what impacts public perception in a responsible manner. If you would like to offer comments on an article posted by us, we request you to email This email address is being protected from spambots. You need JavaScript enabled to view it.. Our executive will consider your submission and if found suitable will carry it.

The explicit intention behind this section is not to discredit the work of colleagues or further rumours. Therefore, we will try and stick to reputed and reliable news sources. Additionally, we are educating ourselves on the ethics of journalism and are learning about how we can more responsibly report on the news.

  • In Afghanistan, a Booming Kidney Trade Preys on the Poor

    Earlier this month saw the publication of a major investigative piece by the New York Times on what they have described as a large paid kidney donation activity in Herat in Afghanistan. The DICG along with the TTS have written to the hospital authorities to obtain more information on the matter.

    Read the article

  • Dhs3m fine, 7 years in jail for trading in human organs and tissues in UAE

    There have been several news reports on this story.

    Additional Report

    Read the article

  • Kidney transplantation racket busted in Noida; Bangladeshi national among 2 held

    Read the article

Recent Publications

The renewed focus on the issue of racial disparity in healthcare has been the subject of many recent journal articles, including articles dealing with organ donation and transplantation. Whilst the Declaration of Istanbul (DoI) does not directly address racial inequalities, one of its principles clearly states that 'Organs for transplantation should be equitably allocated within countries or jurisdictions, in conformity with objective, non-discriminatory, externally justified and transparent rules, guided by clinical criteria and ethical norms.' It is not the DoI's nature to detail how to deal with such issues, but it provides universal principles guiding ethical organ donation and transplantation practices globally.

In this edition of the newsletter, we've collected some complementary articles, contributing to our understanding of the nature and ethics of racial discrimination in organ donation and transplantation. The DICG does not necessarily endorse each of the individual articles' recommendations but wishes to build on a library of resources for DICG members to use while addressing unfair discrimination in practice.

This month's publication selection has been prepared by Maryn Reyneke

  • Race, Racism, and Access to Renal Transplantation among African Americans

    Link: https://doi.org/10.1353/hpu.2017.0005  

    Author: Kimberly Jacob Arriola

    Journal reference: Journal of Health Care for the Poor and Underserved 28 (2017): 30–45.

    Summary: This normative article by Jacob Arriola takes two major theories and places them in the practical context of transplantation. The author motivates us to move beyond the documentation of ethnic disparities in transplantation but to get a deeper understanding of why these disparities exist. The role of racism is complex, and prevention or compensation interventions often do not address the problem's multiple and interconnected layers. The paper gives a detailed overview of the manifestation of racism, namely internalized, personally- mediated, and institutionalized racism, and describes how they can be recognized in the different levels of the social ecology of healthcare and transplantation. This paper concludes with clinical, research, and policy recommendations.

    To do so, they made use of advanced google searches and interrupted time series analysis methodology. They collected data on “kidney trade,” “kidney sale,” “organ trafficking,” and “transplant tourism” reporting in 25 different countries with time points well before and after the 2008 promulgation of the DoI. They found that the DOI has a positive impact on the reporting of “organ trafficking” and “transplant tourism” but not on the reporting of “kidney sale” and “kidney trade.” They conclude to say that the increased reporting of “kidney sale” and “kidney trade” can be indicative of an impact of DOI on public awareness and increased reporting of the residual transplantation related crimes. 

    The authors then provide commentary, seemingly unrelated to the study conducted, and advocate for the legalization of organ trade. While this commentary is in direct conflict with the principles of the DoI, the results ofthe research could still provide valuable insight into the impact of the DoI.

  • Racial Disparities in Preemptive Waitlisting and Deceased Donor Kidney Transplantation: Ethics and Solutions

    Link: https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.16392 

    Author: Reese, P; Mohan, M. et al.

    Journal reference: American Journal of Transplantation. 2021;00:1–10.

    Summary: Preemptive renal transplantation holds various benefits for patients with end-stage renal disease and should be the aim of all transplant programs. Reese et al. recognized that preemptive renal transplantation practices also give us a clear case presentation to study the effects of systematic racial disparities. Their article provides an excellent description backed up with empirical data of where and why White, better educated, and privately insured patients access the benefits of preemptive transplantation more than other racial groups. They, furthermore, provide an ethical analysis of one of the main exacerbation factors, namely allocation policies based on the first-come-first-serve approach, and propose initiatives to improve this inequity. 

  • Social Determinants of Health and Race Disparities in Kidney Transplant

    Link: https://doi.org/10.2215/CJN.04860420

    Author: Wesselman, H.; Ford, C. G. et al.

    Journal reference: Clinical Journal of the American Society of Nephrology. 2021. Vol 16. Issue 2

    Summary: In the article by Wesselman et al., the authors pin down the medical and social determinants of health associated with racial disparities in transplantation by prospectively examining 1056 patients referred for renal transplantation. While it is no surprise that their study confirmed the high incidence of renal failure, combined with a lower rate of deceased and living donor transplantation in Black population groups, this study contributes to our nuanced understanding of where inequalities exist. The data provides insights on how to tailor transplant education, deploying media campaigns to increase awareness of transplant options, and support disadvantaged groups through the process of organ donation and transplantation.

Thematic Discussion

Approximately every other month, the DICG council hosts thematic discussions around topics relating to the DOI's concerns, including emerging issues in ethics and equity in global transplantation. This month, there was a thematic discussion on "The impact of transplantation in the private sector; Lessons from South Asia" lead by Sanjay Nagral.

In March, we will have another thematic discussion on "Gender disparity in access to transplantation" which will be lead by Nancy Ascher.

We look forward to reporting on these two thematic discussions in the next newsletter.

New Endorsing Organizations:

The DOI has been endorsed by numerous organizations. This list and the procedure for endorsement is available on our website. We look to our endorsing societies to help further the principles of the DOI. We ask that our endorsing societies make sure that their logo and information is correct on the site. Additionally, we welcome endorsing organizations' to send news or event notification. If applicable, we will carry it in the next newsletter.

View Past Newsletters

The newsletter is brought to you on behalf of the executive council of the Declaration of Istanbul Custodian Group which works to protect and promote the principles enunciated in the Declaration of Istanbul(DOI), a landmark document in the history of global transplantation.

Newsletter - July 2021

Welcome to the July issue!

In this newsletter we highlight recent awards & achievements of DICG current and past leadership, current events as well as other important topics.

And, in case you missed it in April, 2021 we launched the DICG Course on Ethical Issues in Transplantation and The Declaration of Istanbul.

Pontifical Academy of Sciences Workshop

The Role of Science in the Development of International Standards of Organ Donation and Transplantation


"The Pontifical Academy of Sciences (PAS) is a scientific academy of the Vatican City, established in 1936 by Pope Pius XI, and thriving with the blessing of the Papacy ever since. Its aim is to promote the progress of the mathematical, physical, and natural sciences and the study of related epistemological problems. The PAS under the leadership of Pope Francis has been engaging with the global problem of slavery. In 2017, it organised a Pontifical Academy Summit on Organ Trafficking and Transplant Tourism. The objectives were to describe the widespread extent of transplant tourism and organ trafficking (testimony given by attendees from countries with transplant services currently throughout the world); prepare a Statement referable to the Pontifical Academy Summit that would be signed by the participants and distributed worldwide; engage a group of stakeholders (Government Officials, Prosecutors, Investigators, Justices, and Journalists) who can be influential in the long term in combatting organ trafficking in an alliance with transplant professionals; develop an alliance of individuals committed to combating organ trafficking and transplant tourism – and engaging health authorities to achieve a prohibition of organ trafficking as a form of human slavery – by the representatives participating in the Pontifical Academy Summit."

Click To Access This Statement On The PAS Website

This report was written by Francis Delmonico, Beatriz Dominguez-Gil and Nancy Ascher.

A Workshop of health officials was convened on June 21-22 by the Pontifical Academy of Sciences and cosponsored by the WHO promoting the Role of Science in the Development of International Standards of Organ Donation and Transplantation by addressing these health care issues:

  • Evaluation of the burden of disease that results in organ failure and necessitating organ transplantation for treatment;
  • A compelling case for prioritizing organ transplantation in the treatment of organ failure.
  • Technical considerations for developing and optimizing organ transplantation as a health care treatment option for patients with organ failure;
  • Strengthening the regulatory capacity for oversight of practice.
  • The role of transplantation in the treatment continuum of organ failure as a part of Universal Health Care.

Below are the most recent data of the ONT WHO Global Observatory regarding the global activity in organ transplantation.

A report of the deliberations of this workshop will be distributed to the international community of stakeholders that present recommendations to address the burden of disease and the epidemic of organ failure - in the context of achieving universal healthcare and optimizing organ transplantation as a treatment. The recommendations of the Workshop will also address international standards needed to achieve quality and safety for transplant recipients and their living organ donors.


In The News

We have chosen to highlight two notable articles on illegal kidney transplantation.

We are aware that it is not always possible for us to verify the contents of all the news being highlighted in popular media across the globe. However, we feel that since the media is talking about these issues, it may be important for us to know what the global population is seeing. If you would like to offer comments on an article posted by us, we request you to email This email address is being protected from spambots. You need JavaScript enabled to view it.. Our executive will consider your submission and if found suitable will carry it. The explicit intention behind this section is not to discredit the work of colleagues or further rumours. Therefore, we will try and stick to reputed and reliable news sources.

Recognition

      Past and Present DICG Leadership

Recently, past and present members of the DICG leadership have been recognized globally for their accomplishments. We are very proud of the DICG community for their acheivements and what they have done for the global transplant community.


Recent Publications

      South Asia Edition

Over the past couple of months there have been a couple of notable publications on South Asia. One of which is co-authored by DICG council member, John Gill.
We have asked John Gill share with us his thoughts and some background on the publication.
The tremendous advances in living donor transplantation in India are an extraordinary achievement. However, it is now time to build upon that success to ensure that the established expertise and infrastructure benefits more Indian patients in need of life saving transplants. This can only be achieved by investment in deceased donation. The editorial proposes some tangible steps that the Indian government could implement to advance deceased donor services given the realities of finite resources. The solutions may or may not be feasible, but our intent was to focus attention on the urgent need for government action. While the editorial exposes problems within the current system, our motivation was not to be critical– rather it is our hope that the editorial will help leaders in the Indian transplant community to advocate for government leadership and investment to advance deceased donation in India for the benefit of all patients in need of an organ transplant.

https://doi.org/10.1111/ajt.16537


Transplantation's Most Downloaded Paper

Thank you to all of our members and endorsing organizations for promoting the DOI and the DICG which has lead to the 2018 edition of the DOI being the most downloaded paper last week!

Click Here To View (Open Access)


The DICG Course on Ethical Issues in Transplantation and The Declaration of Istanbul

In case you missed the launch of the DICG Course on Ethical Issues In Transplantation and The Declaration of Istanbul be sure to register! The course was designed to give a complete overview of the DOI. There are three main modules in the curriculum. History of the DOI, 2018 Edition of the DOI and Ethical Issues Related to the DOI. There is also a series of regional updates. While the Modules are all available at this time, periodically, there will be updates and additions to the content.

The course is free and open to all participants who want to learn about ethics in transplantation, the DOI and the DICG. Upon completion, all participants will be eligable for a certificate.

Please encourage your colleagues, fellows and trainees to participate!

Click Here To Access The Course


View Past Newsletters

The newsletter is brought to you on behalf of the executive council of the Declaration of Istanbul Custodian Group which works to protect and promote the principles enunciated in the Declaration of Istanbul(DOI), a landmark document in the history of global transplantation.

Newsletter - April 2021


Welcome Message

Welcome to the April issue of the DICG newsletter.

In this newsletter we highlight new legislation in organ donation and transplantation, past meetings and thematic discussions, publications concerning the GKE as well as other important topics.

We are also excited to announce the launch of the DICG Course on Ethical Issues in Transplantation and The Declaration of Istanbul.

The DICG Course on Ethical Issues in Transplantation and The Declaration of Istanbul

We are excited to launch the the DICG Course on Ethical Issues In Transplantation and The Declaration of Istanbul. The course was designed to give a complete overview of the DOI. There are three main modules in the curriculum. History of the DOI, 2018 Edition of the DOI and Ethical Issues Related to the DOI. There is also a series of regional updates. While the Modules are all available at this time, periodically, there will be updates and additions to the content.

The course is free and open to all participants who want to learn about ethics in transplantation, the DOI and the DICG. Upon completion, all participants will be eligable for a certificate.

Please encourage your colleagues, fellows and trainees to participate!

Click Here To Access The Course

In The News

This month, we are highlighting new laws and regulations accross the globe relating to organ donation and transplantation.

If you would like to offer comments on the articles posted by us, we request you to email This email address is being protected from spambots. You need JavaScript enabled to view it.. Our executive will consider your submission and if found suitable will carry it.

  • Canada: An Act to amend the Criminal Code and the Immigration and Refugee Protection Act (trafficking in human organs)

    Read the article

  • Sri Lanka: Launch of ‘National Organ Donor Card’ gives fresh lease of life to many

    Read the article

  • Saudi Arabia: The Cabinet approved the human organ donation regulation

    Read the article

Recent Publications: GKE Edition

The Global Kidney Exchange (GKE) is a cross-border paired kidney exchange between pairs from countries with different economic backgrounds and healthcare systems. While the idea is noble and could hold solutions to the global crisis in organ shortages, we believe the particular benefit-sharing model is deceptive, provides disproportionate benefits to high-income countries and puts donor-recipient pairs from low-to-middle-income countries at risk for organ trafficking and exploitation.

Since the start of the GKE, the program methodology has been much contested and remains controversial. While the DICG leaders condemn the program in its current form, we believe that DICG members should stay up to date and informed with the debate on the GKE. As Marino et al. (2017) aptly titled one of their response letters: “Open dialogue between professionals with different opinions builds the best policy”.

Our regular newsletter contributor, Maryn Reyneke, has recently published an article on the GKE. We’ve used the moment and asked her to provide us with a literature update.

Read the full article...

The Global Kidney Exchange basics

The GKE concept has been introduced and piloted by a group of clinicians, ethicist and economist lead by Prof Michael Rees in the United States. While they envision the GKE concept to be replicated by other clinical centres1 they are currently the only known centre to have implemented a GKE program. Their first publication in 2017 on the pilot study, titled ‘Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation’2, a letter to the editor in response to commentary on the first article3 and a 3-year review4, provide us with the program methodology, some practicalities and clinical findings.

Supporting, condemning and commentary on the Global Kidney Exchange

The GKE evoked much controversy and various international groups and organisations have taken positions for or against the GKE concept in its current form. Shortly after the publication of ‘Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation’2, the WHO Task Force on Donation and Transplantation of Human Organs and Tissues5, the Council of Europe's Committee on Organ Transplantation6, and the Declaration of Istanbul Custodian Group7 condemned the GKE, while the American Society of Transplant Surgeons8 publicly approved it. This initial wave of position statements and various editorial letters by leaders in the field of transplantation (9–12) strongly focussed on questions of financial neutrality, exploitation and organ trafficking.

In 2019, the bioethicists Minerva, Savulescu and Singer 13 published an article supporting the GKE concept. They described the GKE as a benefit-sharing transaction with certain risks carried by both the high-income country pairs and the low to middle-income country (LMIC) pairs. They also viewed the GKE through a different philosophical lens. While most opponents of the GKE, so far, argued from a deontological perspective and based their arguments on principles like the principles of the Declaration of Istanbul, this group asked what is the greatest good for the greatest number. From this perspective, some burdens may be allowed if it saves lives.

A publication by the European Society for Organ Transplantation14 in 2020 focused the GKE debate on a more practical level, raising concerns related to the management of escrow funds and potential corruption. This publication furthermore highlighted the need for empirical research and patient views.14 The latest publication related to the GKE, published by a DICG member, picked up the initial concern of exploitation and viewed it through different theoretical lenses15. This article also placed the focus on the previously unnamed stakeholder group namely, future end-stage renal disease patients who could carry additional burdens if present benefit-sharing decisions do not take them into account.15

The vast majority of authors commenting on the GKE are from high-income countries. While some Indian and Egyptian authors briefly mentioned cross-cultural challenges and logistics as reasons why LMICs should not participate in global or transnational exchanges,16,17 the voices of LMICs remains underrepresented in the literature.

References

1. Roth AE, Marino IR, Ekwenna O, et al. Global Kidney Exchange should expand wisely. Transplant International. Published online 2020:0-2. doi:10.1111/tri.13656

2. Rees MA, Dunn TB, Kuhr CS, et al. Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation. American Journal of Transplantation. 2017;17(3):782-790. doi:10.1111/ajt.14106

3. Rees MA, Paloyo SR, Roth AE, et al. Global kidney exchange: Financially incompatible pairs are not transplantable compatible pairs. American Journal of Transplantation. 2017;17(10):2743-2744. doi:10.1111/ajt.14451

4. Bozek DN, Dunn TB, Kuhr CS, et al. Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up. European Urology Focus. 2018;4(2):190-197. doi:10.1016/j.euf.2018.07.021

5. WHO Task Force on Donation and Transplantation of Human Organs and Tissues. Position Statement on the Proposal for a Global Kidney Exchange as Adopted by the WHO Task Force on Donation and Transplantation of Human Organs and Tissues.; 2018. Accessed May 4, 2020. https://www.who.int/transplantation/donation/GKE-statement.pdf

6. Council of Europe. CD-P-TO Position Statement on Global Kidney Exchange Concept.; 2018. https://www.edqm.eu/sites/default/files/statement-transplantation-global-kidney-exchange-concept-april2018.pdf

7. DICG. Statement of the Declaration of Istanbul Custodian Group concerning Ethical Objections to the Proposed Global Kidney Exchange Program. Published 2018. Accessed December 4, 2019. http://declarationofistanbul.org/resources/policy-documents/795-statement-of-the-declaration-of-istanbul-custodian-group-concerning-ethical-objections-to-the-proposed-globalkidney-exchange-program

8. American Society of Transplant Surgeons. ASTS Position on Global Kidney Exchanges. Published 2017. Accessed December 27, 2019. https://asts.org/about-asts/position-statements#.XgWWuRdKjfY

9. Delmonico FI, Ascher NL. Opposition to irresponsible global kidney exchange. American Journal of Transplantation. 2017;17:2745-2746. doi:10.1111/ajt.14473

10. Pullen LC. Global Kidney Exchange: Overcoming the Barrier of Poverty. American Journal of Transplantation. 2017;17(10):2499-2500. doi:10.1111/ajt.14469

11. Valera L, Carrasco MA. On the Global Kidney Exchange programme. The Lancet. 2020;395(10235):1484-1485. doi:10.1016/S0140-6736(20)30625-5

12. Brunner R, Ekwenna O, Reese S, et al. Global Kidney Exchange: An international approach to expanding living donor kidney transplantation in minority groups. 2018.

13.Minerva F, Savulescu J, Singer P. The ethics of the Global Kidney Exchange programme. The Lancet Health Policy. 2019;394(394):1775-1778. doi:10.1016/S0140-6736(19)32474-2

14. Ambagtsheer F, Haase-Kromwijk B, Dor JMF, et al. Global Kidney Exchange: Opportunity or Exploitation? An ELPAT/ESOT Appraisal. Transplant International. Published online 2020.

15. Reyneke M, Borry P. The Global Kidney Exchange: Revisiting exploitation arguments. Developing World Bioethics. 2021;44(November 2020):1-8. doi:10.1111/dewb.12311

16. Kute V, Jindal RM, Prasad N. Kidney Paired-Donation Program Versus Global Kidney Exchange in India. American Journal of Transplantation. 2017;17(10):2740-2741. doi:10.1111/ajt.14324

17. Elrggal ME, Tawfik M, Gawad MA, Sheasha HA. Kidney paired donation program, a national solution against commercial transplantation? Journal of The Egyptian Society of Nephrology and Transplantation. 2018;18:6-10. doi:10.4103/jesnt.jesnt_1_18

Thematic Discussion

The DICG council hosts thematic discussions around topics relating to the DOI's concerns, including emerging issues in ethics and equity in global transplantation.

In March, the DICG held another thematic discussion on "Gender disparity in access to transplantation" which was lead by Nancy Ascher.

Click below to view a snapshot from the thematic discussion presented by Curie Ahn (South Korea) where she discusses findings from a recent Women in Transplantation Meeting about gender disparity in Asia.

DICG Session at WCN 2021:

On April 14th, 2021, a DICG session was organized during the World Congress of Nephrology 2021. This session was chaired by Dr John Gill (Vancouver, Canada) and Dr Eric Rondeau (Paris, France) and included 4 presentations given by outstanding speakers.

The first speaker was Dr Nancy Ascher (San Francisco, USA) who recalled the history of the Declaration of Istanbul and the many actions of DICG since its creation. She also encouraged young professionals involved in transplantation to become DICG members.

The second speaker was Dr Marie-Chantal Fortin (Montréal, Canada) who spoke about the transplantation of foreign nationals (non citizens, non residents) in North America. She noted that the ethical issues are numerous and the organizations may vary from one state/province to another.

The third speaker was Dr Jim Rodrigue (Boston, USA) who analyzed what does financial neutrality for living donors means, and discussed payment, incentives and financial neutrality for living donors.

Finally, Dr Toby Coates (Adelaïde, Australia), described the Global Organ Trafficking Registry (GOTR) project that DICG is about to launch, to improve our knowledge of potential cases of organ trafficking and hotspots for illegal travels for transplantation.

Those who were registered for WCN2021 but missed the session can log in and view it Here.

View Past Newsletters

The newsletter is brought to you on behalf of the executive council of the Declaration of Istanbul Custodian Group which works to protect and promote the principles enunciated in the Declaration of Istanbul(DOI), a landmark document in the history of global transplantation.

Newsletter - September 2021


Welcome to the September issue!

Focus on India!

Welcome to the September Issue of the DICG Newsletter. In this issue, we have decided to focus on recent news articles and publications with a spotlight on India. The articles were written by members of the DICG council. India now performs one of largest number of transplants world-wide. We acknowledge the great strides our colleagues in India have taken to eradicate Organ Trafficking and Organ Comericialism in India as well as promote equity in transplantation. The focus on India is to better understand some of the challenges to ethical transplantation. Our colleagues and endorsing organizations are working hard to improve all aspects of transplantation in India. We encourage discussion and hope that this newsletter will be a catalyst for open discourse.

In The News

We have chosen to highlight a notable article on organ trafficking in Assam, India. Which has been written by DICG members from India. In a leading national daily newspaper.

The DICG has reached out to local government officials, as well as endorsing organizations of the DOI to address the reports. We have recieved a handful of responses and will be following up. We support the ongoing efforts of our colleagues and officials in India who are working to promote ethical transplantation and hold those responsible accountable.


Recent Publications

      South Asia Edition

Over the few past months there have been a couple of notable publications on South Asia in leading transplantation journals. One of which is co-authored by DICG council member, John Gill and DICG member Sunil Shroff. The second is co-authored by DICG co-chair Sanjay Nagral and DICG member Vivekanand Jha along with colleagues from India. The third publication is written by ISOT secretary and TTS Ethics Committee co-chair, Vivek Kute and colleagues from India.
We have asked John Gill share with us his thoughts and some background on the publication.
The tremendous advances in living donor transplantation in India are an extraordinary achievement. However, it is now time to build upon that success to ensure that the established expertise and infrastructure benefits more Indian patients in need of life saving transplants. This can only be achieved by investment in deceased donation. The editorial proposes some tangible steps that the Indian government could implement to advance deceased donor services given the realities of finite resources. The solutions may or may not be feasible, but our intent was to focus attention on the urgent need for government action. While the editorial exposes problems within the current system, our motivation was not to be critical– rather it is our hope that the editorial will help leaders in the Indian transplant community to advocate for government leadership and investment to advance deceased donation in India for the benefit of all patients in need of an organ transplant.

Bold policy changes are needed to meet the need for organ transplantation in India - AJT February, 2021


DICG Representation In The 2021 ASHI Hybrid Meeting Program

DICG Co-Chair, Eric Rondeau and Executive Council Member, Maria Amalia Matamoros will be part of a pannel in a session entitled "Challenges and Opportunities in Transplantation Worldwide."

The session will describe the landscape of solid-organ and stem-cell transplantation in different areas of the world (the Middle East, China and India) highlighting the similarities and differences with transplant activities in the West. The speakers will discuss challenges in histocompatibility testing related to multiple areas, including the disease landscape, donor types and availability (related and unrelated), HLA typing, clinical practices, clinical data management and legal, ethical, and social considerations. The workshop will include three 20-minute presentations followed by a 30-minute panel discussion.

Click Here to Learn More About the Session


ISN-TTS Sister Transplant Centers Program Application Deadline

The ISN - TTS Sister Transplant Centers Program is now accepting applications until October 1st, 2021

The program is a joint partnership between the International Society of Nephrology (ISN) and The Transplantation Society (TTS) who are the parent organizations of the DICG, to help establish new kidney transplant centers and develop existing kidney transplant programs in emerging countries. Please note that the program is open to all ISN and TTS members. This initiative fosters partnerships between experienced transplant centers in the developed world (Supporting Centers or SCs) and new and developing transplant centers (Emerging Centers or ECs) in low-resource regions, providing a framework and funding for up to six years of collaboration if adequate progress is made.

Click Here to Learn More About The Program and How to Apply

A similar program for liver centers which is a partnership between TTS and ILTS called the TTS-ILTS Paired Transplant Centers Program. This program will be accepting applications later this fall with a deadline of January 1st. More information can be found at TTS-ILTS.ORG

The Philippine Society of Nephrology (PSN) webinar "Organ Trafficking in the 2020s – A Persisting Challenge for Transplant Professionals" Summary

The Philippine Society of Nephrology (PSN) started a webinar series on ethics and professionalism in November 2020. In the seventh session of the series, held on July 28, 2021, the topic was “Organ Trafficking in the 2020s – A Persisting Challenge for Transplant Professionals.” The ISN graciously agreed to co-host this event and Dr. Agnes Fogo gave the opening remarks. This is a particularly relevant topic for the organization because the Philippines was declared an organ trafficking hotspot by the WHO in 2007. Since then, the PSN has been on the forefront of promoting ethical practices in transplantation.

Dr. Benita Padilla, a DICG Council member and past president of the PSN, described how changes in the regulations in the Philippines more than a decade ago successfully turned the tide against organ trafficking but new challenges continue to crop up. The talk of Dr. Dominique Martin, focusing on how ethical principles can be converted to concrete actions, was particularly relevant in suggesting strategies to combat these new challenges. Dr. Sanjay Nagral and Dr. Guia Crisostomo-Tan contributed other perspectives, noting that there are many commonalities in the ethical challenges that transplant professionals in India and in the Philippines have to face.


The DICG Course on Ethical Issues in Transplantation and The Declaration of Istanbul

In case you missed the launch of the DICG Course on Ethical Issues In Transplantation and The Declaration of Istanbul be sure to register! The course was designed to give a complete overview of the DOI. There are three main modules in the curriculum. History of the DOI, 2018 Edition of the DOI and Ethical Issues Related to the DOI. There is also a series of regional updates. While the Modules are all available at this time, periodically, there will be updates and additions to the content.

The course is free and open to all participants who want to learn about ethics in transplantation, the DOI and the DICG. Upon completion, all participants will be eligable for a certificate.

Please encourage your colleagues, fellows and trainees to participate!

Click Here To Access The Course


View Past Newsletters

The newsletter is brought to you on behalf of the executive council of the Declaration of Istanbul Custodian Group which works to protect and promote the principles enunciated in the Declaration of Istanbul(DOI), a landmark document in the history of global transplantation.

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