Comparison of Spousal With Other Donor Groups: Study of

a Single Center
J. Roozbeh, A.R. Mehdizadeh, M.A. Izadfar, A. Razmkon, H. Salahi, and S.-A. Malek-Hosseini

ABSTRACT
In coping with the shortage of living-related and cadaveric donor groups for renal
transplantation, and in the fear of organ marketing, spousal donors are considered an
invaluable potential source. Survival rates have been reported to be as high as even some
related groups. This study evaluated 1039 renal transplantations up to 2003. Patient
survival rates in different donor groups were determined using the Kaplan-Meier method.
The 3-year patient survival rates were 93% for kidneys from 61 spouses; 92% for kidneys
from 433 living-related donors; 91% for kidneys from 427 living-unrelated (excluding
spouses) donors; and 90.5% for 118 cadaveric kidneys. Such results were consistent with
many other reports which consistently showed that spousal donors were at least as good as
living-related donors, representing a reliable source in cases of organ shortage. The high
survival rate of spousal donors is probably related to their strong emotional support.

T HE SEVERE SHORTAGE of organs is one of the

major barriers facing the issue of transplantation
today. One of the proposals designated to overcome this
serious problem is to increase the use of genetically unre-
lated living kidney donors.1– 4 Recent studies have shown
that the survival rates of kidney transplantation among
spouses are as high as even some related groups, despite
poor HLA matching.5 Kidney donation by spouses has been
ethically approved in many countries, but is prohibited by
law in others.6,7 In Iran, kidney transplantation from spou-
sal donors has been a part of living-unrelated kidney
programs. In the Iran model of the living-unrelated donor
renal transplant program, all renal transplant candidates
are told of the advantages of living-related donors com-
pared with living-unrelated donors. If the patient has no
living-related donor, he or she is referred to the Dialysis
and Transplant Patients Association (DTPA) to find a
suitable living-unrelated donor. The objectives of this study
were to evaluate the patient and graft survival rates in
spousal combinations compared with the corresponding
rates in living-related, living-unrelated, and cadaveric donor
grafts in our center, as well as to compare the results of wife
to husband and husband to wife kidney transplantation.
MATERIALS AND METHODS
Up to 2003, we performed 1039 renal transplantations. The Kaplan-
Meier method was used to compare the survival rates of patients
and grafts from 61 spouses, 433 living-related donors, 427 living-
unrelated donors (excluding spouses), and 118 cadaveric donors. In
Iran, marriage between relatives (eg, cousins) is common; there-
fore, related spouses were excluded in this study. The minimum
follow-up period was 12 months. The immunosuppressive protocol
consisted of azathioprine, prednisolone, cyclosporine, and myco-
phenolate mofetil, which has been described previously.8 Overall
patient and graft survival rates, patient and graft survival rates in
wife to husband and husband to wife, and the causes of graft loss
were studied. Patient and graft survival rates were compared with
the corresponding rates in living-related, living-unrelated, and
cadaveric transplantations. Graft loss was defined as patient death
or return to chronic dialysis. The diagnosis of acute rejection was
made by a clinical increase in serum blood urea nitrogen (BUN)
and creatinine and confirmed by biopsy. In our center, the cold
ischemia time was short (1–2 hours) and therefore not considered
to be an important contributing factor.
RESULTS
Among the spouses, the donor-recipient relationships were
wife to husband in 49 cases and husband to wife in 12 cases.
The mean age was 36.4 ⫾ 12.5 years (range, 21–56 years).
The 1- and 3-year patient survival rates were 97% and 93%
in 61 spousal renal grafts; 96% and 92% in 433 living-
From the Shiraz Transplant Research Center, Shiraz University
of Medical Sciences (A.R.M., S.-A., M.-H.); and Shiraz Trans-
plant Center, Nemazee Hospital (J.R., H.S., M.A.I., A.R.), Shiraz
University of Medical Sciences, Shiraz, Iran.
Address reprint requests to Ali Razmkon, MD, Shiraz Trans-
plant Scientific Pole, Shiraz University of Medical Sciences
(SUMS), Shiraz, Iran. E-mail: ali_ra@yahoo.com

0041-1345/06/$–see front matter © 2006 by Elsevier Inc. All rights reserved.

doi:10.1016/j.transproceed.2005.12.058 360 Park Avenue South, New York, NY 10010-1710

562 Transplantation Proceedings, 38, 562–563 (2006)

SPOUSAL VERSUS OTHER DONOR GROUPS
related donor cases; 93% and 91% in 427 living-unrelated
donor cases; 93% and 90.5% in 118 cadaveric donor cases;
and finally 94% and 91.5% in all 1039 patients transplanted
at our center. The 1- and 3-year graft survival rates were
91% and 86% in 61 spousal cases; 91% and 85% in
living-related cases; 87% and 82% in living-unrelated cases;
88% and 84% in cadaveric donor cases; and finally 88% and
84% in all 1039 patients transplanted at our center. These
results were similar to other reports which consistently
showed no significant difference between patient and graft
survival rates of spousal donor transplantations and the
corresponding overall, living-related, and living-unrelated
donor transplantation survival rates.1– 6
The patient survival rates at 1 and 3 years were 100% and
97% in 49 wife to husband and 100% and 95% in 12
husband to wife transplantations, respectively. Corresponding
graft survival rates were 98% and 94%, and 96% and 93%,
respectively. There was no significant difference if the wife
had not been pregnant. Among spousal cases, six recipients
died in the posttransplantation period because of renal
failure and cytomegalovirus infection. In the posttransplan-
tation period, there was one case of pancreatitis, two cases
of hypertension, and six cases of acute rejection.
DISCUSSION
The worldwide shortage of organs available for trans-
plantation has led to the use of living-unrelated kidney
donors.9 –11 The waiting list for renal transplantation is
growing by 20% annually, even in countries that have solved
the problem of obtaining cadaveric organs long ago.12 Each
year thousands of patients die while awaiting a renal
transplant. To solve this problem, we recommend the Iran
model of living-unrelated donor program. Adopted in 1988,
this model permits compensated and controlled living-
unrelated donor renal transplantation. It has eliminated the
renal transplant waiting list in Iran. At the end of 2002,
among the 14,288 renal transplantations performed, 78%
were from living-unrelated donors. More than 50% of
the living-unrelated kidney donors have been from the poor
socioeconomic class of Iran. Terasaki and colleagues
reported that although HLA compatibility determined out-
come within any of the subgroups studied, totally mis-
matched or poorly matched organs from living-unrelated
donors functioned as well as kidneys from matched cadav-
eric donors or haploidentical living-related donors in first
transplantations.1,6 Compared with cadaveric donors, living-
unrelated donors are free of general and kidney diseases. In
addition, the recipients of kidneys from spousal donors may
comply better with the immunosuppressive drugs and other
treatments.6 Although the HLA matching is better with a
cadaveric graft than with a spousal graft13,14 or a graft from
another living-unrelated donor, the survival rates of unre-
563
lated donors was almost 10% greater than that of cadaveric
donors in our experience. We believe that this difference is
related to the quality of the kidney. Kidneys from living-
unrelated donors are certainly healthier compared with
cadaveric ones. Kidney donation was more frequent from
wife to husband in our center, similar to studies from other
centers. There was no significant difference between graft
survival rates in wife to husband and husband to wife kidney
transplantations in accordance with previous patient stud-
ies.1,7 The high survival rate of spousal donors is probably
related to the strong emotional support between them. In
this type of donation, the couples are even together in the
operating room, and further postoperative compliance will
be ensured as both the recipient and the donor live to-
gether. Intercourse and pregnancy may also contribute to
better spousal results by the way of prior antigenic presen-
tation and possible desensitization.
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