Kidney failure has become an important public health concern in Nigeria. The burden of chronic kidney disease continues to cause significant distress to patients, their families and a declining healthcare system. Thousands of Nigerians require renal replacement therapy, a research says about 50 people die daily due to chronic kidney disease yet access to dialysis remains limited by both affordability and availability. For patients with end-stage kidney disease, kidney transplantation offers the possibility of longer survival and a better quality of life. However, access to transplantation remains extremely poor.
The increasing burden of kidney disease in Nigeria is multifactorial. Rapid urbanization and changing lifestyles may be contributing to the increasing prevalence of hypertension, diabetes and other risk factors for chronic kidney disease. The inappropriate use or abuse of analgesics, agbo and other herbal preparations, late presentation to healthcare facilities, and inadequate control of chronic diseases may further contribute to kidney injury and progressive renal failure.
It is also important to note that kidney failure is not a disease of the wealthy. In fact, its consequences may be particularly devastating for economically disadvantaged patients. The cost of dialysis, medications, investigations, transportation and repeated hospital visits can rapidly exhaust household resources. Consequently, access to renal replacement therapy is often determined not only by medical need, but also by financial capacity.
When a patient reaches end-stage kidney disease, the search for a suitable kidney can become a matter of life and death. Families become desperate to find a solution. Relatives may volunteer to donate, but they may be medically unsuitable or immunologically incompatible. The patient and family may then begin searching beyond the family, sometimes turning to strangers and, in some circumstances, offering financial inducements.
This reality should not be ignored simply because it is ethically uncomfortable.
There is, however, an important distinction between voluntary donation, financial compensation, financial inducement, coercion, exploitation and organ trafficking. A person who freely and independently consents to kidney donation should not automatically be equated with a person who has been trafficked or coerced. At the same time, financial vulnerability must never become an opportunity for exploitation.
Nigeria, like many countries, has adopted a legal and ethical framework that prohibits the commercialization of human organs. This position is intended to protect vulnerable people from exploitation, coercion and trafficking.
However, prohibition alone does not eliminate the underlying problem.
The demand for kidneys continues to exist. Patients continue to develop end-stage kidney disease, and the number of available kidneys remains inadequate. When there is a significant mismatch between demand and legitimate supply, you will always have problems. Simply criminalizing financial transactions does not make the demand disappear. It may instead create conditions in which desperate patients and vulnerable potential donors seek alternatives outside the formal healthcare system, potentially creating opportunities for trafficking and other forms of exploitation.
The challenge for Nigeria, should not simply be how to prohibit unethical transplantation. The greater challenge is how to develop a system capable of meeting the legitimate need for kidneys while protecting both recipients and donors.
Iran provides an important example of a fundamentally different approach. In 1988, Iran introduced a government regulated system of compensated living-unrelated kidney donation. The underlying idea was straightforward: rather than relying almost exclusively on a limited pool of altruistic donors while thousands of patients compete for available kidneys, the system sought to increase the supply of living donors through a regulated framework in which donors receive financial compensation and other forms of support. This approach has led to a significant reduction in the kidney waiting list in Iran
The significance of the Iranian experience is not that it provides a perfect model. It does not. Rather, its importance lies in demonstrating that a country can approach the problem of organ shortage differently when conventional altruistic donation is insufficient to meet demand.
Nigeria must begin to think of ways it can increase the legitimate supply of kidneys for transplantation while ensuring that potential donors are fully informed, freely consenting, medically protected and shielded from coercion and exploitation. We must be willing to think beyond simply copying models developed in Western countries and develop workable models like Iran did.
What works in a high income country with extensive deceased donor infrastructure and comprehensive healthcare financing may not necessarily be sufficient for Nigeria.
We need to have an honest national conversation about whether a carefully regulated system of donor compensation could be developed, if appropriate safeguards can be established.
If compensation is ever considered, it must not become an open marketplace in which desperate recipients negotiate directly with vulnerable individuals. There must be a central body who carries out independent donor assessment, psychological evaluation, develops strict medical eligibility criteria, transparent and standardized compensation, long-term donor follow-up, protection from trafficking, and mechanisms to ensure that financial vulnerability does not become the reason a person undergoes donation.
David Kardi.
