Pakistan has a population of 169 million with an estimated incidence of endstage renal failure (ESRF) of 100 pmp. More than 40% of the people live below poverty line on less than $1 a day. Paucity of dialysis and transplant facilities in the public centers and high cost in private ones render more than 90% of the ESRF population disfranchised from treatment. Renal transplantation started in 1979 from living related altruistic donors. Initially, the activity was low at about 50/year but rose to more than 500/year by late 1990s. Absence of a deceased donor program, growing short-age of organs and developed transplant expertise led to unrelated commercial transplants. Their numbers exceeded more than 1000 by year 2000 mostly done in private centres. Initially, recipients were locals; however by 2005 over 1000 transplants/year were performed for transplant tourists. Commercial centres offered transplant packages of $6000-10,000 for locals and $20,000-30,000 for foreigners Vendors were the poorest of the society where 34% lived below poverty line on less than $1 a day, 90% were illiterate and 69% were bonded (slave) laborers. The health status and renal function of vendors showed that 27% were hepatitis C positive and 7.7% hepatitis B. Hypertension was found in 17% and a third had GFR less than 60 ml/min. On the other hand, rrecipients of commercial transplants had poor outcome. Acute rejections were found in 33%, surgical complications in 22%, TB in 11%, acute hepatitis in 16%, CMV in 26% and recurrent UTI in 28%. Overall 1 and 5 year graft survival was only 86% and 45% as compared to living related transplants where 1 and 5 years survival was 92% and 85%. Transplant tourism and exploitation of the kidney vendors led to judicial activation which forced the government to promulgate "The Transplantation of Human Tissues and Organ Ordinance 2007" in September 2007. The ordinance has banned commercial transplants and has set up a monitoring authority. The Ordinance has almost put an end to vendor kidney transplants and positively increased living related donor transplants. At our institution an integrated dialysis and live related renal transplant programme was initiated in 1986 which was offered "free with dignity" by a model of government-community partnership. Initial rates were 20 per year rising to the present rate of over 450/year. All facilities are provided free including immunosuppressive drugs and follow-up care of the recipient as well as the donor. One and 5 year graft survival rates are 92% and 85% respectively. As transplantation is available free of cost there are no waiting list at our institute. Good results and follow-up care has given confidence to the recipients as well as the donors in the family. Kidney transplantation from unrelated commercial donors failed to achieve a high transplant rate or fulfill the requirements of patients with ESRF. The way forward is to establish a fully integrated dialysis and transplantation program in public sector hospitals funded by the government or by model of community-government partnership as at SIUT. Increased availability of dialysis and transplantation to all who need it irrespective of financial status is more likely to open the door to a viable deceased donor program in the future.

Keywords: Kidney Transplantation