The success of the genetically engineered pig kidney transplant is a major breakthrough for the world of medicine and molecular biology.

The world of medicine continues to develop, bringing new hope, including for patients with kidney failure. Not long ago, on March 16, 2024, a team of doctors at Massachusetts General Hospital, Boston, USA, successfully performed a genetically engineered pig kidney transplant into the body of Richard Slayman, a 62-year-old male patient.

At that time, Richard felt happy and enthusiastic because he regained a normally functioning kidney and no longer had to undergo routine dialysis that had burdened him for years.

This is the first successful attempt, as previous pig-to-human kidney transplants have always failed. In 2018, Richard had actually undergone a human kidney transplant from a deceased donor. However, this medical procedure was unable to improve his deteriorating kidney condition. In 2023, he experienced heart failure.

Pig kidneys that have been transplanted have been genetically modified by the pharmaceutical company eGenesis based in Cambridge. Genetic engineering is conducted to remove dangerous pig genes and add certain human genes so that the pig kidneys become compatible with human bodies. Over the past five years, eGenesis has conducted a series of xenotransplantation research (organ transplantation between species).

The genetic engineering pig kidney transplantation to humans has been approved by the Food and Drug Administration (FDA), using a procedure called the Expanded Access for Medical Devices Protocol, which opens access to experimental treatments that have not been approved for widespread use to address patients with life-threatening diseases.

In new drugs, to suppress the immune system and prevent rejection by the body's organs, this protocol is also used.

The success of transplanting genetically engineered pig kidneys into the human body is a major breakthrough for the world of medicine and molecular biology, even though the research has actually been going on for a long time.

The trial of genetically engineered pig kidney transplantation continued on the second patient, Lisa Pisano, at NYU Langone Health in New York, USA.

However, this pig kidney transplant is still a research treatment procedure that is continuously being monitored for its effectiveness and safety.

Two months after the transplantation, Richard passed away on May 11, 2024. Massachusetts Hospital stated that there was no indication that the death was due to the transplantation. The second patient also passed away as the artificial kidney that was transplanted was damaged due to their heart treatment.

The death of both patients was not due to the kidney transplant, but because of other causes. However, further research is necessary so that pig kidney transplantation can continue to develop into an effective, efficient, and safe method. If the development is good and safe, this method has the potential to replace the hemodialysis method that has burdened millions of kidney failure patients worldwide.

So far, there are two methods of treating kidney failure. First, the dialysis method (blood washing), either using a hemodialysis machine or CAPD (continuous ambulatory peritoneal dialysis, a blood washing method performed through the stomach). Both are done to remove dirt and toxins dissolved as a result of the metabolic process.

Patients who choose hemodialysis have to have their blood washed 2-3 times a week, depending on their clinical condition. In addition to being very physically burdensome for patients, routine blood washing also drains a significant amount of funds.

The second method is kidney transplantation or grafting. Until now, the transplanted kidney comes from a human donor, either from a deceased person or a living one. In terms of a living donor, it is legally acceptable if it is voluntary, for example, a child donates his or her kidney to their parent. A normal person has two kidneys, so in an emergency situation, a child can donate one of their kidneys to their parent.

Illegal kidney trade

In reality, the number of kidney donors is very small, while those who need them are very many, so donor kidneys are a rare and very expensive commodity. This is what causes the illegal kidney trade.

BBC News Indonesia has previously reported on the rampant black market for kidneys in China that involves a network of collectors, traders, as well as doctors and paramedics. The cost of kidney transplantation is very expensive and can reach up to 57,000 US dollars (more than 900 million Indonesian Rupiah).

For years, medical practitioners in China have taken organs from executed convicts to meet the demand for transplants. This practice was stopped in early 2015 due to international condemnation. The sale of human organs has been banned in China since 2007.

The Chinese Government claimed to have successfully found legally valid organ donors. However, the queue for patients in need of a transplant is still quite long.

With the successful genetically engineered pig kidney transplant, if mass production can be done and the supply is sufficient, there will no longer be a need for kidney donors from living humans. Therefore, the illegal kidney trade can also be eliminated. The physically exhausting and costly method of dialysis will also be increasingly abandoned.

Here, the importance of molecular biology research plays a significant role in eGenesis's success in genetically engineering pigs so that their kidneys become compatible with the human body. Cutting out dangerous pig genes and adding specific human genes are part of the genetic editing process that will become increasingly popular in the future.

This molecular biology research will eventually place engineered pig kidneys in the medical commodities market, which can be mass-produced, produced elsewhere, and by other parties with a license, and can be distributed anywhere, making it more accessible to patients anywhere. If this situation is achieved in the future, millions of kidney failure patients worldwide can be better treated and more affordably.

BPJS cost sucker

Kidney failure is the second leading cause of death in the world. In Indonesia, according to the Ministry of Health on the commemoration of World Kidney Day on March 9, 2023, it is the 10th leading cause of death with over 42,000 deaths per year. By the end of 2023, the number of kidney failure patients in Indonesia is around 740,000 people.

From year to year, the prevalence of kidney failure is increasing and now it is more prevalent among younger ages. This means that the productive population is already affected by this disease.

The number of chronic kidney disease patients in Indonesia is increasing from year to year. Referring to the Basic Health Research (Riskesdas) in 2013, the prevalence of chronic kidney disease was only 0.2% of the total Indonesian population. In Riskesdas 2018, the number increased to 0.38% or almost double.

However, this number is considered to not reflect the actual reality. The Indonesian Nephrology Association (Pernefri) estimates that the actual number is larger. Pernefri's research in 2006 in several areas in Java found that 12.5 percent or 25 million to 30 million people had experienced a decline in kidney function. This figure is much larger than the Riskesdas calculation. However, since the Covid-19 pandemic, there has not been another Riskesdas, so we do not yet know the latest developments in the numbers up until now.

The 2016 BPJS Financial Report also shows a fantastic trend of increasing numbers of kidney failure sufferers, namely from 15,128 patients in 2013 to 17,193 patients (2014), 21,050 patients (2015), and 25,446 patients (2016). Unfortunately, the majority of chronic kidney failure sufferers are of productive age. Data from the 7th Report of the Indonesian Renal Registry 2014 shows that 56 percent of kidney failure sufferers are under 56 years old. This is clearly a worrying trend.

Kidney failure ranks 10th as a leading cause of death in Indonesia. The top rank is occupied by stroke, followed by heart disease, diabetes, tuberculosis, and hypertension. Despite being ranked 10th, kidney failure is second on the list of diseases that incur the highest medical treatment costs.

The 2016 Financial Report of BPJS Kesehatan stated that heart disease is in the top spot, consuming a budget of Rp 7.48 trillion, followed by kidney failure at Rp 2.59 trillion, and cancer at Rp 2.35 trillion.

For diabetes that falls into the silent killer category, the treatment and care are relatively inexpensive. As long as the patient is disciplined—both in prevention, care, and treatment, he can live a normal and healthy life, relatively without spending much money.

It is very different from kidney failure patients. For prevention of those who are still healthy, regularly drinking boiled water with celery can maintain kidney health. However, if already experiencing end-stage kidney failure, patients must undergo regular dialysis or kidney transplant.

The frequency of hemodialysis can be 2-3 times a week, depending on the doctor's assessment. According to BPJS services, the cost of one hemodialysis session is at least around Rp 840,000. Outside of BPJS facilities, the cost ranges from Rp 1.2 million to Rp 1.5 million. If hemodialysis is performed once or twice a week, it means that the cost will drain at least Rp 6.7 million (BPJS) per month or more than Rp 9.6 million for non-BPJS services.

Not to mention the cost of medication and other care services. Many say that kidney failure is "a disease of the wealthy". Economically disadvantaged individuals should avoid getting kidney failure at all costs, even if covered by BPJS.

With the news of the discovery of genetically engineered pig kidneys and their successful transplantation into human bodies, it is hoped that they can be mass-produced and their benefits can also be enjoyed by kidney failure patients in Indonesia.

Halal or haram?

Nevertheless, the success of pig kidney transplantation still poses a problem, especially for Muslims. Pigs are animals whose meat is forbidden for Muslims to eat. Until now, the use of pig organs for any medical purpose still generates debates among Muslims.

MUI (Indonesian Muslim Scholars Council) once issued a fatwa declaring AstraZeneca's Covid-19 vaccine as haram due to the suspicion of using pig-derived products in its production process. MUI issued this fatwa to protect the Muslim community. However, despite being forbidden, MUI allowed its use during the pandemic under the justification of emergency situations that could threaten lives. Therefore, in a wise manner, something that is forbidden temporarily may be consumed in a life-threatening emergency situation.

Djoko Santoso
Professor of Medicine
Airlangga University