The History of Renal Transplantation in the Arab World: A View From Saudi Arabia
2008; Elsevier BV; Volume: 51; Issue: 6 Linguagem: Inglês
10.1053/j.ajkd.2008.01.016
ISSN1523-6838
Autores Tópico(s)Organ and Tissue Transplantation Research
ResumoThe first successful renal transplantation in the Arab world took place in Jordan in 1972. Surprisingly, the kidney transplanted was from a non–heart-beating deceased donor. Many Arab countries followed suit, starting their transplantation programs in the 1970s and 1980s, but all were from living related donors. Very few Arab countries managed to start deceased donor programs, notable among which is the Kingdom of Saudi Arabia. Religion has an important part in personal life and government legislation in the Arab world; thus, organ procurement and transplantation had to wait for religious edicts (fatwas) to be passed about the permissibility of organ donation and brain death diagnosis before starting transplantation activities. In Saudi Arabia, the renal transplantation service went through several developmental phases, culminating in the establishment of the Saudi Center for Organ Transplantation, which has become the prototype of a successful multiorgan procurement center to be emulated by Arab and Muslim countries. The story of transplantation in the Arab world is intertwined and shaped by the prevailing socioeconomic and health indicators in the different countries. It also is the story of hard-working pioneers and of human endeavor against adversity, exemplified by 2 of the pioneers having received organ transplants. Arab countries have had more than their fair share of strife and wars, and this has impacted on transplantation services and programs. The first successful renal transplantation in the Arab world took place in Jordan in 1972. Surprisingly, the kidney transplanted was from a non–heart-beating deceased donor. Many Arab countries followed suit, starting their transplantation programs in the 1970s and 1980s, but all were from living related donors. Very few Arab countries managed to start deceased donor programs, notable among which is the Kingdom of Saudi Arabia. Religion has an important part in personal life and government legislation in the Arab world; thus, organ procurement and transplantation had to wait for religious edicts (fatwas) to be passed about the permissibility of organ donation and brain death diagnosis before starting transplantation activities. In Saudi Arabia, the renal transplantation service went through several developmental phases, culminating in the establishment of the Saudi Center for Organ Transplantation, which has become the prototype of a successful multiorgan procurement center to be emulated by Arab and Muslim countries. The story of transplantation in the Arab world is intertwined and shaped by the prevailing socioeconomic and health indicators in the different countries. It also is the story of hard-working pioneers and of human endeavor against adversity, exemplified by 2 of the pioneers having received organ transplants. Arab countries have had more than their fair share of strife and wars, and this has impacted on transplantation services and programs. The first kidney transplantation in the Arab world was performed in Jordan in 1972 at King Hussein Medical Center. The surgeons were Daoud Hanania and Said Karmi; the attending nephrologist was Tarek Suheimat. It is ironic that the first successful kidney transplantation in the Arab world used a kidney from a non–heart-beating deceased donor, yet we are still having enormous difficulties in establishing successful deceased donor donation programs in this region. The recipient was a 28-year-old army sergeant who had been on hemodialysis therapy for 3 years before the transplantation. The deceased donor was a 23-year-old whose blood group matched that of the recipient; no tissue typing was done. Immunosuppression consisted of prednisolone and azathioprine. Postoperatively, there was anuria for 16 days. Diuresis then ensued and the patient was discharged on postoperative day 25. The patient remained well until 1988, when he experienced an acute myocardial infarction and died with normal renal function. Daoud Hanania, a 1957 graduate of St Mary's Hospital, London, UK, later became the Director General of Medical Services for the Royal Jordanian Armed Forces and a Senator in the Jordanian upper house. He also is credited with performing the first cardiac transplantation in the Arab world in 1985.1Hanania D. Goussous Y. Al-Jitawi S. Abu-Aishah N. Nesheiwat H. Cardiac transplant first operation in the Middle East: Case report.Arab J Med. 1986; 5: 4-7Google Scholar Said Karmi moved to the United States and became Professor of Urology and Director of Kidney Transplantation at Georgetown University, Washington, DC, from 1980 to 1995, where he performed more than 600 kidney transplantations. He received a cardiac transplant in 1995, but died in 2005. Tarek Suheimat became Director of the King Hussein Medical Center, a Senator, and a Minister of Telecommunication (in 1993) and Health (in 2001) in Jordanian cabinets. In researching this article, I was struck by the fact that most of those involved in the early history of Arab renal transplantation went on to other achievements and held high administrative and clinical positions later in their careers; I summarize this information in Table 1.Table 1Some Pioneers in Arab Renal Transplantation and Subsequent Steps in Their CareersPlace in Arab Renal Transplantation HistoryWhat Happened AfterwardsDaoud HananiaFirst transplantation in Arab worldDirector of Medical Services, Royal Jordanian Forces, Member of the SenateTarek SuheimatFirst transplantation in Arab worldDirector of King Hussein Medical Center, Minister of Telecommunication (1993) and Health (2001), Member of the SenateSaid KarmiFirst transplantation in Arab worldProfessor of Urology, Georgetown University, Washington, DC; Director of Kidney Transplantation, George Washington University, 1980-1995Omar BelielSecond transplantation in Arab world and first in SudanProfessor of Surgery, Rector, Khartoum UniversityHassan Abu AishaSecond transplantation in Arab world and first in SudanProfessor of Medicine, King Saud University; Rector, AlRabat University SudanFaissal ShaheenFirst transplantation in Aden (Yemen)President of MESOT (2004-2006), Director of Saudi Center for Organ TransplantationNadey HakimFirst transplantation in Aden (Yemen)President, International College of Surgeons (2005, 2006); the youngest ever PresidentAbdullah DaarFirst transplantation in Oman and United Arab EmiratesProfessor of Public Health Sciences and Surgery, University of Toronto; Director of Program in Applied Ethics and Biotechnology, Joint Center for BioethicsGeorge AbounaFirst transplantation in Kuwait and BahrainPresident of MESOT (1990-1992), Professor of Surgery, Drexel University Medical College, Philadelphia, PARashad BarsoumFirst transplantation in EgyptPresident of Arab Society, African Society, and Secretary General ISNKetab Al OtaibiFirst deceased donor transplantation in Saudi ArabiaDirector, Armed Forces Hospital; Director of Medical Services, Royal Saudi ForcesRene ChangFirst deceased donor transplantation in Saudi ArabiaDirector of Transplantation, St Georges Hospital, University of LondonMaher HousamiFirst transplantation in SyriaMinister of Health (2005 to present)Abdulkareem SheibanFirst transplantation in YemenDeputy Minister of Health (2000-2005)Antoine StephanFirst transplantation in LebanonPresident of MESOT (2002-2004)Abdelhamid AberkaneFirst transplantation in AlgeriaMinister of Health (2001-2003)Abbreviations: MESOT, Middle East Society for Organ Transplantation; ISN, International Society of Nephrology. Open table in a new tab Abbreviations: MESOT, Middle East Society for Organ Transplantation; ISN, International Society of Nephrology. I gathered the data for this article from my own personal experience and knowledge, from a questionnaire I sent to leading nephrologists in the Arab world, by searching PubMed for articles published from 1960 to 2007, and by reviewing all issues of the Saudi Journal of Kidney Disease and Transplantation, which has published articles on Arab nephrology and renal transplantation since 1990. Questionnaires were sent to 16 of the 21 Arab countries (exceptions were Mauritania, Somalia, Palestine, Djibouti, and Comoros, for which I could not identify a contact). I received responses from 12 Arab countries. The Arab world is a unique group of nations that covers an area from the Atlantic Ocean in the west to the Arabian/Persian Gulf in the east and from the Mediterranean Sea in the north to Central Africa and the Indian Ocean in the south. It has a combined population of 325 million people and spans an area of 12.9 million square kilometers (5 million square miles) in 2 continents. In terms of total area, it surpasses the geographical foot prints of Europe, China, India, and the United States. Notably, every Arab country borders a sea or ocean. People wrongly equate the Arab World to the Middle East, but two thirds of the Arab population resides in Africa. For the purposes of this article, the Arab world is defined as the 21 countries that are members of the Arab League (Fig 1). Arabs are not all of the same ethnic stock. However, apart from all being in the Arab League, Arab peoples have in common the Arabic language, albeit using different dialects; a relatively common history; similar taste in music; and a tendency to "flock together" when they are expatriates in a foreign land. Arab countries have a wide variation in per capita total health expenditures and rates of out-of-pocket expenditures on health. Table 2 lists demographic and health indicators in Arab countries. Table 3 lists mean values of demographic, socioeconomic, and health indicators in the Arab world as a whole. Table 4 lists the gross domestic product (GDP) per capita and the place of each Arab country in the world league of GDPs. As listed in Table 4, Arab countries occupy positions ranging from number 2 in the rankings (Qatar) with per capita GDP of $75,900 to number 227 (Somalia) with per capita GDP of $600 (ie, a 126.5-fold difference). Table 5 lists the status of hemodialysis and its prevalence per million population, which ranges from 50.8 in Yemen to 747.7 in Tunisia.Table 2Demographic and Health Indicators in Arab CountriesJordanBahrainDjoboutiEgyptIraqKuwaitLebanonLibyaMoroccoOmanPalestineQatarSaudi ArabiaSomaliaSudanSyriaTunisiaUAEYemenPopulation * 1,0005,48572581770,66827,9632,8674,4356,09829,8922,5093,63879622,673.58,29834,51218,13810,0314,21020,738Death rate/1,00073.1156.4101.74.12.65.52.52.81.93.817.611.5461.611.4Population growth rate (%)2.52.72.61.92.78.41.61.81.42.22.65.22.43.42.52.51.15.93Age < 15 y (%)37.127.337.637.843.321.827.332.431.238.946.322.53644.841.739.526.725.5NAAge > 65 y (%)3.82.52.83.42.81.67.545.22.23.11.232.743.36.81NALiteracy rate (%)918849615693888657819190—195081788653Access to clean water (%)9810084946110010098717597100892060889110031Unemployment rate (%)1565910271101711NA27NANANA181214312Per capita total health expenditure (US $)177555475523579573171722781388623666215913766132Out-of-pocket health expenditure (%)40.518.933.153.548.220.556.237.150.99.5NA22.86.955.454.651.845.117.856.5MOH/total government budgets (%)5.777.23.44.76.33.6NA5.44.7NA76NA2.43.77.67.75.2Doctors/10,000 population23.627.21.824.36.61823.612.55.616.79.726.419NA5.514.49.816.92.2Population with primary care (%)991008010097100981008597100100NA7266959510050Life expectancy (y)71.574.844.171.45877.571.369.570.374.372.676.773.6NA56.67273.472.662.9Neonates with low birth weight (%)682012587NA68785261175723Children underweight (%)4836113NA452NA5NA6263364NA46Infant mortality rate/1,000 live births22.08.910220.5107.98.218.6254010.320.58.219.11206217.120.68.175Maternal mortality/10,00040.3054662.72944884022715.41122.4121,60059058481366Malaria cases/y8601,61604700000001,05928,5291,988,132000200,560Pulmonary tuberculosis/y1621712,1018,5163,3812471311,62214,270131411622,1929,53520,2201,339915873,610Note: Data not shown for Algeria, Comoros, and Mauritania.Abbreviations: NA, not available; UAE, United Arab Emirates; MOH, Ministry of Health.Source data for country profiles obtained from the East Mediterranean Regional Office of the World Health Organization.2The World Health Organization East Mediterranean Regional Offices: Country Profilehttp://www.emro.who.int/emrinfo/index.asp?Ctry=egyGoogle Scholar Open table in a new tab Table 3Mean Demographic, Socioeconomic, and Health Indicators in the Arab WorldUrban population (%)53.3Death rate/1,0007.3Population growth rate (%)2.3Age < 15 y (%)37.2Age > 65 y (%)3.7Literacy rate (%)81.8Per capita gross national product (US $)3,333Unemployed (%)14.2Smoking (%)18.9Gross domestic product per capita2,444Per capital total health expenditure (US $)109.0Out-of-pocket expenditure (%)46.6Doctors/10,000 population13.7Life expectancy (y)84.6Neonates with low birth weight (%)10Infant mortality rate/1,000 live births37.6Maternal mortality/10,000233.4Note: Calculated from data on country profiles obtained from the East Mediterranean Regional Office of the World Health Organization.2The World Health Organization East Mediterranean Regional Offices: Country Profilehttp://www.emro.who.int/emrinfo/index.asp?Ctry=egyGoogle Scholar Open table in a new tab Table 4Gross Domestic Product per Capita in the Arab WorldCountryGross Domestic Product per Capita1Hanania D. Goussous Y. Al-Jitawi S. Abu-Aishah N. Nesheiwat H. Cardiac transplant first operation in the Middle East: Case report.Arab J Med. 1986; 5: 4-7Google Scholar ($)Rank in WorldSomalia600227Comoros600225Djibouti1,000207Mauritania1,800185Yemen2,400171Sudan2,500170Iraq3,600155Morocco3,800152Syria4,500142Jordan4,700140Egypt5,400129Tunisia7,500116Algeria8,100109Lebanon10,40096Libya13,10082Oman19,10065Saudi Arabia20,70059Bahrain34,70030United Arab Emirates55,2007Kuwait55,3006Qatar75,9002United States46,0009Note: Gross domestic product on a purchasing power parity basis divided by population.Data obtained from CIA World Factbook.3CIA World Factbookwww.cia.gov/library/publications/the-world-factbook/rankorder/2004rank.htmlGoogle Scholar Open table in a new tab Table 5Data for Hemodialysis and Peritoneal Dialysis Activities in Selected Arab CountriesCountryDate of First HDPhysicians InvolvedNo. on HD TherapyNo. of HD CentersPatients on HD Therapy (pmp)Date of First PDPhysicians InvolvedNo. on PD TherapyNo. of PD CentersQatar1979Awad Rashed, V. Patel3505439.71996Awad Rashed, Elsayyed851United Arab Emirates1977Avinash Pingle80061901985Avinash Pingle, Salahudin802Saudi Arabia1972Al Ghoniemi9,000150396.9NAHassan Abu Aisha75013Oman1983F. Woods70012279.01983NATunisia1967Hassouna Ben Ayad, Fethi Hafsia, Ferid Akrout7,500120747.7NAAziz El Matri, Taieb Ben Abdullah22040Jordan1968Tarek Suheimat2,800>50NA1990NA23Syria1976Josef Sayegh2,80066154.71984Akram Khatib, Hassan Salloum12080Egypt1958Nagy Muhhalawi, Abulmoinem Hassaballah30,000300424.51963Abulmoinem Hassaballah10Iraq1967Mahmoud ThamerNA27NA2004Dawood Hussien, Sami Akram251Yemen1982Abdulkareem Sheiban1,0531350.81984Abdulkareem Sheiban0Sudan1973272,12961.72005777Algeria1975A. Drif10,000150304.41980G. Krouri52010Abbreviations: HD, hemodialysis; PD, peritoneal dialysis; pmp, per million population; NA, not available. Open table in a new tab Note: Data not shown for Algeria, Comoros, and Mauritania. Abbreviations: NA, not available; UAE, United Arab Emirates; MOH, Ministry of Health. Source data for country profiles obtained from the East Mediterranean Regional Office of the World Health Organization.2The World Health Organization East Mediterranean Regional Offices: Country Profilehttp://www.emro.who.int/emrinfo/index.asp?Ctry=egyGoogle Scholar Note: Calculated from data on country profiles obtained from the East Mediterranean Regional Office of the World Health Organization.2The World Health Organization East Mediterranean Regional Offices: Country Profilehttp://www.emro.who.int/emrinfo/index.asp?Ctry=egyGoogle Scholar Note: Gross domestic product on a purchasing power parity basis divided by population. Data obtained from CIA World Factbook.3CIA World Factbookwww.cia.gov/library/publications/the-world-factbook/rankorder/2004rank.htmlGoogle Scholar Abbreviations: HD, hemodialysis; PD, peritoneal dialysis; pmp, per million population; NA, not available. Although it generally is believed that Arabs are all Muslims, a significant number of Arabs are Christians and a few are Jews. Nevertheless, the Islamic religion is critical to many Arabs, and in many Arab countries, laws governing areas of potential social or ethical controversy have to be in agreement with Islamic teaching. This dogma also applies to laws governing kidney transplantations. A landmark fatwa (Islamic religious opinion) in Saudi Arabia came about in Decision No. 99, dated 06-11-1402 by the Hijri calendar (1982 CE), opining that according to Islamic Jurisprudence, it is permissible to perform deceased donor transplantation, which paved the way for us to start a cadaveric renal transplant program. Although the first kidney transplant in the Arab world was from a deceased person, deceased organ transplantation programs have been difficult to establish in many Arab countries (Fig 1). Consents for the first deceased donor kidney transplantations in both Qatar and Oman were obtained from expatriate families (Irish and American, respectively) who came forward to offer their loved ones' kidneys spontaneously. The initial reluctance to start deceased donor kidney transplantation programs was because of a lack of fatwas regarding its permissibility. However, positive fatwas came along in many Arab counties. A progressive fatwa from the meeting of the Islamic Jurisprudence Conference in 1986 in Amman declared that the diagnosis of brain death was permissible and can be used to diagnose an irreversible process. Another landmark fatwa issued in Saudi Arabia in 1988 allowed cessation of therapy, including ventilation, in hopeless cases. In Islam, there is no pastoral hierarchy and Muslims can ask any scholar they trust for a fatwa or can follow what their conscience dictates after obtaining all the relevant facts about a subject. It therefore follows that even in the presence of positive fatwas from "official fatwa councils," at the end of the day, many people simply make up their own minds about whether deceased kidney donation is permissible. All Arab countries that have deceased organ programs follow the opt-in (required consent) system. The only exception is Tunisia, which has had an opt-out (presumed consent) system since 1991. Egypt, which is the largest Arab country, has had only 2 deceased donors. The program could have been set back by the unfortunate fact that the organs were procured from criminals who were executed in Alexandria, intubated immediately after hanging, ventilated, and transferred by ambulance to Cairo, where a surgical team transplanted 2 livers and 4 kidneys. This provoked an intense ethical reaction in the media, leading to abandonment of deceased donor transplantations to date. Renal transplantation in Saudi Arabia went through 5 phases. Phase 1 entailed sending Saudi patients with renal failure abroad for renal transplantation. The majority went to the United States and some went to Europe; that was during the 1970s when it was still possible for non-US citizens to receive deceased donor kidneys in the United States. This phase was very informative for us because these patients were among the first to receive cyclosporine (and later tacrolimus) as immunosuppressive agents and thus we obtained very early experience in the use of these drugs.4Al-Khader A. Chang R. Jawdat M. et al.Cyclosporine in living related renal transplantation—Single unit experience.Transplant Proc. 1987; 19: 3669-3670PubMed Google Scholar This model of sending patients abroad for transplantation was adopted by many Arab countries in the 1970s and 1980s, particularly in the Gulf region countries (which usually sent patients to the United States and United Kingdom) and North Africa (which usually sent patients to France). The second phase consisted of living related transplantation by a visiting team from St Thomas's Hospital, London, UK. The team came every few weeks and stayed for a week or so to perform a few living related transplantations. This phase lasted for 2 years (1979 to 1981) while Saudi transplant physicians and surgeons were being trained. This model was not adopted by many Arab countries because of costs. Instead, they opted to send physicians abroad for training in transplantation, with the intention that they would come back to start the programs in their countries. Similarly, many Saudis were trained abroad during the third and fourth phases in the Saudi model. The third phase consisted of continuing living related transplantation and also obtaining kidneys from Eurotransplant; this phase started in 1981 and continued for 3 years. During this period, we received 64 kidneys, and all transplantations were performed at Riyadh Armed Forces Hospital. This phase was of enormous benefit to us because it introduced us to the important business of organ procurement logistics and coordination. However, the only high-quality kidneys sent were from AB blood group donors when no suitable recipients were found in Europe. The vast majority of these kidneys were what today would be classified as marginal or "expanded pool" kidneys, and most had been refused by European centers and had long cold ischemic times.5Shaheen F. Abdur Rehman M. Mousa D. al-Sulaiman M. Chang R.W. al-Khader A.A. Long-term outcome in transplanted kidneys with long cold ischemia times.Transplant Proc. 1994; 26: 2580-2581PubMed Google Scholar Of course, we had to use these kidneys because then, as now, we faced a shortage of kidneys. These types of kidneys are now being used by Eurotransplant and the United Network for Organ Sharing because the organ shortage problem began to take hold in Europe and the United States. Among the kidneys we used were half a "horseshoe" kidney, a "third-hand" kidney,6Al-Hasani M.K. Saltissi D. Chang R. Van Goor H. Tegzess A.M. Successful regrafting of an explanted transplant kidney.Transplantation. 1987; 43: 916-917Crossref PubMed Google Scholar and kidneys with cold ischemic time as long as 72 hours.7Chang R.W. Saltissi D. Al-Khader A. Abomelha M. Jawdat M. Survival of sub-optimal cadaver renal grafts with prolonged cold ischaemic times using cyclosporin.Nephrol Dial Transplant. 1987; 1: 246-250PubMed Google Scholar In 1983, George Abouna in Kuwait used 2 kidneys from a diabetic donor with proteinuria whose baseline renal biopsy showed severe diabetic changes and proved that these changes reversed when the kidneys were placed in the normoglycemic milieu of the recipients.9Abouna G.M. Al-Adnani M.S. Kremer G.D. Kumar S.A. Daddah S.K. Kusma G. Reversal of diabetic nephropathy in human cadaveric kidneys after transplantation into non-diabetic recipients.Lancet. 1983; 3: 1274-1276Abstract Scopus (126) Google Scholar Sadly, we also had the unfortunate experience of unwittingly using 2 kidneys from a human immunodeficiency virus–positive donor. This was before human immunodeficiency virus testing or even acquired immunodeficiency syndrome became widely known. We learned of this after the fact with the retrospective testing of the stored sera of the 2 recipients.10Al-Sulaiman M. al-Khader A.A. al-Hasani M.K. Dhar J.M. Impact of HIV infection on dialysis and renal transplantation.Transplant Proc. 1989; 21: 1970-1971PubMed Google Scholar The fourth phase involved the use of kidneys from deceased donors procured locally. (Only a few Arab countries managed to move to this phase; see the map in Fig 1 and Table 6.) The fifth phase witnessed the establishment of the Saudi Center for Organ Transplantation (SCOT) and the spread of renal transplantation across the country with the founding of 10 transplantation centers serving all the regions of the country and the introduction by SCOT of multiorgan donation.11Shaheen F.A. Souqiyyeh M.Z. Attar M.B. al-Swailem A.R. The Saudi Center for Organ Transplantation: An ideal model for Arabic countries to improve treatment of end-stage organ failure.Transplant Proc. 1996; 28: 247-249PubMed Google Scholar, 12Al-Khader A.A. Cadaveric renal transplantation in the Kingdom of Saudi Arabia.Nephrol Dial Transplant. 1999; 14: 846-850Crossref PubMed Scopus (8) Google Scholar, 13Shaheen F.A. Souqiyyeh M.Z. Attar M.B. et al.Multiorgan donation from brain-death cases in the Kingdom of Saudi Arabia.Transplant Proc. 1996; 28: 250-253PubMed Google ScholarTable 6Data for the First Transplants/Transplantation Activities in Selected Arab CountriesCountryDate of First LRDPhysicians Involved in First LRDNo. of LRDs to DateFirst DDNo. of DD KidneysPhysicians involved in First DDNo. of Current Transplant CentersYear of Passage of Transplant LawQatar1986Ali Hijazi, Awad Rashed, Abu Shalla80198890Ali Hijazi, Saleh AbuRomeh, Awad Rashed1YesUnited Arab Emirates1985Avinash Pingle, Abdulla Daar40ND01993Kuwait1979George Abouna, V. JohnnyNANANAMustafa MousawiNANABahrain1996George Abouna, Ahmed Al-ArrayedNANANA1998Saudi Arabia1979J. Thompson, Anthony Wing, Norman Jones3,86219841,704Al Otaibi, Chang, Al Sayyari101982Oman1988Abdullah Daar, Feidhlim Woods230199815Abdullah Daar, Nabil Mohsin21993Lebanon1985Antoine Stephan4701990Tunisia1986Aziz l. Matri, Saadeddine Zemrli4151986175Aziz l. Matri, Saadeddine Zemrli41991Jordan1972Daoud Hanania, Tarek Suheimat, Said Karmi2,8001972101977Syria1976Maher Housami, Bachir Yafi1,555NDND81974Egypt1976M. Ghoneim, M. Sobh, (Mansoura University), R. Barsoum, A. Hassaballa, M. Safwat (Cairo University)4,00019924Khafagy, A. Hassaballah, S. Lotfy151945Iraq1973W. Kayal, S. Khatab, S. ShammaND21978Yemen1998Mansoura University group (Egypt), Ibrahim Al Nono36ND12002Sudan1974Omar Beliel, Hassan Abu Aisha378ND4Algeria1986A. Drif, Aberkane40020025Aberkane, Bendjaballah101985Abbreviations: LRD, live related donation; DD, deceased donation; NA, not available; ND, not done. Open table in a new tab Abbreviations: LRD, live related donation; DD, deceased donation; NA, not available; ND, not done. I became directly involved in this fourth phase on December 24, 1984, when I had a call from Syd Jacobs, the intensivist at Riyadh Armed Forces Hospital, telling me that a Saudi patient had been diagnosed with brain death in the intensive care unit and asking if I would talk to the family about kidney donation. Such a request had never been made before in the strictly religious and tribal society of Saudi Arabia. We had no idea what the family's response would be and we feared the worst. The family was very gracious and responded with empathy to our predicament. The result was the first 2 kidney transplantations from a deceased donor to be performed in Saudi Arabia. The donor, a Saudi teenager, was overwhelmed by smoke from a fire at home, which also killed 2 members of his family. The brain death diagnosis was made by Chris Pallis, a neurologist from the Hammersmith Hospital, who wrote extensively on brain stem death, including a series of 6 articles in the British Medical Journal entitled "ABC of brain stem death."14Pallis C. ABC of brain stem death The arguments about the EEG.Br Med J. 1983; 286: 284-287Crossref PubMed Google Scholar Pallis happened to be in Riyadh as a speaker in a symposium on renal transplantation and brain death. The consent for donation was quickly handwritten. It is to the credit of the then-Director of the hospital, General Sherbini, a nonphysician, that he gave his approval for this "controversial" operation to take place.15Al-Otaibi K. Al Khader A.A. Abomelha M. First local cadaveric renal transplantation in Saudi Arabia.Saudi Med J. 1985; 663: 217-223Google Scholar The 2 kidneys donated were transplanted into 2 young Saudi girls. Ketab Al Otaibi, then a consultant urologist at the Riyadh Armed Forces Hospital performed 1 transplantation, and the other was performed by Rene Chang. Al Otaibi later become the Director of the Riyadh Armed Force Hospital and is now the Director General of Medical Services of the Saudi Royal Forces; Rene Chang currently is the Director of Transplantation, St George's Hospital, University of London. The first deceased donor kidney donation at King Faisal Specialist Hospital and Research Center, which occurred in 1985, was interesting in that the donor had a urinary tract infection caused by Escherichia coli, hypertension, and borderline high serum creatinine level. Despite the suboptimal status of the donor (especially as viewed in those days), after a intensive vigorous debate, nephrologists Saadi Taher and Osman Alfurayh decided to go ahead with the transplantation after discussion with the microbiologist, Dr Pavillard, indicated that the E coli was "manageable." Fortunately, the recipient did extremely well. Khalid Meshari now heads this center, with the remarkable achievement of performing 150 renal transplantations annually, including some in highly sensitized patients.16Al-Meshari K. Al-Shaibani K. Hamawi K. et al.The Kidney Transplant Program at King Faisal Specialist Hospital and Research Center.Clin Transpl. 2005; 19: 119-129Google Scholar The first case of successful desensitization and transplantation from a living donor was done in this center in 2002. The first Ministry of Health Hospital to perform transplantation was Alshaty Hospital in Jeddah in 1985. This operation was done by Nabeel Nezamuddin, who was involved in renal transplantation activities in 5 other transplantation centers in the Kingdom. Nezamuddin is a remarkable surgeon with many other firsts in the Arab world: the first no
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