Status of Liver Transplantation in the Arab World

The liver transplantation experience of 11 countries in the League of Arab States is presented in this Regional Perspective and provided in an ongoing series of such perspectives through the auspices of The Transplantation Society (^1–3). The history and current experience of 27 liver transplant centers throughout these 11 countries is a seminal recording of both deceased (DDLT) and living donor (LDLT) liver transplantation in the Arab World. The data of this report were assembled by responses to an email questionnaire from 26 of the 27 centers with information regarding the date of the first liver transplant (LT), the total number of LT (including DDLT and LDLT), and the most common indication for LT in those centers.

The Arab World is composed of 22 countries in the League of Arab States founded in 1945. It has a combined population of approximately 350 million people and is united by Arabic language, culture, Islamic religion, and geographic contiguity. Additionally, certain Arab countries share a high prevalence of viral hepatitis with an increasing need for LT in those countries (^{4, 5}). The first DDLT in the Arab World was performed in 1990 at Riyadh Military Hospital in Saudi Arabia (⁶). The first LDLT was performed in 1991 at the National Liver Institute in Egypt (⁷). Between 1990 and August 2013, 3,804 liver transplants (3,052 [80%] LDLT and 752 [20%] DDLT) were performed at the 27 in 11 Arab countries (Table 1). The largest percentage of liver transplantation has been performed by 13 transplant centers in Egypt (56%) followed by four transplant centers in Saudi Arabia (35%) and two transplant centers in Jordan (5%). In the remaining eight Arab countries, liver transplant activity has been limited to one program in each country. The most common indication for LT in this series was end-stage liver cirrhosis caused by hepatitis C virus or hepatitis B virus, with or without hepatocellular carcinoma.

TABLE 1: Liver transplant activity in the Arab world until August 2013 arranged according to date of the first liver transplant

More than 70% of the LDLT in this series were performed by the transplant centers in Egypt (Table 2) with five living donor deaths reported (0.2% rate of mortality) (^8–12). Egypt has the highest prevalence of hepatitis C virus (HCV) worldwide, estimated to be 15% and 26% of the population (¹³). More than 90% of the DDLT in this series were performed in Saudi Arabia; four liver transplant centers in Saudi Arabia have collectively performed 1,338 LT (52% DDLT and 48% LDLT), including 13 split LT procedures. There were no reported living donor deaths in Saudi Arabia (^{14, 15}). A small number of transplants have been performed in Algeria, Tunisia, and Lebanon (^{16, 17}). The initial transplant programs in Libya, Kuwait, and United Arab Emirates performed a few liver transplants, but they were subsequently suspended because of logistical and technical reasons. A program for LDLT has recently been developed in Iraq with a potential of performing 15 LDLT per year; also, a DDLT program has begun in Qatar with four transplants performed to date (¹⁸).

TABLE 2: Liver transplant activity in Egypt until August 2013 arranged according to date of the first liver transplant

Missing in this report are the current annual data of patient and allograft survival. The progress of liver transplantation in the Arab world will ultimately necessitate such data to validate the ongoing expertise of the transplant programs. The Pan Arab Liver Transplant Society intends to develop a registry of outcome data and also include a recording of a relationship of the living donor to the recipient. This relationship is an important concern throughout the region but especially in Egypt, considering the high poverty rates in the country and noting that the largest percentage of LDLT has been performed by the transplant centers of Egypt (^{19, 20}). Consequently, the Egyptian parliament has recently enacted a law banning the sale of human organs, imposing restrictions on transplant operations for foreigners, and stipulating jail sentences and fines for violation of the law. The absence of deceased organ donation in Egypt is troublesome but not surprising in view of the cultural barriers and the current political unrest (²¹).

The Saudi Center of Organ Transplantation (SCOT) is a well-recognized national organ donation agency that has collaborated with the liver transplant programs of Saudi Arabia in propelling deceased organ donation (²²). Because almost all of the deceased donors are derived from expatriate workers residing temporarily in Saudi Arabia, there have been ethical concerns that the inducement to donate is a result of a cash payment to the next of kin of the donor provided from the Saudi government and administered through SCOT (²³). SCOT has responded that such payments constitute an expression of gratitude to the family for their donation.

The assessment of deceased organ donor potential by the WHO Critical Pathway that was developed with SCOT leadership will be another component of data that will be a helpful reflection of Saudi contribution to the practice of deceased donation in the region. The SCOT program is to be commended for the opportunity of expatriate patients to undergo liver transplantation in Saudi Arabia. The transparent display of a waitlist with specific allocation to patients on the list based upon medical urgency becomes an important model of ethical propriety for Saudi Arabia, for the region, and the rest of the world.

The Qatar Center for Organ Donation is working closely with The Transplantation Society and the Declaration of Istanbul Custodian Group to develop a donation system that fulfills global standards in accordance with WHO Guiding Principles. This combined effort has led to the Doha Donation Accord in an attempt to encourage deceased donation and increase consent rates. The Accord provides a government sponsored support to the families of all potential deceased donors (³).

The survey of this report clearly reveals the current necessity for both deceased and living donor liver transplantation to meet the patient needs of each country. The best rate in the region is being achieved by Saudi Arabia but only providing 25% of the demand. The high prevalence of HCV, for example in Egypt, also impacts both the deceased and living donor pool. Thus, patients from Arab countries are still traveling to foreign destinations to undergo transplantation entailing much cost and resulting in inadequate care. Poor outcomes are well known to be associated with commercial liver transplantation (²⁴).

In conclusion, both DDLT and LDLT are now routinely and successfully performed in the Arab World. As elsewhere, the organ shortage remains the biggest hurdle facing the increasing need for LT in most of the Arab countries. Although deceased organ donation has been legalized, implementation remains limited because of cultural and logistical barriers. The increasing demand and scarce supply of organs in the Arab World has generated appropriate concern related to organ trafficking and transplant tourism. These shared challenges can only be faced through continued collaboration between the liver transplant programs in the Arab World and the international transplant community.

ACKNOWLEDGMENT

The authors wish to express their appreciation to Francis L. Delmonico, President of The Transplantation Society, for his editorial review and suggestions and his support for the Pan Arab Liver Transplant Society.