Ethiopia, a country on the Horn of Africa, is the second most populous nation on the continent. According to 2016 estimates, Ethiopia has a population of 102 million, a life expectancy at birth of 65.5 years, and a per capita gross national income of $660.1
The incidence and prevalence of end-stage organ failure in Ethiopia, including those of end-stage renal disease, are not known. Facilities providing maintenance dialysis did not exist before 2001. In the past 17 years, chronic hemodialysis has become available in private institutions, mostly in the nation’s capital, Addis Ababa, and more recently in a few other urban and semi-urban regions. At present, there are 30 hemodialysis centers with a total of 186 hemodialysis chairs and approximately 800 patients on hemodialysis. Costs of a single hemodialysis session are close to $70 US dollars, an unaffordable expense for the majority of patients. Among patients on maintenance dialysis, only about one-third receive treatment 3× per year; 1-year survival on hemodialysis is 42.1%.2
NUMBERS OF TRANSPLANT PROGRAMS
The first and only living related kidney transplant program was established in September 2015 in collaboration with the University of Michigan. Coordinated by the Ethiopian Federal Ministry of Health, the project was from the start geared toward establishing local competency. In 2010, the Ethiopian government identified St. Paul’s Hospital Millennium Medical College (SPHMMC) in the Capital City, Addis Ababa, (Figure 1) as the future home of the transplant program. An ISN fellow was recruited in 2012 who established a nephrology unit at SPHMMC with acute inpatient hemodialysis services that were later expanded to provide outpatient hemodialysis as a bridge to kidney transplantation. A team of surgeons, internists, nurses, and other health professionals were identified to staff the planned transplant center. From 2013 to 2015, the team completed a series of preparations for transplant including (1) remodeling of a nearby building as the National Transplant Center, (2) updating the radiology department and clinical laboratories with modern equipment and expanding service availability from daytime only to around the clock, (3) training surgeons on a porcine kidney transplant model, (4) developing clinical protocols, and (5) establishing procedures for procurement of materials and supplies. In addition to gaining experience of the local team by visiting transplant programs in India, Egypt, Brazil, and the United States, all training has occurred at SPHMMC. The Ministry of Health funded the travel of nephrologists, transplant surgeons, nurses, and social workers from established Transplant programs (primarily the University of Michigan) to Addis Ababa for multiple visits over a 30-month period. In 2016, a nephrology fellowship program was initiated and the first group of nephrologists and transplant surgeons graduated in mid-2018.
The Ethiopian government covers all costs of pretransplant evaluation, surgery, and perioperative care; however, transplant candidates must be able to afford the costs of maintenance immunosuppression and chemoprophylaxis from the third postoperative month onward to be eligible for kidney transplantation. Medications are obtained through a public national procurement system and distributed at cost to patients through SPHMMC transplant pharmacy. All maintenance immunosuppressants are generic and cost on average $150 US dollars per month. Social workers help recipients find sponsors, usually local businesses, to help cover the costs of transplant medications.
DATA SYSTEMS AND OVERALL TRANSPLANT VOLUME
A national registry of end-stage renal disease or kidney transplantation does not exist in Ethiopia. Since the first kidney transplant on September 22, 2015, a team from Michigan has traveled to Ethiopia nearly every month on 1-week missions, performing 3-5 transplants during each visit. To date, 90 living donor kidney transplants have been performed. The program currently accepts candidates 14 years and older.
LIVING AND DECEASED DONATION PRACTICES
To discourage commercialization, current regulations permit organ donation only by individuals related by blood or marriage. Evaluations are multidisciplinary, involving transplant nephrology, surgery and social work or psychiatry and following a generally accepted model as practiced in the United States. Potential living donors are evaluated by a psychiatrist, acting as a donor advocate with the authority to reject potential donors who might be at risk of donating under coercion. Before the release of funds, all proposed transplants are reviewed by a National Transplant Committee with representatives of the Ministry of Health, clergy, physicians, law enforcement, and the judiciary to verify that relevant facts of the donation are truly represented.
The volume of transplants and living donations has increased in parallel to skills and expertise of the local staff (Figure 2). Notably, there are also patients who still travel with their donors outside of the country (mainly to India or Thailand) for transplantation. Altogether, approximately 300 transplant recipients who received kidney transplants at SPHMMC or abroad reside in the country.
Ethiopia has established a legal framework for brain death, but deceased donation has not yet begun, and a team of local and international experts is exploring ways of implementing deceased donation. In parallel, work on establishing a histocompatibility laboratory is in progress.
BARRIERS TO LIVING/DECEASED DONATION
There are no data on public perception of organ donation and transplantation. While large family size and close bonds within extended families favor living donation, misconceptions about the risks of organ donation prevent some patients from getting transplants.
SIGNIFICANT ACHIEVEMENTS AND CHALLENGES
Outcomes for transplant recipients have been comparable to those achieved in many US and European centers with 91% 1-year graft and 93% patient survival by 3 years. To date, 90 living donor kidney transplants have been performed; there were a total of 6 recipient deaths and 2 additional graft failures. Infections of the lung have been the most frequent cause of death. The first 44 living donor nephrectomies have been through a hand-assisted minimal invasive transperitoneal approach, with 3 conversions to an open approach for technical reasons. The most recent 46 donor nephrectomies have been performed with an open flank incision. The change to open nephrectomy was primarily driven by the prohibitive cost of consumables required for laparoscopic procedures. There have been no major donor complications; 1 patient each suffered a small bowel obstruction due to adhesions, while in the Hospital and a pneumothorax, both successfully treated. All donors are being followed periodically according to our internal protocol, and all remain in good health.
Establishing local competencies has been the central focus of the kidney transplant programs in Ethiopia. Modernization of laboratory and radiology services at SPHMMC triggered by the kidney transplant project has improved patient care throughout the entire hospital. Transplant and nephrology teams include now 4 nephrologists, 4 transplant surgeons, 1 social worker, 2 psychiatrists, a renal pathologist, and many nurses, all well positioned to sustain active clinical and training programs.
To maintain and expand early achievements, transplant programs face important challenges. First, pathology and microbiology services are not yet fully developed, limiting the ability of the program to manage complex medical risks or complications. Second, histocompatibility and virological tests are currently sent to a laboratory outside the country, at significant costs and with long turnaround times. Third, as the number of transplants and recipients increase, the cost of transplants may strain government resources, endangering the sustainability of the program. Fourth, governmental, charitable, and social organizations need to collaborate to make transplantation accessible to patients who cannot afford posttransplant medications.
GOVERNMENTAL AND REGULATORY SYSTEMS INVOLVEMENT AND OVERSIGHT
In 2014, the Ethiopian government enacted legislation governing organ transplantation. The law delegates rule-making authority to the Federal Ministry of Health. Existing regulations permit transplants only at hospitals that have been issued a transplant license. Potential living donors must be related by blood or marriage. A National Transplant Committee must review and approve donor and recipient pairs before surgery.
The transplant program in Ethiopia owes its success to strong governmental support, careful strategic planning, and ongoing collaboration with experts at leading transplant institutions, particularly the University of Michigan. The Ethiopian approach of training specialists, nursing, and ancillary staff in-country may serve as a model to establish sustainable transplant programs in other developing nations; the approach may also be suitable for the implementation of other highly multidisciplinary treatments.
The authors acknowledge the personal support and commitment of Drs Zerihun Abebe and Kesetebirhan Admasu, who served as the Provost of St. Paul’s Hospital Millennium Medical College (SPHMMC) and Minister of Health, respectively, during the development of the National Transplant Center at SPHMMC.