INNOVATION AND TRADITION IN EGYPT
The idea of transplantation has already attracted the attention of ancient Egyptians. The Sphinx with a human head “transplanted” onto a lion’s body watching over the pyramids in Gizeh represents this spirit.
Mansoura is the capital of the Dakahlia Governorate, a city of approximately 1 Mio inhabitants in Egypt, 110 km north of the capital Cairo (Figure 1). The team in Mansoura continued the spirit of innovation by ancient Egyptians and has been the first to perform renal transplants in the country (1976).1
THE UROLOGY AND NEPHROLOGY CENTER IN MANSOURA
The Urology and Nephrology Center (UNC) in Mansoura was found in 1983 by Professor M. Ghoneim as a nonprofit hospital dedicated to urology, transplantation, and nephrology services.
UNC has 270 hospital beds and 8 operating rooms. The institution offers 18 outpatient clinics per day. UNC is equipped with cutting-edge technology. In addition to the urology department and the nephrology unit, the institution offers up-to-date imaging modalities (Computerized tomography, Doppler elastography, nuclear, and MRI). Laboratory facilities provide services for histopathology, cytology, microbiology, biochemistry, immunology, and immunogenetics.
The evaluation of recipients includes clinical examinations, laboratory and radiological tests, immunological profiles, endoscopies, and, finally, the consent for transplantation. The assessment of donors starts with the consent, followed by a clinical history, clinical examination, blood and urine tests, immunological workup, and, finally, the radiology assessment.
UNC offers 2 pretransplant clinics per week in which 40–50 recipients and live donors are seen. Approximately, half of our potential living donors are not approved based on medical reasons (34.4%), nephrological disorders (25.6%), urological diseases (11.7%), immunological concerns (16.2%), or other causes (12.1%).2 The vast majority (90%) of living donors are relatives of recipients; approximately 10% are unrelated donors, mostly in special situations (inherited diseases, unavailable or nonsuitable related donors, or for recipients of second renal transplants). Paired kidney exchange programs have not been implemented in Egypt thus far.
The Mansoura team provides transplantation services to patients throughout all of Egypt. The entire care, including immunosuppression and follow-up, is covered by either medical insurance or government support.
Standard surgical procedures have been adopted for most renal transplants and include an extraperitoneal approach with the renal vein anastomosed to the external iliac vein and the renal artery connected to the internal iliac artery via an end-to-end anastomosis. Urinary continuity is created either as a ureterovesical reimplantation in an extravesical or transvesical approach.3
Length of stay for donor and recipients averages 4 and 12 days, respectively. Recipients are followed regularly in 3 weekly outpatient clinics, with approximately 100 patients seen in each clinic. Clinical evaluation, biochemistry, hematology, urine analysis, and drug monitoring are being assessed during each visit.
Notably, all donors are followed indefinitely at regular intervals in our outpatient clinics.
Serum creatinine and creatinine clearance of donors have averaged 1.1 ± 1.2 mg% and 109 ± 33 mL/min during long-term follow-up. Proteinuria (>300 mg/d) has been diagnosed in 1.5% of donors; 22% became hypertensive; 51% gained weight (body mass index [BMI] of donors presurgery and postsurgery: 28.7 ± 2.2 and 29.7 ± 2.6, respectively; P = 0.014, mean±standard deviation); and 6.8% diagnosed with diabetes (32% controlled by oral antidiabetic drugs and 68% required insulin).4
Pretransplant, intraoperative, and posttransplant risk factors affecting graft survival have been studied by univariate and multivariate analyses (Tables 1 and 2).5
Five- and 10-year survival of our living donor transplant recipients has been 91% and 82%, respectively, with graft survival rates of 82% and 63% (Figure 2).
The first kidney retransplantation in Mansoura was performed in 1983,6 and the first pediatric transplant was performed in 1989, with both procedures representing “firsts” in Egypt; redo and pediatric transplantation contribute with 3.2% and 12.5% to our overall transplant volume. Surgical complications including bleeding, hematomas, renal artery thrombosis, renal vein thrombosis, wound dehiscence counted for 0.6%, and urologic complications, including urinary leakage, obstruction, and lymphocele, have been observed in 5.8%. We have seen the first pregnancy in a transplant recipient in 19837 with a total of 200 pregnancies in 447 transplant recipients of reproductive age.
Six cases of bladder cancer have been observed since 1990 in renal transplant recipients, and all managed successfully by radical cystectomies with urethral Kock pouches.
Our center has performed >3040 transplants since 1976, averaging an annual rate of 100 transplants during the most recent 15 years. Most donor nephrectomies have been performed through an open approach; minimal invasive donor nephrectomies have been performed in 200 individuals with a ratio of 70/30 (open versus minimal invasive donor nephrectomies).
In parallel to our clinical efforts, the Mansoura Institute has been academically productive. Among 21 Arab countries, Egypt has contributed with >40% of publications in the areas of experimental and clinical urology, nephrology, and transplantation. More than one-third of those publications originated from Mansoura University.8 Professor Ghoneim has had the most prolific academic record at UNC.
Professor Bakr has been an active member of Istanbul declaration steering committee (2005), the Istanbul summit 2008,9 and contributed significantly to the kidney disease/improving global outcome initiative improving global outcomes for living donor renal transplantation.10
The lack of deceased donor transplants represents the main challenge not only in Mansoura but also in entire Egypt and other Arabic countries. The procurement of kidneys from 2 executed criminals (1991–1992) had caused a vigorous public debate concluding with a clear ethical decision of banning the use of organs from executed prisoners. Nevertheless, this event enhanced the general distrust in procuring organs from deceased donors. Although there have been numerous activities in support of deceased donation in the recent past (institution of a legal framework, scientific presentations and publications, campaigns by key opinion leaders in law and religion, in addition to Transplantation Procurement Management courses, in collaboration with Barcelona University 2014–2016), a strong public support of deceased donation remains missing.
1. Bakr MA, Ghoneim MA. Living donor renal transplantation, 1976–2003: the Mansoura experience. Saudi J Kidney Dis Transpl. 2005; 16:573–583
2. Wafa EW, Donia AF, Ali-El-Dein B, et al. Evaluation and selection of potential live kidney donors. J Urol. 2004; 171:1424–1427
3. Shokeir AA, Sobh MA, Bakr MA, et al. Vesico-ureteral reimplantation in kidney transplantation from living relative donor: extravesical or transvesical? Urologic complications and long-term results evaluation. Prog Urol. 1992; 2:241–248
4. El-Agroudy AE, Sabry AA, Wafa EW, et al. Long-term follow-up of living kidney donors: a longitudinal study. BJU Int. 2007; 100:1351–1355
5. Ghoneim MA, Bakr MA, Refaie AF, et al. Factors affecting graft survival among patients receiving kidneys from live donors: a single-center experience. Biomed Res Int. 2013; 2013:912413
6. Bakr MA, Denewar AA, Abbas MH. Challenges for renal retransplant: an overview. Exp Clin Transplant. 2016; 14Suppl 321–26
7. Ghanem ME, El-Baghdadi LA, Badawy AM, et al. Pregnancy outcome after renal allograft transplantation: 15 years experience. Eur J Obstet Gynecol Reprod Biol. 2005; 121:178–181
8. Sweileh WM, Zyoud SH, Al-Jabi SW, et al. Assessing urology and nephrology research activity in Arab countries using ISI web of science bibliometric database. BMC Res Notes. 2014; 7:258
9. International Summit on Transplant Tourism and Organ TraffickingThe Declaration of Istanbul on organ trafficking and transplant tourism. Clin J Am Soc Nephrol. 2008; 3:1227–1231
10. Lentine KL, Kasiske BL, Levey AS, et al. KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Transplantation. 2017; 1018S Suppl 1S1–S109