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Organ Donation in the Eastern Mediterranean Region

Bader, Feras MD, MS, FACC, FHFSA1; Manla, Yosef MD1; Hammouri, Marwa MD2; Attallah, and Nizar MD3

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doi: 10.1097/TP.0000000000003375
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In recent years, there has been a noticeable growth of deceased donors, transplanted organs, and registered transplantation centers in the Eastern Mediterranean Region. Although most countries in the region have enacted laws regulating organ donation for transplantation from both living and deceased donors, there are still many obstacles to meet the increasing demand of organ transplantation for the rapidly growing population in this geographic area.


According to the World Health Organization (WHO), the Eastern Mediterranean Region (EMR) consists of 21 countries including Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, and Yemen1 with an estimated population of 664 million (20162; Figure 1). Inevitably, risk factor exposure in addition to morbidity and mortality rates is affected by socioeconomic factors and health policies in each country.3

The Eastern Mediterranean Region.

The median life expectancy in the 21 EMR countries ranges from 54 to 79 years and 57 to 80 years for men and women, respectively.2


According to data of the WHO, the number of actual deceased organ donors has grown rapidly in the EMR; from 20 donors resulting in 47 organ transplants in the year 2000, to 986 donors resulting in 2629 organ transplants in 2016 (Figure 2). Critically important for this substantial increase has been an overall improvement of the healthcare infrastructure. By 2016, 11 heart, 104 kidney, 40 liver, 3 lung, 5 pancreas, and 2 small bowel transplant centers had been registered in the region.4

Total number of organs transplanted from deceased donors in the EMR (2000–2016). Data of the WHO-ONT global observatory on donation and transplantation. EMR, Eastern Mediterranean Region; WHO-ONT, World Health Organization-Spanish Ministry of Health (Organización Nacional de Trasplantes).

Solid organ transplantation began in the EMR in the 1970s, with kidney transplants leading the way.5 The first successful kidney transplant in the EMR was performed in Jordan in 1972 by a team led by Dr Daoud Hanania, utilizing a kidney from a deceased donor.6 Notably, Dr Hanania was a cardiac surgeon who played a pivotal role in the development of transplantation; he also performed the first heart transplant in the region (1985).7


As in the rest of the world, organ shortage represents one of the main challenges in the EMR.8 Data from Saudi Arabia estimated 200 patients per million population (PMP) waiting for kidney transplants compared with 40 available organs from either deceased or living donors; comparable ratios are observed for patients awaiting liver transplants (40–50 patients/9 available donors PMP) with a particular need for heart transplants (15–20 patients/1.5 donors PMP).9

Different approaches have been implemented to tackle those shortcomings, including the use of HLA incompatible organs, ABO incompatible organs, and paired live organ donation. Implementing those concepts relied heavily on legal revision, organizational changes, and the support by local authorities. For live donations, donors >50 years, obese donors (body mass index ≤35), and those with controlled hypertension have been considered.10


The Islamic religion is strongly in support of transplantation utilizing organs from both living and deceased donors.5 The Amman declaration in 1986 represented an important milestone that paved the way for organ donation and transplantation from deceased donors in the Arabic countries.11 Resolution number 5 of the declaration states the following:

A person is considered legally dead, and all the principles of the Sharīʿah can be applied when one of the following signs is established:

  • Complete discontinuation of pulmonary and circulatory activities, deemed irreversible by physicians.
  • Complete discontinuation of all vital functions of the brain, deemed irreversible by physicians.

Under these circumstances, it is justified to disconnect life supporting systems, although some organs continue to function through supporting devices.12

This declaration has been approved in 1982 by a resolution of the Islamic Council in Saudi Arabia that sanctioned the donation of organs from living and the deceased donors.11

As a result of these declarations, most Arab countries in the EMR have now enacted laws regulating organ donation and transplantation.

The additional main religions in the region (Judaism, Christianity) are also in support of deceased organ donation.

It needs to be noted, however, that the religious leaders in the region have neither actively encouraged the gift of life,13 nor have they taken a stand of favoring deceased over living organ donation. A survey in the UAE in 2018 showed 51.3% participants confirming that their religion supports organ donation, while only 7.1% strongly stated that their religion was not in support.14 A survey in Pakistan revealed that 31.5% of the population believed that organ donation was not supported by their religion.15 Interestingly, an Iranian study showed that both individuals willing (48.34%; n = 175) or unwilling (51.66%; n = 187) to donate their organs claimed religious support for their reasoning.16


The WHO declared in 2007 that organ trafficking was responsible for 10% of the world transplants.17 Organ trafficking is at particular risk in a region with a stark discrepancy between demand and supply.8 Moreover, illegal transplant practices and unfortunate outcomes do not support trust. Notably, 69 recipients of commercial transplants experienced significant short-term and long-term complications.18

Efforts have been made to address issues with commercial transplant. The declaration of Istanbul did not only very clearly condemn commercial transplants; it also authorized deceased-donor tourism transplantation only if undergoing transplant is based on official reciprocated organ sharing programs between or among jurisdictions.17 Moreover, the Declaration of Istanbul Custodian Group has been working closely with international societies including The Transplantation Society, WHO, International Society of Nephrology, and the American Society of Nephrology. Local societies including Middle East Society of Organ Transplantation have promoted ethical practices of organ donation and transplantation. Declaration of Istanbul Custodian Group has worked with governmental agencies in several EMR countries, especially in Pakistan and the Gulf countries, to fight transplant tourism and organ trafficking.19


As brain death criteria have been accepted across the region, deceased-donor rates have increased. The Global Observatory on Donation and Transplantation reports that 48.4% of all liver transplants and 24.6% of all kidney transplants in 2014 originated from deceased donors in the EMR.4 Although laws supporting brain death criteria for organ donation are essential (Table 1),7,20 there is a significant need for public education focusing on the irreversibility of the condition. Moreover, active religious support of the concept is needed.

TABLE 1. - Legal and ethical frameworks for organ transplantation in EMR countries
Country Transplantation law Transplantation law date Brain death law Government support Ethics committee
Bahrain Yes NA Yes Yes Yes
Egypt Yes 2010 NA Partial NA
Jordan Yes 1977 No Yes Yes
Iran Yes 2000 Yes Yes Yes
Iraq Yes 1985 Yes Yes NA
KSA Yes 1986 Yes Yes Yes
Kuwait Yes 1987 Yes Yes Yes
Lebanon Yes 1999 Yes Yes Yes
Libya Yes 1982 Yes Yes Yes
Morocco Yes 1999 Yes Yes No
Oman Yes 1993 Yes Yes Yes
Pakistan Yes 2010 Yes No Yes
Qatar Yes 1997 Yes Yes Yes
Syria Yes 2003 No Yes Yes
Tunisia Yes 1991 Yes Yes Yes
UAE Yes 1993 Yes Yes Yes
Yamen Yes 2002 No Yes No
EMR, Eastern Mediterranean Region; KSA, Kingdom of Saudi Arabia; NA, not available; UAE, United Arab Emirates.

Notably, knowledge about organ donation and willingness to donate organs differs significantly geographically in the region. A recent meta-analysis of 14 original studies showed a pooled overall knowledge regarding organ donation by 69% of participants with an overall willingness to donate organs by 49.8%.21 International cooperation, in addition to national efforts, can favorably impact this activity. In the UAE, for example, a collaboration between the national transplant committee and Donation and Transplantation Institute in Spain organizes quarterly transplant procurement management workshops educating ICU physicians, nurses, and social workers on brain death diagnosis and conversations with families. The Saudi Center for Organ Transplantation also plays a major role in supporting education in the region at all levels and increasing donation and procurement. Campaigns through regular and social media in recent years have promoted success stories of organ donation highlighting the need, progress, as well as outcomes emphasizing the number of lives saved for every case of deceased organ donation.


Despite the remarkable recent advances in the deceased organ donation in the EMR, more efforts need to be pursued to overcome current obstacles and to improve knowledge about organ donation. Those efforts will need to include the support by religious leaders and governments in the region.


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