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Renal Transplantation in Iraq

Ali, Ala FEBTM, FASN, FACP1

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doi: 10.1097/TP.0000000000003426
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Iraq is a federal parliamentary republic with nearly 40 million inhabitants; the country consists of 18 governorates with 3 of those constituting the Kurdistan region in the Northern part of the country. Culturally, Iraq has a very rich heritage and celebrates the achievements of its past. The region between the Tigris and Euphrates rivers, historically known as Mesopotamia, is often referred to as the cradle of civilization. It was here that mankind first began to read, write, create laws, and live in cities under an organized government termed Uruk, from which “Iraq” is derived.1

The world’s first ethical health code that regulated the practice of medicine emerged from Hammurabi’s Code of Law in Babylon. The code specified “If a surgeon performs a major operation on an ‘awelum’ (nobleman), with a bronze lancet and caused the death of this man, they shall cut off his hands.” However, there is no proof that such a punishment was ever carried out, but it reflected the good intention of providing safe health services. Hammurabi also specified fees for lifesaving operations.2

The modern history of Iraq has been shaped by many conflicts, wars, and economic crises. Iraq’s economy is dominated by the oil sector. Before 2003, Iraq had a centrally planned political system, economy, and civil services. After 2003, efforts of decentralization and a tendency to privatizing some services have been put in place. In 2010, spending on health care accounted for 6.84% of the country’s gross domestic product (4.2% in 2017). In 2018, Ministry of Health reported on 0.83 physicians and 2.1 nurses available per 1000 people; life expectancy at birth is 70 years. The country traditionally been depended on large-scale imports of medicines and equipment. Nevertheless, Iraq has a few tertiary hospitals providing advanced medical procedures by specialist. All health care is provided by the Iraqi central government.3

The first renal transplant in Iraq was performed in June 1973 at Al-Rasheed military teaching hospital. The donor was a mother giving a kidney to her son. Transplant activities thereafter remained limited to live donor blood group–compatible transplants. In March 1985, the first renal transplant in a civil hospital supported by the Iraqi Ministry of Health had been done in Baghdad’s Medical City Teaching Hospital. In the same year, the Iraqi government contracted with an Irish transplant team to treat Iraqi patients at the Ibn Al-Bitar Hospital in Baghdad. In 1987, a transplant team started a live related donor program at this institution headed by Dr Peter John Little (1930–2011), a New Zealand born nephrologist with continuing weekly transplant activities until 1990. Kurdistan, the northern territory of Iraq, started its renal transplantation program in Erbil in 2001. In 2015, additional transplant activities have been initiated in the southern part of the country at Al-Basra Nephrology and Renal Transplantation Centre.4,5

INFRASTRUCTURES, LEGISLATION, ORGANIZATIONAL ASPECTS, AND TRAINING PROGRAMS

Currently, 8 renal transplant units are active in Iraq (Figure 1). The largest governmental center is the Nephrology and Renal Transplantation Centre, Medical City in Baghdad. Renal transplants are also performed at another unit in Baghdad, 1 in Basra, and 3 in Kurdistan. An additional renal transplant center in the Holy City of Najaf has been active until 2009. Two units have recently been established in the city of Karbala, in hospitals supported by religious authorities helping with management, donor support, and financial assistance for patients in need.

FIGURE 1.
FIGURE 1.:
Renal transplantation units and data: 2019.

Until December 31, 2019, approximately 5400 renal transplants have been performed in Iraq. Annual numbers have been increasing, and approximately 650 transplants have been performed in 2019 (16.25 per million population [PMP]).6 There are 35 hemodialysis centers with approximately 6000 patients on dialysis. Efforts to establish chronic peritoneal dialysis have thus far been limited.

According to data published in the 2016 United States Renal Data System Annual Report, Iraq has a lower transplant rate (146 PMP) compared with other countries in the region including Iran (294 PMP), Qatar (358 PMP), and Kuwait (559 PMP).7 Data collection, particularly on outcomes, remains limited (Table 1).8–12

TABLE 1. - Iraq renal transplantation activity, survival data
Study Date Center Time Type No. 1 y 3 y 5 y 10 y
P G P G P G P G
Sh Al-Taee et al8 2005 Al-Rasheed MH 1979–1999 Retrospective analysis 182 83.5% 83.9% 79.7% 64.5% 71.2% 61.6%
Al-Jebory et al9 2007 Al-Karama HAl-Khayal Private H 1979–2005 Retrospective analysis 512 91% 89%
Al-Bazzaz10 2010 Erbil 6 mo Retrospective analysis 88 The patient and graft survival were (90% and 80%)
Ali et al11 2015 Medical City H 2009–2014 Follow-up data 250 94% 94.4% 90% 91% 88% 87.1%
Ali et al12 2018 Medical City H 2015–2018 Follow-up data 210 90% 90% 87% 88%
Ali et al12 2018 Basra Center 2015–2018 Follow-up data 60 100% 95% 95% 92%
G, graft; H, hospital; M, military; P, patient.

There are also extrarenal transplant activities in Iraq. Four hundred fifty corneal transplants have been performed in 2018 (10.5 PMP), with corneas imported from India. Eighty bone marrow transplant procedures (2 PMP) have been performed in 2018. There is limited liver transplant activity at Kurdistan supported by the California Pacific Medical Center, San Francisco. Most patients in need for a liver transplant have been travelling abroad with some Ministry of Health and additional out of pocket support. Few patients had lung transplants in India.

Iraq has been pioneering legislation on organ transplantation and donation in the Middle East. In 1981, a first law on organ donation and transplantation including an article on deceased donation had been passed. In 1985, Iraq has endorsed a clear legal definition of brain death which was refined in 1989. These laws have included articles explaining live and deceased donation, donor criteria, (nonpaid) donation, and consent. To prevent the exploitation of vulnerable patients and organ trafficking, it is prohibited for Iraqi citizens to donate to non-Iraqis. In 2016, the Iraqi parliament approved a law that prohibits and penalizes organ trafficking. Since 2017, revisions and updates on legal provisions of organ donation and transplantation have been under way.

Licensing of transplant centers is granted by the Nephrology and Renal Transplant Committee and the Commission of Specialty Centers at the Ministry of Health. Iraq does not have a single national body for regulating the process of organ donation and transplantation, in contrast to other countries in the region.13

Expertise in transplantation, skills, and surgery training are supervised by the respective Iraq and Arab boards. Nephrology training (adults and pediatrics) is based on a 3-year curriculum that includes at least 6 months of training in renal transplantation, following a 4-year training in internal medicine and pediatrics. The Arab board in Iraq established a renal transplant surgery fellowship program in 2015. This is a 2-year clinical program at a transplant center following a 5-year residency in urology or general surgery. There is no dedicated training program for transplant coordinators. A proposal for a specialized nurses training program in nephrology and transplantation has been submitted to the Ministry of Health and the Ministry of Higher Education.

CHALLENGES AND OPPORTUNITIES

Donation Activities

Despite established legislation for deceased donation, living donation remains the sole transplant activity in Iraq as in many other Arab and Islamic countries with tribal and religious barriers as the main obstacles in addition to a lack of active support by politicians and health policymakers. An unpublished survey in the general population of Baghdad did not support religious and social beliefs as barriers to either living or deceased organ donation.14 Nevertheless, more educational efforts are necessary to move the needle.

Public awareness alone may not be sufficient. We are currently in a dialogue with religious leaders, human rights and nongovernmental organizations, and the Ministry of Health. A model of public-private partnership under governmental control may provide a culturally appropriate approach.

Commercial Transplantation

During the 1980s and especially 1990s, there were deep and growing concerns about paid donation and organ trafficking through the work of private hospitals in Iraq amid the paramount detrimental effect of wars and economic sanctions on Iraqi people. The World Health Organization identified Iraq as a country exporting organ.15 Political and economic challenges after 2003 with increasing numbers of refugees and displaced and disadvantaged people may have contributed to the exploitation of those vulnerable groups, contributing to organ trafficking. Recent news reported on commercial transplantation from economically challenged Iraqi Arabs to well-off recipients in the northern Kurdistan area or displaced people selling body parts for food in private hospitals in Baghdad.16

To overcome this issue, the Ministry of Health has established a central committee for accepting donors. The committee is a multiprofessional team headed by a nephrologist, includes a psychiatrist, in addition to representatives from the ministries of health and interior. The main duty of this committee is to refute any suspicion of commercial deals and to assign the procedure to a governmental or private hospital. A similar committee has been established in Kurdistan. From 2014 to 2018, the committee in Baghdad has interviewed a total of 1118 donors.

According to the Iraqi Ministry of Interior there was no report of organ trafficking during the past 5 years. Transplant units (governmental and private) in Baghdad and the mid and southern parts of Iraq never performed a transplant for non-Iraqis. To the best of our knowledge, there was no such practice in Kurdistan in the last few years.

Public Versus Private Practice

Currently, there are private hospitals in Baghdad (1) and Kurdistan (3). Approximately 20% of transplant procedures in Baghdad are performed in the private sector. The distribution of private versus governmental transplants in Kurdistan is not known. The existence of the private sector hospitals with transplant services raises many questions about commercial interests and potential delays in implementing deceased donor programs. To assure full transparency, it may be best to limit transplantation to the public sector while ensuring a complete compliance with recommendations by the Transplantation Society and the Declaration of Istanbul.17 The recent Karbala city experience of a public-private partnership through the collaboration of the Iraqi Society of Nephrology and Renal Transplantation and the religious authority in the Holy city to support transplantation for economically disadvantaged people is interesting but needs evaluation and long-term audit.

Data Collection

The recently established Iraqi Renal Transplant registry (2017) and its inaugural report in 2020 represents a great addition to the progress of transplantation in Iraq.18 Nevertheless, there are some limitations with a lack or incomplete data on transplants performed outside Iraq, location (public or private), in addition to limited donor data challenging a proper donor follow-up beyond the currently mandatory 3-month period.

Inequity

The majority of transplant recipients (69%) in Iraq is <51 years of age, potentially related to lower life expectancy. Nevertheless, there could be a potential ethical dilemma limiting older patients from getting transplants. Moreover, transplant recipients are predominantly men (72.8%), and women are more likely to donate a kidney. Dominating tribal mentalities are the main cause of this inequity that will need to be addressed through educational initiatives.19

Sensitized Patients

About 30% of transplant candidates are currently sensitized.20 This adds to the challenge of establishing state-of-the-art tissue typing facilities, adding to treatment costs. Implementing a paired kidney exchange program could potentially alleviate this problem.

Limited Nephrology Workforce and Transplantation Infrastructures

Among Middle East countries, Iraq reports one of the lowest nephrology workforces with 1.03 PMP nephrologists and 0.32 trainees PMP.21 Surgical skill transfer remains a major challenge. Only a few laparoscopic donor nephrectomies have been done in Kurdistan and Basra. Necessary infrastructures for deceased donation including intensive care units, transport, organ storage, and allocation systems are not readily available. With more sensitized patients, tissue typing and immunology laboratories will need an upgrade in expertise and equipment. Moreover, the availability and the timely provision of transplant medications are at risk at any time of crisis.

Health System, Politics, and Finances

Healthcare delivery in Iraq is predominantly governed by the public sector with the risk that resources will be diverted to more urgent issues in situations of a crisis, potentially limiting access to healthcare and transplantation services that would be skewed toward more wealthy communities and more urban areas. This risk may increase commercial organ donation in areas where potential donors cannot be protected by specific legislation.17

The Current Coronavirus Disease 2019 Pandemic

From February 24 to May 24, Iraq has recorded 4469 laboratory-confirmed COVID-19 cases22 including 15 hemodialysis patients of which 11 recovered. Four renal transplant patients have been diagnosed with COVID-19 of which 2 recovered. The diagnosis of COVID in renal patients is made by nephrologists and transplant physicians based on clinical symptoms, polymerase chain reaction tests, and chest computed tomography scans. The treatment consisted mainly of supportive therapies and the reduction of immunosuppression. Transplant activities ceased from February to May, and a few cases have been performed since then in Kurdistan.

In conclusion, renal transplantation has continued since 1973 despite major obstacles in Iraq. Improved infrastructures, well-trained experts, and stable financial support are in need. Above all, a reliable data bank and a well-regulated deceased donor program are in need to move transplantation forward.

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