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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 2  |  Page : 270-276
Organ Failure in Syria: Initiating a National Deceased Donation Program


1 Surgical Kidney Hospital, Ibn Alnafis Medical Complex, Damascus, Syria
2 Al-Mouassat Hospital, Damascus University, Damascus, Syria
3 Eye Bank, Eye Surgical Hospital, Ibn Alnafis Medical Complex, Damascus, Syria
4 Hemodialysis Unit, Damascus Hospital, Damascus, Syria
5 Hemodialysis unit, Douma Hospital, Damascus, Syria
6 Gastroenterlogy department, Ibn Alnafis Hospital, Damascus, Syria

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   Abstract 

In the absence of formal registry data, the volume and causes of organ failure in Syria are difficult to establish with certainty. However, we evaluated in this study the extent of organ failure by collecting data from health care authorities in different medical institutions who are involved in caring for patients with organ failure. Subsequently, we assessed the problem of the widening gap between organ supply and demand in our country, and we highlighted the obstacles to initiating a national deceased donation program as a viable option to address the challenge of organ shortage. The estimated prevalence of corneal blindness in Syria is 2.3 per one thousand population. The estimated incidence of viral-induced cirrhosis is 49 - 67 per one million population (pmp); these include both HCV and HBV, which constitute the leading causes of liver failure. We estimated the incidence of end-stage renal disease (ESRD) to be from 80 - 100 pmp. Obstacles to initiating a national deceased donation program include lack of awareness of the public at large and health care professionals to the importance of organ donation and transplan­tation. Other obstacles include lack of adequate resources in terms of finance, personnel and services, and the unavailability of a national center for organ transplantation that influences public attitude, sets national guidelines, and supervises all activities related to organ donation and transplantation.

Keywords: Transplantation, Renal, Liver, Cornea, Donation, Organ Failure

How to cite this article:
Saeed B, Derani R, Hajibrahim M, Roumani J, Al-Shaer MB, Saeed R, Damerli S, Al-Saadi R, Kayyal B, Haddad M. Organ Failure in Syria: Initiating a National Deceased Donation Program. Saudi J Kidney Dis Transpl 2007;18:270-6

How to cite this URL:
Saeed B, Derani R, Hajibrahim M, Roumani J, Al-Shaer MB, Saeed R, Damerli S, Al-Saadi R, Kayyal B, Haddad M. Organ Failure in Syria: Initiating a National Deceased Donation Program. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2020 May 26];18:270-6. Available from: http://www.sjkdt.org/text.asp?2007/18/2/270/32325

   Introduction Top


The incidence of ESRD in developing countries is 48 to 240 pmp, compared with 76 to 268 pmp in the developed regions of North America, [1] Europe, [2] and the Asia-Pacific region.[3] ESRD in developing countries seems to be at least as common, if not more common, than in developed countries.[4] The figures given probably underestimate the true inci­dence because most of the people live in rural areas, where there is limited access to health care, and they do not reach urban dialysis facilities.[5] In the absence of an established renal transplant program, it is economically a large burden to maintain large numbers of patients on a maintenance dialysis program in a developing country.[4] Renal transplantation is a viable option for most patients with irreversible renal failure in developing countries because it is more cost-effective, leads to a better quality of life, and involves better rehabilitation than dialysis. There is a worldwide shortage of organs and a progre­ssive gap between supply and demand. Lack of resources and awareness of the importance of organ donation and transplantation contribute to such shortage.[6]

In the absence of formal registry data, it is usually difficult to establish with certainty the prevalence and incidence of organ failure.[5],[7] We evaluated in this study the collected data from health care authorities in different medical institutions who are involved in caring for organ failure patients. The kidney and cornea are the only two organs that can be transplanted in Syria. In the past, heart transplantation was performed for a few patients, but then this practice was stopped, whereas transplantation of the liver, pancreas, lung, bone marrow, and intestine have never been undertaken in our country. Kidneys, followed by liver and cornea, were the only organs for which we were able to collect sufficient data on their failure in our country.


   Corneal Failure Top


Currently, corneal transplantation is by far the most common and successful of all the transplant surgeries. According to the World Health Organization (WHO) statistics; the estimated total number of patients suffering from severe poor vision or blindness in Syria is 125,000 (0.7%) patients.[8] Thirty­seven percent of them have a diseased cornea as a cause of their blindness; therefore, the estimated prevalence of corneal blindness is 2.3 per one thousand population.

Eye Surgical Hospital in Damascus is the biggest ophthalmology center in Syria. This is where the Eye Bank is located and 8032 patients with corneal blindness have been registered on the waiting list as of April 2006; out of them, 2496 patients have unilateral diseased cornea, and 5536 patients have bilateral diseased cornea. Therefore, 13568 eyes require cornea transplantation. Of these, 1494 cornea transplant surgeries were performed at the Eye Surgical Hospital using donated corneas, and 4042 patients are still registered and waiting for one cornea. However, unfortunately for the last two years, the Eye Surgical Hospital in Damascus did not receive any donated corneas; therefore, cornea transplantation is withheld in this center but continues in a very occasional manner in some private centers using "purchased" corneas, while the vast majority of patients are still waiting for sight to be restored.


   Liver failure Top


Since a national registry is lacking, the prevalence and incidence of chronic liver failure in Syria are unknown. However, one may roughly estimate the prevalence of viral cirrhosis, which is the most common cause of chronic liver failure in adults in our country.

In the year 2005, The Blood Transfusion Center of Damascus University (BTCDU) published the registered data of the pre­valence of HBV and HCV among blood donors.[9] In our study, we extrapolated these data to the HBV and HCV carrier status in the general population. Accordingly, the estimated total number of Syrian HBV carriers is 540,000 (2.7%) patients. If 4% of those carriers have the risk of developing liver failure within 15 to 25 years, [10],[11] then there would be an estimated 865 new cases of HBV-induced liver failure every year. On the other hand, the estimated total number of Syrian HCV carriers is around 200,000 (1%) patients. If 5 to 20% of the carriers have the possibility of developing chronic liver disease (CLD), and subsequently 30% of them develop end-stage HCV-related liver disease within 15 to 25 years,[12],[13] then there would be an estimated 118 to 482 new cases of HCV-induced liver failure every year. If we combine the estimated new cases of both HBV and HCV, there will be from 983 to 1347 new patients with HBV and HCV-induced end stage liver disease annually, or an estimated incidence of viral cirrhosis of 49 - 67 pmp.


   Renal Failure Top


In 1997, the incidence of ESRD in Syria was estimated as 75 pmp; [14] however, this figure probably underestimates the true incidence, because most of the people live in rural areas where there is limited access to health care and patients do not reach urban dialysis facilities.

In May 2005, the annual report of renal replacement therapy (RRT) in Syria, which was issued by the statistic department of the ministry of health, revealed that there were 2750 new patients on hemodialysis (HD) and 111 patients on continuous ambulatory peritoneal dialysis (CAPD), Accordingly, the estimated incidence and prevalence were 100 and 143 pmp, respectively. The geographic distribution of HD patients in Syria is displayed in [Figure - 1]. This incidence is close to what has been reported in the neighboring countries; for example, 200 pmp in Egypt,[15] and 120 pmp in Jordan.[16]

The HD patients undergo their dialysis in four different health sectors: the ministry of health (MOH), university hospitals, private centers, and military hospitals; the MOH provides health care for more than 50% of HD patients. Accommodating the new patients has technical and economical problems, especially for patients in the rural areas. This mandates the establishment of a renal transplant program, which is a more cost-effective approach for RRT.

We reviewed the reported mortality of patients receiving HD in several hemodialysis units in our country for the last three years. The three year survival rate of HD patients in Syria ranged from 26 to 64%. This rate is far from being satisfactory, although it is not that different from what it has been reported from other developing countries; for instance, it ranged from 25 to 52% in Egypt,[17] South Africa,[18] and Taiwan. [19]

In developed countries, 56 to 60% of ESRD patients receive dialysis; [20],[21] with an initial acceptance rate from 61 to 99%. [22] However, we do not have data on the percentage of ESRD patients who receive dialysis in Syria.

PD is grossly underused in Syria. In the year 2005, less than 4% of dialyzed ESRD patients were receiving PD. This is due mainly to physician bias and lack of skills, as well as patients' lack of education and motivation. [5],[23],[24]


   Renal Transplantation Top


The number of kidney transplants performed pmp correlates with the socioeconomic status of a country. [25] In 2005, 264 (13 pmp) kidney transplants were performed in Syria. This figure is quiet better than most developing countries, where it ranges from 1 to 5 pmp with an average of 2 pmp in the middle east and Afro-Arab region. [26] However, it is still far from being satisfactory because of the large gap with the estimated incidence of ESRD in our country of 100 pmp. Developed countries perform 20 to 40 transplants pmp per year.[27] However, an exemplary experience is that of Cyprus, in which ESRD incidence is 80 pmp and a transplantation rate is 60 pmp, of which deceased donors make up one third. [28]


   Essential factors for initiating a national deceased donation program in Syria Top


A national deceased donation program is a viable option to address the widening gap between organ supply and demand. Renal transplantation in Syria as in many other developing countries is marked by its exclusive reliance on living donor transplan­tation. The use of deceased and/or non-related donors has been proposed as one possible solution to ameliorate the situation. [29]

In November 2003, the so-called "law number 30" was enacted that recognized the concept of brain death and allowed the use of organs from deceased donors in addition to living donors (either related or non­related). Since the commencement of organ transplantation in Syria in the 1980s, transplantation activities were exclusively from living related donors. This very important law was preceded by another big stride, which was the acceptance by the Islamic religious authorities in the country in September 2001 of the principle of procurement of organs from the deceased donors, provided that consent should be obtained from the next of kin. In November 2004, the ministry of health issued guidelines which regulated the legal and medical aspects of organ donation and transplantation in Syria, including the definition of death and brain death criteria, the consent for deceased organ donation, banning commercialism, defining donors, and how to evaluate potential organ donors.

The practice of living unrelated donor transplantation has been marked in our country, and has negatively impacted the living related donation. Furthermore, it may have a similar negative impact on the development of a local deceased donation program in the future.[31]

The major limiting factor inhibiting the institution and growth of a deceased organ donation program in Syria as in many other developing countries is educating the public to the importance of organ donation and transplantation in order to change negative public attitudes and to gain societal acceptance since the success of this program requires a high degree of public trust and acceptance.[32]

Inadequate awareness of health profes­sionals of the importance of organ donation and transplantation has been identified as another major limiting factor to the initiation of a deceased organ donation program, exactly as it has been pointed out in other developing countries.[6],[32]

Establishment of a coordinating center for organ donation and transplantation requires appropriate legislation and financial support by the government. Such a center is funda­mental for the success of a deceased donation program as it supervises and coordinates the whole process of organ donation between the donating hospital and the transplant center in addition to other functions such as applying strategies to increase the awareness of the medical community and public at large to the importance of organ donation and empha­sizing ethics.

Once the coordinating center is establi­shed, a network of regional organ procure­ment organizations (OPO) can be created and supported financially by the national health authorities.

The availability of trained transplant coordi­nators is one of the most important issues that has to be addressed before the initiation of a deceased donation program in our country. Transplant coordination is still in its infancy in Syria. With an understanding of local socio­cultural beliefs and a sensitivity to the needs and concerns of families, transplant coordi­nators could form a vital link between the public and the transplant team.[33] The transplant coordinator can play a growing role in the identification and care of potential donors and their families. Moreover, the transplant coordinator could increase the supply of organs by organizing and facilitating the logistics of organ procure­ment.

Adequate financial resources for personnel and services are crucial because deceased donor programs tend to be more expensive than living donor transplantation.[25] However, many reports have confirmed that transplant­tation is less expensive than dialysis in developing countries. [5],[6],[17],[34] This issue has to be very clearly pointed out to all health care administrators and health insurers in order to get their support of our "overall less costly" deceased donation program.

Shortage of intensive care unit (ICU) beds can be a major limitation. [33],[6] Moreover, the education and training of key personnel in the ICU is at least as important if not more important than increasing ICU beds, because they are the ones who usually identify potential donors and ensure the ICU standard care and quality of recovered organs.

A reliable comprehensive tissue center where we can perform HLA-typing is also needed. Having available all methods of cross-matching tests and panel reactive antibodies with 24-hour service is of crucial importance.

Finally, a national registry and data bank for all organ failure cases can lead to precise information about the prevalence and inci­dence of organs failure, which are substantial elements for profiling the national policy of organ transplantation.


   Preemptive renal transplantation in Syria Top


In the case of living donor transplantation, considerable cost can be saved if a patient receives a graft without prior dialysis. This early preemptive transplantation is an ideal choice for primary treatment of ESRD in developing countries. Avoiding hemodialysis not only saves costs, but also avoids the inconvenience and discomfort of dialysis and protects the patient from undue exposure to blood products. [35],(36) Lastly, it results in a better graft survival.

Preemptive renal transplantation is still not widely practiced in Syria. However, there is currently a tendency to apply it for an increasing number of patients, as most transplant teams in our country have realized its lower cost and favorable outcome.

We conclude that the success of a national deceased donation program requires several factors to be addressed, the most important of which is the government support for organ procurement efforts and the enactment of national laws and policies that facilitate transplantation.


   Acknowledgement Top


We would like to thank all the staff of the Surgical Kidney Hospital in Damascus whose care and attention to details have been a major contribution to this work.

 
   References Top

1.U.S. Renal Data System. USRDS 1998 annual data report. National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, Md.  Back to cited text no. 1    
2.Mallick NP, Jones E, Selwood N. The European (European Dialysis and Transplantation Association-European Renal Association) Registry. Am J Kidney. Dis 1995; 25:176-87.  Back to cited text no. 2    
3.Ota K. Strategies for increasing transplantation in Asia and prospects of organ sharing: the Japanese experience. Transplant Proc1998;30:3650-2.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.McLigeyo SO, Otieno LS, Kinuthia DM, Ongeri SK, Mwongera FK, Wairagu SG. Problems with a renal replacement program in a developing country. Postgrad Med J 1988;64:783-6.  Back to cited text no. 4  [PUBMED]  
5.Chugh KS, Jha V. Differences in the care of ESRD patients worldwide: required resources and future outlook. Kidney Int 1995;50:S7-13.  Back to cited text no. 5    
6.Naqvi A, Rizvi A. Renal transplantation in Pakistan. Transplant Proc 1995;27:2778.  Back to cited text no. 6    
7.Kang Z, Fang G, Chen W. A comparative study of the outcome of renal transplantation in peritoneal dialysis and hemodialysis patients. Chin Med Sci J 1992;7: 49.  Back to cited text no. 7  [PUBMED]  
8.Implementation of VISION 2020 in the Eastern Mediterranean Region. Report on a regional planning workshop. Cairo, Egypt, 14-17 December 2003.27.  Back to cited text no. 8    
9.Ali T. Prevalence of HBV & HCV among blood donors in the Blood Transfusion Center of Damascus University. Updating in Gastroenterology Diseases. SWGSVH 2005;2:15.  Back to cited text no. 9    
10.de Franches R, Hadenque A, Lau G, et al. EASL International consensus conference on hepatitis B. J Hepatol 2003;39 suppl1:S3-25.  Back to cited text no. 10    
11.Fattovitch G. Natural history of hepatitis B. J Hepatol 2003;39Suppl 1: S50-8.  Back to cited text no. 11    
12.Afdhal NH. The natural history of hepatitis C. Semin liver dis 2004;24 Suppl 2:3-8.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Seef LB, Hollinger FB, Alter HJ, et al. Long term mortality and morbidity of transfusion-associated non-A, non-B and type C hepatitis. A National Heart, Lung and blood Institute collaborative study. Hepatology 2001;33:455-63..  Back to cited text no. 13    
14.Ayash Z. Renal replacement therapy in Syria. Saudi J Kidney Dis. Transpl. 1997;8:436-7.  Back to cited text no. 14    
15.Barsoum RS. The Egyptian transplant experience. Transplant Proc 1992; 24:2417­20.  Back to cited text no. 15  [PUBMED]  
16.Said R. Renal replacement therapy in Jordan. Saudi J. Kidney Dis. Transpl. 1999;10:64-5.  Back to cited text no. 16    
17.du Toit ED, Pascoe M, MacGregor K, Tompson PD, SADTR. (1994). Combined report on maintenance dialysis and transplantation in the Republic of South Africa. Cape Town, South Africa.  Back to cited text no. 17    
18.Lai MK, Huang SH, Chuang CK, Huang JY. Two-hundred and thirty cases of kidney transplantation: single center experience in Taiwan. Transplant Proc 1992;24:1452-4.  Back to cited text no. 18    
19.Geerlings W, Tufveson G, Ehrich JH, et al. Report on management of renal failure in Europe, XXIII. Nephrol Dial Transplant 1994;9Suppl 1:6-9.  Back to cited text no. 19    
20.U.S. Renal Data System. USRDS 1994 annual data report. National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, Md.  Back to cited text no. 20    
21.Schena FP. Report of the first meeting of the chairmen of the national and international registries. Kidney Int 1997; 52:1422.  Back to cited text no. 21    
22.Abu-Aisha H, Paul TT. CAPD: is it a viable mode of RRP in Saudi Arabia? Saudi J Kidney Dis Transpl. 1994;5:154.  Back to cited text no. 22    
23.Arije A, Akinlade KS, Kadiri S, Akinkugbe OO. The problems of peritoneal dialysis in the management of chronic uraemia in Nigeria. Trop Geogr Med. 1995;47:74-7.  Back to cited text no. 23    
24.Chugh KS, Jha V. Commerce in transplantation in Third World Countries. Kidney Int1996;49:1181-6.  Back to cited text no. 24  [PUBMED]  
25.Abomelha MS. Renal failure and transplantation activity in the Arab World. Arab Society of Nephrology and Renal Transplantation. Nephrol Dial Transplant 1996;11: 28-29.  Back to cited text no. 25    
26.Chevalier C, Busson M, Hors J, Foulon G. Medical care of end-stage renal disease in 52 countries: evolution since 1975 and potential activity for the next 5 years. Transplant Proc1991;23:2529-30.  Back to cited text no. 26  [PUBMED]  
27.Kyriakides GK, Hadjigavriel M, Hadjicostas P, Nicolaides A, Kyriakides, M. Renal transplantation in Cyprus. Transplant Proc 1993;25:2361.  Back to cited text no. 27    
28.Daar AS. The case for using living non­related donors to alleviate the world-wide shortage of deceased kidneys for transplantation. Ann Acad Med Singapore 1991;20:443-52.  Back to cited text no. 28  [PUBMED]  
29.Shaheen FAM, Souqiyyeh MZ, Attar MB, Al-Swailem AR. The Saudi Center for Organ Transplantation: An ideal model for Arab countries to improve treatment of end­stage organ failure. Transplant Proc 1996;28:247-9.  Back to cited text no. 29    
30.Abouna GM. Negative impact of trading in human organs in the development of transplantation in the Middle East. Transplant Proc 1993;25,:2310.  Back to cited text no. 30    
31.Cheng IK. Special issues related to transplantation in Hong Cong. Transplant Proc1992; 24:2423-5.  Back to cited text no. 31  [PUBMED]  
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33.Rizvi SA, Naqvi A. The need to increase transplantation activity in developing countries. Transplant Proc 1995;27:2739-40.  Back to cited text no. 33  [PUBMED]  
34.Evans R. Cost-effectiveness analysis of transplantation. Surg Clin North Am 1986;66:603-16.  Back to cited text no. 34    
35.John AG, Rao M, Jacob CK. Preemptive live-related renal transplantation. Transplantation 1998;66:204-9.  Back to cited text no. 35  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Bassam Saeed
Surgical Kidney Hospital, Ibn Alnafis Medical Complex Damascus
Syria
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    Abstract
    Introduction
    Corneal Failure
    Liver failure
    Renal Failure
    Renal Transplant...
    Essential factor...
    Preemptive renal...
    Acknowledgement
    References
    Article Figures
 

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