| Abstract|| |
The objective of this study was to evaluate the current activity of pediatric versus adult kidney transplantation activity in the Arab world. A questionnaire was mailed to all kidney transplant centers in Arab countries to collect data on the kidney transplant activity in a recent single year. Three thousand three hundred and nine kidney transplants were performed in one year, with a transplant rate of 9.5 per million populations (PMP); 298 were performed for children with a pediatric kidney transplant (PKT) rate of 0.87 PMP, which is much lower than that of developed countries where it mostly ranges from 5 to 10. The pediatric share of all transplants is 9%, which is twice as high as that of European children. Kidney transplant programs in most Arab countries rely exclusively on living donors as there is a severe shortage of deceased donors. 93.5% of all transplants, combined adult and pediatric, were from living donors. Deceased transplant activity in Arab countries accounts for 14-31% of all transplants in the three countries with deceased donor programs. Of the 212 adult and pediatric transplants that were performed from deceased donors in eight countries, only 29 cases were for pediatric recipients. Deceased PKT is available in the Kingdom of Saudi Arabia (KSA), Tunisia and Kuwait. Surprisingly, the PKT share was not better in the countries with higher overall kidney transplant rate and or in those where deceased transplant was available. PKT is still inactive in most Arab countries and mostly relies on living donors. The lack of well-developed deceased donor programs is the main issue to be addressed.
|How to cite this article:|
Saeed B. Pediatric versus adult kidney transplantation activity in Arab countries. Saudi J Kidney Dis Transpl 2013;24:1031-8
| Introduction|| |
Transplantation is currently the best option for children with end-stage renal disease (ESRD). Surgery and modern immunosuppression have demonstrated excellent results, provided the children are managed in a pediatric center with experience in the management of all aspects of pediatric kidney transplant (PKT). However, such a therapeutic option is not accessible to all children in the world because of political, religious, economic and cultural issues in developing countries. Most developing countries lack national kidney foundations and insurance systems, and although renal transplantation is more cost-effective than dialysis, only a limited number of political strategies are in favor of promoting transplantation.
In contrast to the increasing availability of information pertaining to PKT from large scale observational and interventional studies, epidemiological information on PKT from Arab countries as well as that from other developing countries is currently limited, imprecise and flawed by methodological differences between the various data sources. ,,,,
| Patients and Methods|| |
The Arab population comprises a population of around 350 million; of them, 35% are aged less than 15 years according to the World Health Organization (WHO) 2010 report, which makes the estimated Arab pediatric population to be around 122 million. It is estimated that one-fourth of the Arabs live in Egypt, 60% of the Arabs live in Africa and the rest live in Asia.
A questionnaire was mailed to all kidney transplant centers in Arab countries to provide the following data on kidney transplant activity during the recent one year: Total number of kidney transplants (living and deceased) for adults and children and the total number of PKT (living and deceased).
The missing data were obtained from the Global Observatory on Donation and Transplantation (GODT) data, produced by the WHO. 
| Results|| |
[Table 1] shows the most recent one-year data obtained from the 17 Arab countries where kidney transplantation is available on the total kidney transplants, kidney transplant rate per million populations (PMP), total deceased kidney transplants if any, percent of total deceased kidney transplant when applicable of the total kidney transplants, total PKT, PKT share of the total kidney transplants, rate of PKT (PMP), PKT from deceased donors when available and the percent of PKT from deceased donors of the total PKT when applicable.
|Table 1: Number of pediatric versus total kidney transplants performed inside Arab countries PMP per 1 year (2008–2011).,|
Click here to view
The total number of kidney transplants performed for all ages in the Arab countries during one year as per the most recent data was 3309 cases. Thus, the average kidney transplant rate PMP, per year, in the Arab world was 9.5 cases.
The total number of PKT performed in the Arab countries in one year was 298 cases. Thus, the average PKT rate PMP per year was 0.87 cases (range: 3.1 in Jordan, 0.0 in Yemen). [Figure 1] shows the total kidney transplants versus the PKT rate PMP per one year in the Arab countries as per the most recent one-year data available (2008-2011).
|Figure 1: Total versus pediatric kidney transplant rate PMP per year in the Arab countries as per the recent one year data available (2008–2011).|
Click here to view
The share of PKT of the total kidney transplants performed for all ages in Arab countries averaged to 9% (298 of 3309 cases) (range: 24% in Algeria, 2.7% in Lebanon). Three thousand and ninety-seven transplants were from living donors and 212 transplants were from deceased donors; therefore, the living and deceased shares of the total were averaged at 93.5% and 6.5%, respectively.
Kidney transplantation from deceased donors is available in eight Arab countries, which are per alphabetical order: Algeria, Kuwait, KSA, Lebanon, Morocco, Oman, Qatar and Tunisia.
A total of 212 kidney transplants from deceased donors were performed for all ages in one year in Arab countries, whereas 3097 cases were from living donors, which makes the average deceased shares of the total kidney transplants in all Arab countries and in the countries where the deceased program is available about 6% (212/3309) and 22% (212/965), respectively. The kidney transplant rates from deceased donor PMP per year in all Arab countries and in the countries where a deceased program is available were around 0.6 (212/348 millions) and 1.8 (212/117 millions), respectively
Deceased PKT was available in three countries: KSA, Tunisia and Kuwait. Together, these countries had performed a total of 29 PKT in a single year. The deceased PKT shares of all PKT in each of these countries were 100% (3/3) in Kuwait, 49% (21/43) in KSA and 42% (5/12) in Tunisia.
| Discussion|| |
The volume of kidney transplant activity varies between and within countries; for instance, Sudan, Algeria and Morocco, where one-third of Arabs lives have together performed only 7% of the total kidney transplants in Arab countries (240 of 3309 cases) and 14% of all pediatric cases (41 of 298 cases).
The averaged PKT share of 9% of the total adult and PKTs in Arab countries seems to be acceptable and exceeds the European share of 2005, where the average pediatric transplant activity was 4-5% of the combined adult and pediatric activity as reported by Cochat in a collaborative survey on pediatric renal allograft allocation practices.  This could be attributed to several factors. First of all, according to the WHO 2010 report, 35% of the populations in the Middle East are aged less than 15 years as compared with 18% in Europe. Thus, one could expect the PKT share in the Middle East countries to be at least twice of that of Europe. Moreover, the presumed higher incidence of certain inherited kidney diseases in Arab countries due to the prevalence of consanguineous marriages, the lack of facilities and expertise for the early detection and/or proper management of pediatric patients with kidney diseases in most parts of this region of the world must lead us to believe that Arab children may have a higher incidence of ESRD and so is the need for kidney transplants. Therefore, both the rate and the share of PKT in Arab countries should exceed a certain extent than that of European children.
On further analysis of the data obtained from the three most active Arab countries in terms of total kidney transplants PMP per year, it was found that Jordan performed a total of cases PMP, Kuwait performed a total of 20 cases PMP and KSA performed a total of cases PMP. We noticed that the average PKT share of the total transplants performed in these three countries together was 8.6% (66/765), which was even lower than that drawn from all Arab countries together (9%), although their average rate of kidney transplant PMP was 21.2 cases PMP, which is higher than that drawn from all Arab countries together (9.5 cases PMP), indicating that the PKT share was not better even in the countries where the overall kidney transplant rate was higher. However, it is worthwhile to mention here that the incidence of pediatric ESRD may differ among Arab countries, especially in countries with a high expatriate population like KSA, Kuwait and UAE not only because expatriates are generally of different ethnicity but, more importantly, because most expatriates who are coming to work are adults. In Kuwait, for instance, two-thirds of the population is expatriates, and this can at least partially explain the smaller number of PKT in some of these countries such as Kuwait compared with Syria, for example, not necessarily because Kuwaiti children are neglected.
In one year, Egypt alone performed 42% of the total PKT in the Arab world (126 of 298 cases), with a population accounting for 24% of the Arab world (85 of 350 million). Four countries, Algeria, Egypt, Saudi Arabia and Syria, performed 75% of the total PKT in the Arab world (225 of 298 cases), although their population accounts for 49% (170 of 350 million), which indicates a big difference in the rate of PKT PMP per year between Arab countries. We figured Jordan as being the most active country with 3.1 PKT PMP per year, followed by KSA with 1.6 and Egypt with 1.5; however, we do not know how many transplants were performed in Jordan for non-Jordanian children and for children coming from Yemen and other Arab countries for the sake of transplantation in private hospitals and then leaving the country. Thereby, these PKT rates do not actually reflect the real status of PKT rate versus the need for the same population in a given country, especially those who are known to perform transplants for foreigners like Jordan and Egypt.
Morocco chose to refer selected patients to developed countries for transplantation and therefore was the least active as only two children were transplanted of a total of 18 kidney transplants in 2011 for a population of 32 million, which makes the PKT PMP rate extremely low and less than 0.1 case [Figure 1]. Yemen is the only Arab country where there is no PKT, although it did show some improvement in the recently launched kidney transplant program at the Al Thaoura Hospital in Sana'a, where 33 adult kidney transplants have been performed in 2010 for a population of 24 millions. Some of the "fortunate" Yemeni children with ESRD are being transplanted abroad, especially in the neighboring Arab countries.
This rate of 0.87 PKT PMP per year in the Arab countries is quite low when compared with that of most of the developed countries. Spain/Catalonia has the highest pediatric transplant rate among Western countries, reaching 15 patients PMP, followed by a rate of 12 patients PMP in the United States and Finland [Figure 2]. 
|Figure 2: Pediatric transplant rates PMP per year in the 0–19 years age group in 2003.|
U.S. Renal Data System, USRDS (2005). The red line indicates the average rate in Arab countries.
Click here to view
Approximately 1200 children (aged 0-19 years) in the United States develop ESRD each year.  This represents approximately 16 cases per 1 million children. Thus, in the Arab world that has a population of 122 million children, nearly 2000 children as a total are expected to develop ESRD per year if we assume Arab children to have a similar incidence of pediatric ESRD as US children. Subsequently, based on the same assumption, we could therefore point out that only 15% (298/2000) of the need for PKT in Arab countries is being met. Hence, one can conclude that although we have no accurate data from the Arab world on the estimated prevalence and incidence of pe-diatric ESRD and the estimated number of children in need for kidneys, the actual rate of PKT being currently performed is clearly lower than what it is supposed to be in all Arab countries, including the most active countries such as Jordan and KSA. This also applies for adult kidney transplantation.
In general, organ transplantation is a very expensive procedure and may therefore be regarded as a public health challenge. The use of living donors is by far the most used source for kidneys in Arab countries (93.5%) for several reasons, essentially because it is less expensive than the development of a national network for organ allocation based on deceased donors. The cost of transplantation is of special importance in certain countries such as Arab countries, where access to transplantation often depends on familial recourses due to the absence of a national health care system versus the private insurance system. The exclusive relying on living donors has led some Arab countries (e.g., Egypt, Syria) to legalize unrelated kidney donation, which rapidly became the main source of transplanted kidneys and, more critically, the practice of kidney donation from unrelated donors fell into commercialism and these "donated" organs were in fact paid for although kidney selling is prohibited by law in these countries.  Certainly, the problem of insufficient access to kidney transplantation for Arab children with ESRD is even wider than in adults. The most important causes preventing the development and/or enhancement of PKT programs in Arab countries probably are age at ESRD (treatment withdrawal may be applied for infants and young children), type of primary disease when identified (inherited inborn error of metabolism), transplant procedure (need for a combined liver and kidney transplant), associated morbidities (mental retardation), lack of facilities and expertise and even, sometimes, cultural reasons that may weaken the interest in providing the best care for children with ESRD. , Moreover, the rate of PKT PMP in some Arab countries such as Kuwait, Lebanon and Iraq does not seem to follow that of the adult kidney transplant rate in the same country, but again, one has to be cautious in interpreting these results, especially in countries with a large adult expatriates population. Nevertheless, this point needs to be further investigated in each country. However, with such a disparity between adult and PKT rate in most Arab countries, one could legitimately show his or her concern of possible "discriminatory" practices against children as being one of the main causes standing behind this unacceptably low PKT rate. Having said this, pediatric nephrologists in developing countries should make a strong plea for the elimination of discriminatory practices against children.  and should continue to claim "the same rights for subjects who were living in the same country but with only a difference of age and size." 
KSA, Tunisia and Kuwait do have a somehow stable deceased donor program as the percents of deceased donor transplants were 31%, 22% and 14% and the PMP rates of deceased transplants were 6, 2.9 and 2.9, respectively. On the contrary, the remaining five countries where deceased transplant is also available (Algeria, Lebanon, Morocco, Oman and Qatar) only perform a few cases [Table 1].
These data were taken from one single year, which however may sometimes poorly reflect the average activity over several years. In Kuwait, for example, the one-year figure of deceased percent (14%) was very low if compared with the average taken from several years (30%). Hence, whenever possible, it may be better to take the data for several years and take the average figure for one year in order to iron out the yearly variation in the programs in these countries.
We point out that the deceased kidney transplant rates in KSA, Tunisia and Kuwait, which ranged from 14% to 31% of the total kidney transplant activity, were much lower than that of European countries, where it averaged 80% [Table 2], indicating how much more efforts are to be made by the Arab countries for establishing well-functioning transplant programs from deceased donors.
|Table 2: Global observatory on donation and transplantation (GODT) 2010 data on kidney transplant activity in European countries, produced by the WHO–ONT collaboration.|
Click here to view
It is worthwhile to notice that deceased PKT was only available in the same above-mentioned three countries that had regular deceased transplant programs, which are KSA, Tunisia and Kuwait. The average deceased PKT share of all PKT performed in all these three countries together was 50% (29/58), which is comparable to the US data, where 49.2% of PKT were from deceased donors according to the NAPRTCS 2010 report and lower than that of European countries, where it averaged 69% [Table 2]. KSA has alone performed 73% (21/29) of all deceased PKT in the Arab world.
The upper age limit for pediatric renal care differs among countries [e.g., 13 (Oman) to 18 (Sudan, Libya)]. We recognize this difference as a limitation in this study. Whatever small variation may occur from this fact, one can conclude that because the most favored ESRD treatment modality in children is renal transplantation, lack of health care resources and deceased transplant programs in most Arab countries limits the provision of renal transplantation in children. Therefore, PKT is still inactive and not responding to the increasing demand for kidneys. Twin cooperation between developing and developed countries/centers should be encouraged in order to provide assistance to developing Arab countries.
| References|| |
|1.||Saeed Saeed B. Pediatric renal transplantation in Syria: A single center experience. Saudi J Kidney Dis Transpl 2005;16:342-7. |
|2.||Al-Ghwery S, Al-Masri A. Chronic renal failure in Riyadh Military Hospital, Riyadh, Saudi Arabia. Saudi J Kidney Dis Transpl 2004;15: 75-8. |
|3.||Kamoun A. Spectrum of pediatric renal diseases in Tunisia. Saudi J Kidney Dis Transpl 1997;8:317-9. |
|4.||Abou-Chaaban M, Al Murbatty B, Abdul Majid M. Spectrum of pediatric renal diseases in Dubai. Saudi J Kidney Dis Transpl 1997;8:310-3. |
|5.||El Aun M, Hazza I, Qudah E, Najada AH, Khairi Y. Causes of chronic renal failure in children in a single hospital in Jordan: A 10 years retrospective study. Saudi J Kidney Dis Transpl 1995;6:290-3. |
|6.||Global Observatory on Donation and Transplantation (GODT) data, produced by the WHO-ONT collaboration. Available from: http://www.transplant-observatory.org [Last accessed on 27 February 2012]. |
|7.||5th Symposium France - Maghreb transplantation of organs, tissues and cells. Nice - France. 23 -24 March 2012. |
|8.||Cochat P. (collaborative survey). 39 th Annual Meeting of the European Society for Pediatric Nephrology, Istanbul, September 10-13, 2005. |
|9.||U.S. renal data system, USRDS 2005. Annual data report: Atlas of end-stage renal disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2005. |
|10.||USRDS. United States Renal Data System. Available http://www.usrds.org/. [Last accessed on 2008 Dec 12]. |
|11.||Saeed B. Current challenges of organ donation programs in Syria. Int J Organ Transpl Med 2010;1:35-9. |
|12.||Saieh-Andonie C. The management of ESRD in underdeveloped countries: A moral and economic problem. Pediatr Nephrol 1990;4: 199-201. |
|13.||Grunberg J. The challenge of care of children with renal disease in developing countries: A Latin American outlook. Indian Pediatr 1996; 33:91-4. |
Pediatric Nephrologist, Kidney Hospital, P. O. Box 8292, Damascus
[Figure 1], [Figure 2]
[Table 1], [Table 2]