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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
EDITORIAL  
Year : 2017  |  Volume : 28  |  Issue : 5  |  Page : 983-991
The story of the first deceased donor kidney donation in Saudi Arabia – by a firsthand witness


Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

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Date of Web Publication21-Sep-2017
 

How to cite this article:
Al-Sayyari AA. The story of the first deceased donor kidney donation in Saudi Arabia – by a firsthand witness. Saudi J Kidney Dis Transpl 2017;28:983-91

How to cite this URL:
Al-Sayyari AA. The story of the first deceased donor kidney donation in Saudi Arabia – by a firsthand witness. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2017 Dec 13];28:983-91. Available from: http://www.sjkdt.org/text.asp?2017/28/5/983/215136


In this paper, I am going to relay to you firsthand accounts of (a) the first locally procured, recovered and transplanted deceased donor kidney in the Kingdom of Saudi Arabia and (b) the story of the procurement and utilization of deceased donor kidneys offered to us by eurotransplant and imported and used in the Kingdom of Saudi Arabia.


   The Story of the First Deceased Kidney Donation from Inside the Kingdom of Saudi Arabia Top


On the morning of Sunday, December 23, 1984, I was contacted by Sid Jacobs, the consultant in charge of the Intensive Care Unit (ICU) at the Riyadh Armed Forces Hospital who said something like this to me “Abdulla, you have told me that you are ready to do the first cadaveric kidney transplant in the Kingdom of Saudi Arabia and that you are simply waiting for our call that we have documented brain death case in the ICU. Well, now is your chance as we have one - a member of a Saudi family which was tragically overwhelmed by house fire.”

I found more details about the donor. He was a Saudi teenager who was previously in good health with negative viral screening who sadly was overwhelmed by smoke from a fire at home, which also killed two members of his family.

Suddenly, I was filled with trepidations and foreboding and did not, in reality, wish to face a family with such a request for the first time ever in Saudi Arabia. We had no idea what the family’s response would be and we feared the worst.

I decided to consult with my friend and colleague, Dr. Ketab Al Otaibi [Figure 1] and went to see him in his urology clinic. He readily agreed that we should go to talk to the brain dead child’s father (Ketab, later on, became the Director of Riyadh Armed Forces Hospital and later still became the Director-General the Medical Services Department of the Saudi Ministry of Defense).
Figure 1: Dr. Ketab Al Otaibi and I had the honor and privilege to have obtained the first cadaveric kidney donation consent in Saudi Arabia.

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The brain dead child’s father was very gracious and responded with empathy to our predicament. To our immense and pleasant surprise, he gave his consent without difficulty.

In fact, he did so with a clear, obvious, and fully aware and mindful altruistic attitude.

The preparation for doing a deceased donor kidney transplantation has been going on for some time in our hospital. The first unavoidable and pivotal thing to do was to ensure the passage of a religious formal fatwa affirming that it is permissible to recover and use organs from deceased persons. This was accomplished two years earlier (Fatwa No. 99 dated 6/11/ 1402H). Protocols for organ harvesting and brain death diagnosis were also established.

Two kidneys were recovered and transplanted into two young female recipients on the same day. The surgeons involved were Drs. Ketab Al Otaibi, Muaffak Jawdat [Figure 2] and Rene Chang [Figure 3]. I had the honor to be the attending nephrologist. Muaffak Jawdat later, in 1990, performed the first ever liver transplant in Saudi Arabia and Rene Chang, later on, became the founding Director of Renal Transplantation at St. George’s Hospital, London University. While, in Riyadh, he developed the famed computer program the “Riyadh Intensive Care Program”[1] and was responsible for developing the disaster plan for King Khalid International Airport, Riyadh.
Figure 2: Dr. Muaffak Jawdat on the left of the picture.

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Figure 3: Dr. Rene Chang.

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It was an amazing coincidence that one of the cosignatories of the brain death certificate was the famed Dr. Christopher Pallis from the Hammersmith Hospital who wrote extensively on brain stem death, including a series of six articles in the British Medical Journal entitled “ABC of brain stem death.”[2],[3] and who happenec to be attending a conference in our hospital at that time [Figure 4]. Upon his death, the obituary of Chris Pallis in the BMJ was entitled “Chris Pallis - Neurologist who defined brainstem death.”[4]
Figure 4: “Chris Pallis - Neurologist who defined brainstem death.”[4]

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Credit should also go Colonel Sherbini who was the hospital director at the time and who was not a doctor but supported the whole venture.

[Figure 5] shows the brain death documentation certificate signed by Drs. Pallis and Jacobs and ratified administratively by Colonel Sherbini, the then Riyadh Armed Forces Hospital Director.
Figure 5: The brain death documentation certificate signed by Drs. Pallis and Jacobs and ratified administratively by Colonel Sherbini, the then Riyadh Armed Forces Hospital Director.

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[Figure 6] shows the handwritten consent form signed by the father of the donor and cosigned – as witnesses – by Dr. Ketab Al Otaibi and I.
Figure 6: The handwritten consent form signed by the father of the donor and cosigned – as witnesses – by Dr. Ketab Al Otaibi and I.

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[Figure 7] shows a note, in the donors’ file, by Dr. Muaffak Jawdat documenting the recovery (harvesting) of the kidneys from the donor with date and time.
Figure 7: A note, in the donors file, by Dr. Muaffak Jawdat documenting the recovery (harvesting) of the kidneys from the donor with date and time.

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The medical team that took part in this effort was personally thanked by the late HRH Prince Sultan bin Abdulaziz who was the Minister of Defense at the time and since the venture was undertaken the flagship Ministry of Defense Hospital, Riyadh Armed Forces Hospital, which is now renamed Prince Sultan Military Medical City [Figure 8].
Figure 8: A congratulatory memo by the late HRH Prince Sultan bin Abdulaziz, the then Minister of Defense and Aviation and Inspector-General saluting the medical team involved acknowledging them by their names. All other members of the medical team received similar congratulatory notes.

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   The Story of Imported Deceased Donor Kidney Transplants from Europe Top


Starting in 1981 and continuing for three years, we were fortunate to obtain kidneys from Eurotransplant. During this period, we received 64 kidneys, and all transplantations were performed at Riyadh Armed Forces Hospital. This was of great benefit to us as it trained us in the important task of organ procurement logistics and coordination.

The credit for us getting those kidneys from Europe goes to Dr. Mohamed Saeed Abo Melha [Figure 9] who formed a strong liaison with the leaders of transplantation in Europe which culminated in this agreement. He also organized an international conference in December 1984 on kidney transplantation and brain death to which Dr. Christopher Pallis was invited (see above). He made considerable and effective relationship with European Transplant Leaders of the time including Professor Kootstra of the Netherlands, Professor Lund of Germany, Professor Pekka Häyry of Finland and Professor Jean-Michel Dubernard of France, all of whom visited our center.
Figure 9: The credit for Eurotransplant deceased donor kidneys offerings goes to Abo Melha (see text).

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Dr. Abo Melha was the Director of the Urology Department at Riyadh Armed Forces Hospital and later became the second ever President of the Arab Society of Nephrology and Renal Transplantation which he was a pivotal person in its creation.

At the time, we did not have a transplant coordinator or pediatric nephrologist, so, the adult nephrologist undertook all the tasks of kidney of procurement logistics and coordination related to the kidneys sent from Europe. He would get a call from the Eurotransplant transplant coordinator who would tell him the details of the offered kidney(s) and the brain dead case and why it was not used (or rejected) in Europe. The nephrologist would then decide on its acceptance or not. If accepted, he would get another call from the European transplant coordinator telling him the flight route the kidney would take. If the final destination in the Kingdom is not Riyadh, the nephrologist will then call Saudi Airlines to arrange for the transfer of the kidney to Riyadh. This is because all the transplants were, then, done in Riyadh Armed Forces Hospital, only. In [Figure 10], you will find the bill I paid to Saudia for carrying one of the first such kidneys. I must add that soon after that Saudia stopped asking for fees for this service.
Figure 10: Saudi Airlines bill.

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While the kidney is being transferred to Riyadh, the nephrologist – acting as the transplant coordinator – would then look for potential recipients at Riyadh Armed Forces Hospital as well as other major dialysis units in the Kingdom by calling them and arranging for potential recipients to come from any part of the Kingdom.

The donor kidneys were normally sent with a piece of the donor’s spleen tissue to perform human leukocyte antigen testing and cross matching on, which can only be done after the arrival of the kidney which added further 4–5 h to the already cold ischemic time.

The kidneys offered from Eurotransplant were often suboptimal, as they were offered only in they could not be used in Europe for one reason or another. However, we were grateful to receive them due to the enormous shortage of donated kidneys in Saudi Arabia at that time. The only time we might receive kidneys of reasonable quality would be if the donor were of an AB blood group type or the brain death occurred during the Christmas or New Year’s festivities in Europe.

Nevertheless, we learned a great deal and had the opportunity to write about different aspects of the use of suboptimal or marginal kidneys. For example, we reported that it is possible to use cyclosporine in patients with delayed graft function with good results,[5] that many of the hitherto discarded (marginal) kidneys could be usefully utilized,[6] that the outcome in transplanted kidneys with long cold ischemia times (reaching at times as long as 72 hours) is reasonably acceptable, and that it is possible to reuse of a third-hand kidney (a kidney donated by a kidney recipient who developed brain death after a road traffic accident)[7] and that HIV infection can be transmitted through solid organ transplantation.[8]

We also had the privilege to have done the first pediatric transplant in Saudi Arabia using one of these kidneys, a 10-year-old boy with Alport’s syndrome. Four months after the transplantation, he developed antiglomerular basement membrane (GBM) glomeruloneph-ritis and lost his graft as a result. Two years later, he received a second deceased donor kidney graft, and 10 months later still, he developed a recurrent anti-GBM glomerulo-nephritis.[9] Thus, we showed that anti-GBM glomerulonephritis in transplanted cases of Alport’s syndrome can recur in subsequent cases.

We also had the opportunity to look after the first successful pregnancy and delivery in Saudi Arabia [Figure 11].
Figure 11: The first Saudi posttransplant baby.

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Saudi kidney transplant female recipients in their reproductive age range are 15 times more likely to get pregnant than their Western counterparts (due to social reasons). We have written extensively on posttransplant pregnancy[10],[11],[12],[13],[14],[15] and reported that there is no long-term nephrotoxicity after exposure to cyclos-porine in utero.[10]

Moreover, since fasting the month of Ramadan is obligatory on able Moslems, we also wrote extensively on the issue of fasting in posttransplant patients.[16],[17],[18],[19],[20]

We have also noticed that Kaposi Sarcoma is, by far, the most common posttransplant malignancy in Saudi kidney transplant recipients and thus wrote extensively on this issue also including its prevalence and incidence, developed a classification for its staging and treatment, described how it affects the lungs, the gastrointestinal tract. and children and its tendency to recur after repeated exposure to immunosuppression.[21],[22],[23],[24],[25],[26],[27],[28],[29]

Saudi Arabia has one of the highest prevalence of diabetes mellitus in the world.[30],[31] Diabetic nephropathy among Saudis seems to progress more rapidly than most other ethnic groups.[32] As a result of this, we published a number of papers about diabetes in Saudi renal transplant recipients.[32],[33],[34],[35],[36]


   A Final Important Note of Gratitude from the Saudi Nephrology Community Top


It would be impossible to overstate the positive impact that the Custodian of the two Holy Mosques, King Salman bin Abdulaziz had on the historical amazing journey of kidney transplantation in Saudi Arabia.

As a result of decisive and pivotal initiatives by King Salman Bin Abdulaziz, the following were implemented.

  1. Issuance of a Fatwa Supreme Council of Scholars allowing organ retrieval from the living or dead for the purposes of transplantation, (Fatwa No. 99 dated 6/11/1402 H.)
  2. Establishing of the National Kidney Foundation (Royal Decree No. 7/1561/M on 15/5/1404 H)
  3. Upgrading of the National Kidney Foundation to the Saudi Center for Organ Transplantation (SCOT) to encompass all other organs besides the kidney (Royal Decree No. (80), on 20/6/1413 H
  4. Establishing a new headquarters for SCOT, which was opened by him on 9 Sha’ban 1421 H corresponding to 5 November 2000 [Figure 12]
  5. Establishing a charitable society serving the needs of kidney failure patients in 1418 AH. (Prince Fahd Bin Salman Society for the Care of Renal Failure Patients “Kulana”)
  6. Entitling the dialysis patients to automatic paid leave on the day of treatment.
Figure 12: King Salman Bin Abdulaziz opening the new headquarters of the Saudi Center for Organ Transplantation on 5 November 2000.

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SCOT has become a model and prototype for an organ procurement organization in the Muslim world. Since its establishment, SCOT has coordinated transplantation of 7625 living related kidneys and 2963 deceased donor kidneys.

In June 2007, Faissal Shaheen, Director-General of SCOT, received the Transplantation Society Award in recognition of the pioneering of the SCOT [Figure 13].
Figure 13: Faissal Shaheen, Director-General of Saudi Center for Organ Transplantation, receiving the Transplantation Society Award for the pioneering work of the Saudi Center for Organ Transplantation.

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   References Top

1.
Bihari DJ, Chang RW. The Riyadh intensive care programme. Anaesthesia 1993;48:345-6.  Back to cited text no. 1
    
2.
Pallis C. Abc of Brain Stem Death. Eweb: 45285; 1983. Available from: https://www. repository.library.georgetown.edu/handle/1082 2/1033430. [Last accessed on 2017 Jul 09].  Back to cited text no. 2
    
3.
Pallis CH. The Abc of Brainstem Death. Eweb:160341; 1996. Available from: https:// www.repository.library.georgetown.edu/handle /10822/889217. [Last accessed on 2017 Jul 09].  Back to cited text no. 3
    
4.
Richmond C. Chris pallis. BMJ 2005;330:908.  Back to cited text no. 4
    
5.
Chang RW, Saltissi D, al Khader AA, Abomelha M, Jawdat M. Successful use of cyclosporine in renal grafts with prolonged ischemic times. Transplant Proc 1987;19:2080.  Back to cited text no. 5
    
6.
Chang RW, Saltissi D, Al-Khader A, Abomelha M, Jawdat M. Survival of suboptimal cadaver renal grafts with prolonged cold ischaemic times using cyclosporin. Nephrol Dial Transplant 1987;1:246-50.  Back to cited text no. 6
    
7.
Al-Hasani MK, Saltissi D, Chang R, Van Goor H, Tegzess AM. Successful regrafting of an explanted transplant kidney. Transplantation 1987;43:916-7.  Back to cited text no. 7
    
8.
Al-Sulaiman M, Al-Khader AA, Al-Hasani MK, Dhar JM. Impact of HIV infection on dialysis and renal transplantation. Transplant Proc 1989;21:1970-1.  Back to cited text no. 8
    
9.
Rassoul Z, al-Khader AA, al-Sulaiman M, Dhar JM, Coode P. Recurrent allograft antiglomerular basement membrane glomerulonephritis in a patient with Alport’s syndrome. Am J Nephrol 1990;10:73-6.  Back to cited text no. 9
    
10.
Shaheen FA, al-Sulaiman MH, al-Khader AA. Long-term nephrotoxicity after exposure to cyclosporine in utero. Transplantation 1993;56:224-5.  Back to cited text no. 10
    
11.
Owda AK, Abdalla AH, Al-Sulaiman MH, et al. No evidence of functional deterioration of renal graft after repeated pregnancies – A report on three women with 17 pregnancies. Nephrol Dial Transplant 1998;13:1281-4.  Back to cited text no. 11
    
12.
Al Duraihimh H, Ghamdi G, Moussa D, et al. Outcome of 234 pregnancies in 140 renal transplant recipients from five middle eastern countries. Transplantation 2008;85:840-3.  Back to cited text no. 12
    
13.
Basri N, Al-Ghamdi, Shaheen F, Flaiw H, Qureshi J, Al-Khader A. Pregnancies in renal transplant recipients-with a focus on babies. Ann Transplant 2004;9:65-7.  Back to cited text no. 13
    
14.
Al-Khader AA, Al-Ghamdi, Basri N, et al. Pregnancies in renal transplant recipients – With a focus on the maternal issues. Ann Transplant 2004;9:62-4.  Back to cited text no. 14
    
15.
Successful Pregnancy in Renal Transplant Recipients Treated: Transplantation LWW. Available from: http://www.journals.lww.com/ transplantjournal/fulltext/1988/05000/successf ul_pregnancy_in_renal_transplant.30.aspx. [Last accessed on 2017 Jul 06].  Back to cited text no. 15
    
16.
Ghalib M, Qureshi J, Tamim H, et al. Does repeated Ramadan fasting adversely affect kidney function in renal transplant patients? Transplantation 2008;85:141-4.  Back to cited text no. 16
    
17.
Qurashi S, Tamimi A, Jaradat M, Al Sayyari A. Effect of fasting for Ramadan on kidney graft function during the hottest month of the year (August) in Riyadh, Saudi Arabia. Exp Clin Transplant 2012;10:551-3.  Back to cited text no. 17
    
18.
Abdalla AH, Shaheen FA, Rassoul Z, et al. Effect of Ramadan fasting on Moslem kidney transplant recipients. Am J Nephrol 1998; 18:101-4.  Back to cited text no. 18
    
19.
Hejaili F, Qurashi S, Binsalih S, Jaradt M, Al Sayyari A. Effect of repeated Ramadan fasting in the hottest months of the year on renal graft function. Nephrourol Mon 2014;6:e14362.  Back to cited text no. 19
    
20.
Al-Khader AA. Ramadan fasting and renal transplantation. Saudi J Kidney Dis Transpl 1994;5:463-5.  Back to cited text no. 20
[PUBMED]  [Full text]  
21.
Al-Sulaiman MH, Mousa DH, Dhar JM, AlKhader AA. Does regressed posttransplantation Kaposi’s sarcoma recur following reintroduction of immunosuppression? Am J Nephrol 1992;12:384-6.  Back to cited text no. 21
    
22.
Hanid MA, Suleiman M, Haleem A, al Karawi M, Al Khader A. Gastrointestinal Kaposi’s sarcoma in renal transplant patients. Q J Med 1989;73:1143-9.  Back to cited text no. 22
    
23.
Al-Suleiman M, Haleen A, Al-Khader A. Kaposi’s sarcoma after renal transplantation. Transplant Proc 1987;19(1 Pt 3):2243-4.  Back to cited text no. 23
    
24.
Al-Sulaiman MH, Al-Khader AA. Kaposi’s sarcoma in renal transplant recipients. Transplant Sci 1994;4:46-60.  Back to cited text no. 24
    
25.
Shaheen FA, Al-Sulaima MH, Ramprasad KS, AI-Khader AA. Kaposi’s sarcoma in renal transplant recipients. Ann Transplant 1997;2: 49-58.  Back to cited text no. 25
    
26.
Al-Khader AA, Suleiman M, Al-Hasani M, Haleem A. Posttransplant Kaposi sarcoma: Staging as a guide to therapy and prognosis. Nephron 1988;48:165.  Back to cited text no. 26
    
27.
Al-Khader AA. Post transplant malignancy. Saudi J Kidney Dis Transpl 2002;13:126-30.  Back to cited text no. 27
[PUBMED]  [Full text]  
28.
Gunawardena KA, Al-Hasani MK, Haleem A, Al-Suleiman M, Al-Khader AA. Pulmonary Kaposi’s sarcoma in two recipients of renal transplants. Thorax 1988;43:653-6.  Back to cited text no. 28
    
29.
Al-Sulaiman MH, Mousa DH, Rassoul Z, et al. Transplant-related Kaposi sarcoma in children. Nephrol Dial Transplant 1994;9:443-5.  Back to cited text no. 29
    
30.
Alqurashi KA, Aljabri KS, Bokhari SA. Prevalence of diabetes mellitus in a Saudi community. Ann Saudi Med 2011;31:19-23.  Back to cited text no. 30
[PUBMED]  [Full text]  
31.
Naeem Z. Burden of diabetes mellitus in Saudi Arabia. Int J Health Sci (Qassim) 2015;9:V-VI.  Back to cited text no. 31
    
32.
Al Suleiman MH, Kfoury HK, Jondeby MS, Burgos NS, Al-Hayyan H, Al-Sayyari A. Progression of diabetic nephropathy in Saudi patients with type 2 diabetes mellitus. Endocrinologist 2008;18:230-2.  Back to cited text no. 32
    
33.
Owda AK, Abdallah AH, Haleem A, et al. De novo diabetes mellitus in kidney allografts: Nodular sclerosis and diffuse glomerulo-sclerosis leading to graft failure. Nephrol Dial Transplant 1999;14:2004-7.  Back to cited text no. 33
    
34.
Al-Khader AA. Impact of diabetes in renal diseases in Saudi Arabia. Nephrol Dial Transplant 2001;16:2132-5.  Back to cited text no. 34
    
35.
Alshamsi S, Basri N, Flaiw A, et al. Predictability and risk factors for development of new-onset type 2 diabetes mellitus after transplant in the Saudi population. Exp Clin Transplant 2016;14:271-5.  Back to cited text no. 35
    
36.
Souqiyyeh MZ, Shaheen FA, Shiek IA, et al. Diabetes and renal transplantation: Saudi experience. Saudi J Kidney Dis Transpl 2000; 11:25-30.  Back to cited text no. 36
[PUBMED]  [Full text]  

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Correspondence Address:
Abdulla Ahmed Al-Sayyari
Department of Medicine, King Abdulaziz Medical City, P. O. Box 22490, Riyadh, 11426
Saudi Arabia
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