Year : 1996 | Volume
: 7 | Issue : 2 | Page : 105--108
Establishment of a Cadaveric Transplantation Program: The Saudi Arabian Experience
Faissal A.M Shaheen, Besher Al-Attar, Mohammed Ziad Souqiyyeh, KS Ramprasad
Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
Faissal A.M Shaheen
Director & Consultant Nephrologist, Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
|How to cite this article:|
Shaheen FA, Al-Attar B, Souqiyyeh MZ, Ramprasad K S. Establishment of a Cadaveric Transplantation Program: The Saudi Arabian Experience.Saudi J Kidney Dis Transpl 1996;7:105-108
|How to cite this URL:|
Shaheen FA, Al-Attar B, Souqiyyeh MZ, Ramprasad K S. Establishment of a Cadaveric Transplantation Program: The Saudi Arabian Experience. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Sep 23 ];7:105-108
Available from: http://www.sjkdt.org/text.asp?1996/7/2/105/39508
Organ transplantation is now an established entity in modern medicine, and is being widely practiced world-wide as a modality of therapy for end-stage organ failure. The concept of establishing organ transplant centers in different parts of the world has become deep-rooted since the first transplant operation was performed in the middle of this century. The importance of co-ordination between the transplant centers was recognized very early as well as the role of co-ordinators supervising the various organ transplantation programs. This article is intended to elucidate our experience concerning the factors which should be fulfilled in order to establish a successful organ transplantation program.
The Concept of Brain-Death
The concept of brain-death was first reported in 1959 by a group of French physicians  . In 1968, the Harvard Criteria were adopted in the USA  . In 1971, a major conceptual advance occurred when Mohandas and Chou, two Minneapolis neurosurgeons, made the challenging suggestion that, in patients with known irreparable intra-cranial lesions, irreversible damage to the brain-stem was the point of no return,  which evolved the concept of brain-stem death. Criteria were laid down for the diagnosis and became known as the Minnesota Criteria. Further important developments took place in 1981, when a large panel of physicians from various specialities contributed to the report on "The Diagnosis of Death" to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in the USA. They recommended uniform criteria for the diagnosis of brain-death and defined brain-death as irreversible cessation of all functions of the entire brain, including the brain-stem  .
The diagnosis of brain-death is now a recognized entity in medicine and must be assessed as a part of the general management of any patient fulfilling the criteria of brain-death ,, . It is only after obtaining confirmation of the diagnosis of brain-death, that matters pertaining to organ donation from the brain-dead subjects can be considered.
The Approval of Scholars of Islam and the Senior Ulama Commission about the Concept of Brain-death and Organ Donation
In 1982 (1402 H), the board of the Senior Ulama Commission in Saudi Arabia resolved the permissibility to remove an organ, or a part thereof from a living person and to graft on to himself. The board also approved the permissibility to remove an organ or a part from a dead person for the benefit of a Muslim in need of it, as well as for a living person to donate one of his organs or a part thereof for the benefit of a Muslim  . In 1986 (1407 H) the council of Islamic Jurisprudence in its third session held in Amman, discussed supportive means in intensive care units. After comprehensive explanation from consultant doctors, it was decided that a person is considered dead by Islamic Shariah in case of complete cessation of all functions of the brain and the consultant doctors have decided that the cessation is irreversible, and the brain has started to degenerate. They justified the decision to stop all efforts of resuscitation and artificial ventilation in case of brain-death even before the heart ceases to beat  .
These facts clarify the position of Islam (Shariah), with regard to the definition of death and organ transplantation.
The Patronization and Support of the Government for the Organ Donation and Transplantation Programs and Issue of Regulations Governing the Practice of Organ Transplantation
Establishing a governmental co-ordinating center for organ transplantation, to be an interface between the legislation and donating hospitals and transplant centers, is essential for the success of a transplant program of any country. This center will be responsible for co-ordinating and supervising all aspects related to organ transplantation and brain-death. The Euro-transplant and the United Network for Organ Sharing (UNOS) are examples of such centers in Europe and USA respectively  .
The National Kidney Foundation (NKF) of Saudi Arabia was established in 1985 by the Government of the Kingdom of Saudi Arabia, to establish and co-ordinate a local cadaveric renal transplantation program. The NKF was upgraded in 1993 and renamed the Saudi Center for Organ Transplantation (SCOT) to encompass transplantation of organs other than the kidney as well.
SCOT as a Model for Co-ordination of an Organ Transplantation Program
There are 110 intensive care units (ICU's) belonging to the Ministry of Health and other governmental and private sectors which are involved in the cadaveric organ donation program in Saudi Arabia. Road traffic accidents represent 60% of the reported cases of brain-death in Saudi Arabia, while other causes such as brain tumor, cerebrovascular accidents and fall from height account for the remaining 40%. Currently, there are 12 renal transplant centers, four liver transplant centers, three heart transplant centers and eight cornea transplant centers actively performing transplantation in the Kingdom.
Several strategies have been carried out by SCOT in order to successfully co-ordinate between the various transplantation centers as well as in the distribution of the retrieved organs to the appropriate transplant centers  . The strategies include the following: a) The presence of a Directory of Regulations for Organ Transplantation in the Kingdom of Saudi Arabia, which outlines the responsibilities of the donating hospitals and transplantation centers, the description of the procedures involved in brain-death protocol, as well as harvesting and distribution of organs among transplant centers , .
b) The presence of scientific committees which meet regularly to evaluate the activities of transplantation and dialysis, and to exchange experiences in the different fields of transplantation. Proposals and suggestions of these committees have proved very beneficial in improving performance in the related fields.
c) Distribution of the donating hospitals to transplant centers (zonal distribution system), wherein hospitals in each zone are attached to a transplant center in that zone. Several countries are following the zonal distribution system including the United States, Germany, Italy, France and Spain , . The transplant center will render help to the attached hospitals in the diagnosis of brain-death. Also, this center will help to increase the awareness of the medical personnel in the attached hospitals, about the importance of brain-death and organ donation. SCOT has adopted the zonal distribution system from early 1993, which has helped in achieving better coordination in the reporting of brain-death cases. The retrieved organs are distributed to the appropriate transplant centers according to pre-arranged lists. This system has further helped in ensuring equal and fair distribution of organs so that a given patient with end-stage organ failure has an equal chance of getting organ transplantation irrespective of where he is located.
d) The formation of a local brain-death committee in each hospital, in order to report any potential brain-death cases to SCOT and to co-ordinate the documentation and management of these cases.
e) The presence of co-ordinators in the donating hospitals to approach families of the brain-dead donors for consent to donate organs. This "opting-in" system is currently being followed, apart from Saudi Arabia, in the United States, England, Canada and Australia  . The other system, the optingout system (presumed consent system), in which organs can be procured from braindead cadavers without explicit consent, is being practiced in several European countries including Austria, France, The Netherlands and Belgium  .
f) The presence of a local co-ordinator in each transplant center named "medical zonal co-ordinator" who will assist the coordinators in the donating hospitals in their work.
g) Ensuring that the brain-death protocol is strictly followed is an important objective of any cadaveric transplant program. The brain-death protocol is reviewed periodically by SCOT. Also, the co-ordinators of SCOT supervise the diagnosis of brain-death in all the reported cases from the medical as well as legal view points.
h) SCOT co-ordinates many research projects in conjunction with some of the major hospitals. SCOT also participates in many conventions and congresses, locally and abroad, highlighting the activities of the various transplantation programs in Saudi Arabia,
i) SCOT organizes many meetings and training courses to increase the awareness of the medical personnel as well as the general public about the concept of brain-death and the importance of organ transplantation. All means of media have been used in this regard and books, booklets, bulletins, and posters about transplantation and organ donation have been printed and widely circulated.
Similar strategies are being followed by many other transplant co-ordination centers in the world and it is well known that these strategies have been useful in increasing organ donation  . SCOT has been striving very hard to achieve self-sufficiency in the number of organs donated. However, the full capability of donation from the cadaveric source has not been achieved as yet. There is an increasing gap between supply and demand for organs in many areas in the world ,, . The same is noticeable in the Kingdom of Saudi Arabia  .
The obstacles precluding the self sufficiency of organ donations in Saudi Arabia can be summarized as follows:
a) There is still a lack of awareness among the general public as well as medical personnel, on the concept of brain-death and the importance of organ donation.
b) The number of skillful co-ordinators, who approach families of the brain-dead donors for consent for donation of organs, is less than adequate.
c) There is a need for boosting further, the co-operation among the various transplant centers and donating hospitals. Despite these obstacles, the results of transplantation in the last 10 years reflect the positive effect of having adequate legislation and a co-ordinating center for organ donation and transplantation. These results are definitely better than those obtained in countries which do not have proper coordination among the different transplant centers and the hospitals.
Finally, due to the universal shortage of donors, we emphasize the need for self-sufficiency of organs in order to minimize the continuously expanding lists of patients waiting for vital organs. There are no artificial methods or non-human sources of donors readily available, which could substitute the cadaveric source of organ donation. The community at large should understand this fact; otherwise the problem will continue.
|1||Mollaret P, Goulon M. Le coma depasse (memoire preliminare). Rev Neurol 1959;101:3-15.|
|2||A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA 1968;205:337-40. |
|3||Mohandas A, Chou SN. Brain death. A clinical and pathological study. J Neuro surg 1971;35:211-8.|
|4||Guidelines for the determination of death. Report of the medical consultants on the diagnosis of death to the president's commission for the study of ethical problems in Medicine and Biomedical and Behavioral Research. JAMA 1981;246:2184. |
|5||Diagnosis of brain death. Statement issued by the honorary secretary of the Conference of Medical Royal Colleges and their Faculties in the United Kingdom on 11 October 1976. Br Med J 1976;2:1187-8.|
|6||Diagnosis of death. Memorandum issued by the honorary secretary of the Conference of Medical Royal Colleges and their faculities in the United Kingdom on 15 January 1979. Br Med J 1979;1:332.|
|7||President's Commission for the study of Ethical Problems in Medicine: Defining death: A report on the Medical, Legal and Ethical issues in the determination of death (1982-371059/8192. United States Government Printing Office, Washing DC, 1982.8. |
|8||Religious aspects of organ transplant: Purport of the Senior Ulama Commission's decision No. 99. Saudi Kidney Dis Transplant Bull 1992;3(3):231.|
|9||Resolution of the council of Islamic Jurisprudence on resuscitation apparatus. Amman 1407 H (1986 G). Saudi Kidney Dis Transplant Bull 1992;3(3):232.|
|10||Pierce GA, Graham WK, Kauffman HM Jr., United Network for Organ Sharing: 1984 to 1994 3rd International Congress of the Society for Organ Sharing, Paris 1995 (Abstract). |
|11||Shaheen FAM. Organ transplantation in the Kingdom of Saudi Arabia: new strategies. Saudi J Kidney Dis Transplant 1994;5(l):3-5. |
|12||Brain death committee. National Kidney Foundation, Riyadh, K.S.A. Diagnosis of brain-death and policy on cadaveric organ procurement in K.S.A. Saudi Kidney Dis Transplant Bull 1992;3(3):199-230. |
|13||The directory of the regulations of organ transplantation in the Kingdom of Saudi Arabia. Ministerial resolution No. 1081/1/29 dated 18/6/ 1414 H. Saudi J Kidney Dis Transplant 1994;5:37-98.|
|14||Salvadori M, Bertoni E, Carmellini M, et al. Regional vs national renal sharing organization: PROS and CONS. 3rd International Congress of the Society for Organ Sharing, Paris 1995 (Abstract). |
|15||Wujeiak T, Opelz G, Abendroth D, et al. Advantageous of regional allocation policy. 3rd International Congress of the Society for Organ Sharing, Paris 1995 (Abstract).|
|16||Kokkedee W. Kidney procurement policies in the Euro-transplant region "opting in" versus "opting out". Soc Sci Med 1992;35:17782.|
|17||Somerville MA. "Procurement" vs "donation" access to tissues and organs for transplantation: should "contracting out" legislation be adopted? Transplant Proc 1985;17:53-68.|
|18||Matesanz R, Miranda B, Felipe C, Naya MT, Cobo C. Integrated ways to improve organ donation in Spain. 3rd International Congress of the Society for Organ Sharing Paris, 1995 (Abstract).|
|19||Spital A. The shortage of organs for transplantation. Where do we go from here? N Engl J Med 1991;325:1423-6. |
|20||Evans RW, Orians CE, Ascher NL. The potential supply of organ donors. An assessment of the efficacy of organ procurement efforts in the United States. JAMA 1992;267:239-46.|
|21||Niemcryk SJ, Aronoff R, Macroni KM, Bower GS. Projections in solid organ transplantation and wait list activity through the year 2000. J Transplant Coord 1994;4:23-30. |
|22||Shaheen FAM, Souqiyyeh MZ, Al-Swailem AR. Saudi Center for Organ Transplantation: activities and achievements. Saudi J Kidney Dis Transplant 1995;6(l):41-52.|