The History of Renal Transplantation in the Arab World: A View From Saudi Arabia

The Arab World 

The Arab world is a unique group of nations that covers an area from the Atlantic Ocean in the west to the Arabian/Persian Gulf in the east and from the Mediterranean Sea in the north to Central Africa and the Indian Ocean in the south. It has a combined population of 325 million people and spans an area of 12.9 million square kilometers (5 million square miles) in 2 continents. In terms of total area, it surpasses the geographical foot prints of Europe, China, India, and the United States. Notably, every Arab country borders a sea or ocean. People wrongly equate the Arab World to the Middle East, but two thirds of the Arab population resides in Africa.

For the purposes of this article, the Arab world is defined as the 21 countries that are members of the Arab League (Fig 1). Arabs are not all of the same ethnic stock. However, apart from all being in the Arab League, Arab peoples have in common the Arabic language, albeit using different dialects; a relatively common history; similar taste in music; and a tendency to “flock together” when they are expatriates in a foreign land.

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Figure 1. Map shows transplantation activity in selected countries in the Arab world. Arab League countries that are not shown or labeled in this map are Bahrain, Comoros, Djibouti, Jordan, Kuwait, Lebanon, and Qatar. Adapted from a map provided by Dr Faissal Shaheen.

Arab countries have a wide variation in per capita total health expenditures and rates of out-of-pocket expenditures on health. Table 2 lists demographic and health indicators in Arab countries. Table 3 lists mean values of demographic, socioeconomic, and health indicators in the Arab world as a whole. Table 4 lists the gross domestic product (GDP) per capita and the place of each Arab country in the world league of GDPs. As listed in Table 4, Arab countries occupy positions ranging from number 2 in the rankings (Qatar) with per capita GDP of $75,900 to number 227 (Somalia) with per capita GDP of $600 (ie, a 126.5-fold difference). Table 5 lists the status of hemodialysis and its prevalence per million population, which ranges from 50.8 in Yemen to 747.7 in Tunisia.

Table 2. Demographic and Health Indicators in Arab Countries

		Jordan	Bahrain	Djobouti	Egypt	Iraq	Kuwait	Lebanon	Libya	Morocco	Oman	Palestine	Qatar	Saudi Arabia	Somalia	Sudan	Syria	Tunisia	UAE	Yemen
	Population * 1,000	5,485	725	817	70,668	27,963	2,867	4,435	6,098	29,892	2,509	3,638	796	22,673.5	8,298	34,512	18,138	10,031	4,210	20,738
	Death rate/1,000	7	3.1	15	6.4	10	1.7	4.1	2.6	5.5	2.5	2.8	1.9	3.8	17.6	11.5	4	6	1.6	11.4
	Population growth rate (%)	2.5	2.7	2.6	1.9	2.7	8.4	1.6	1.8	1.4	2.2	2.6	5.2	2.4	3.4	2.5	2.5	1.1	5.9	3
	Age < 15 y (%)	37.1	27.3	37.6	37.8	43.3	21.8	27.3	32.4	31.2	38.9	46.3	22.5	36	44.8	41.7	39.5	26.7	25.5	NA
	Age > 65 y (%)	3.8	2.5	2.8	3.4	2.8	1.6	7.5	4	5.2	2.2	3.1	1.2	3	2.7	4	3.3	6.8	1	NA
	Literacy rate (%)	91	88	49	61	56	93	88	86	57	81	91	90	—	19	50	81	78	86	53
	Access to clean water (%)	98	100	84	94	61	100	100	98	71	75	97	100	89	20	60	88	91	100	31
	Unemployment rate (%)	15	6	59	10	27	1	10	17	11	NA	27	NA	NA	NA	18	12	14	3	12
	Per capita total health expenditure (US $)	177	555	47	55	23	579	573	171	72	278	138	862	366	6	21	59	137	661	32
	Out-of-pocket health expenditure (%)	40.5	18.9	33.1	53.5	48.2	20.5	56.2	37.1	50.9	9.5	NA	22.8	6.9	55.4	54.6	51.8	45.1	17.8	56.5
	MOH/total government budgets (%)	5.7	7	7.2	3.4	4.7	6.3	3.6	NA	5.4	4.7	NA	7	6	NA	2.4	3.7	7.6	7.7	5.2
	Doctors/10,000 population	23.6	27.2	1.8	24.3	6.6	18	23.6	12.5	5.6	16.7	9.7	26.4	19	NA	5.5	14.4	9.8	16.9	2.2
	Population with primary care (%)	99	100	80	100	97	100	98	100	85	97	100	100	NA	72	66	95	95	100	50
	Life expectancy (y)	71.5	74.8	44.1	71.4	58	77.5	71.3	69.5	70.3	74.3	72.6	76.7	73.6	NA	56.6	72	73.4	72.6	62.9
	Neonates with low birth weight (%)	6	8	20	12	5	8	7	NA	6	8	7	8	5	26	11	7	5	7	23
	Children underweight (%)	4	8	36	1	13	NA	4	5	2	NA	5	NA	6	26	33	6	4	NA	46
	Infant mortality rate/1,000 live births	22.0	8.9	102	20.5	107.9	8.2	18.6	25	40	10.3	20.5	8.2	19.1	120	62	17.1	20.6	8.1	75
	Maternal mortality/10,000	40.3	0	546	62.7	294	4	88	40	227	15.4	11	22.4	12	1,600	590	58	48	1	366
	Malaria cases/y	86	0	1,616	0	47	0	0	0	0	0	0	0	1,059	28,529	1,988,132	0	0	0	200,560
	Pulmonary tuberculosis/y	162	171	2,101	8,516	3,381	247	131	1,622	14,270	131	41	162	2,192	9,535	20,220	1,339	915	87	3,610

Note: Data not shown for Algeria, Comoros, and Mauritania. Abbreviations: NA, not available; UAE, United Arab Emirates; MOH, Ministry of Health. Source data for country profiles obtained from the East Mediterranean Regional Office of the World Health Organization.2

Table 3. Mean Demographic, Socioeconomic, and Health Indicators in the Arab World

	Urban population (%)	53.3
	Death rate/1,000	7.3
	Population growth rate (%)	2.3
	Age < 15 y (%)	37.2
	Age > 65 y (%)	3.7
	Literacy rate (%)	81.8
	Per capita gross national product (US $)	3,333
	Unemployed (%)	14.2
	Smoking (%)	18.9
	Gross domestic product per capita	2,444
	Per capital total health expenditure (US $)	109.0
	Out-of-pocket expenditure (%)	46.6
	Doctors/10,000 population	13.7
	Life expectancy (y)	84.6
	Neonates with low birth weight (%)	10
	Infant mortality rate/1,000 live births	37.6
	Maternal mortality/10,000	233.4

Note: Calculated from data on country profiles obtained from the East Mediterranean Regional Office of the World Health Organization.2

Table 4. Gross Domestic Product per Capita in the Arab World

	Country	Gross Domestic Product per Capita1 ($)	Rank in World
	Somalia	600	227
	Comoros	600	225
	Djibouti	1,000	207
	Mauritania	1,800	185
	Yemen	2,400	171
	Sudan	2,500	170
	Iraq	3,600	155
	Morocco	3,800	152
	Syria	4,500	142
	Jordan	4,700	140
	Egypt	5,400	129
	Tunisia	7,500	116
	Algeria	8,100	109
	Lebanon	10,400	96
	Libya	13,100	82
	Oman	19,100	65
	Saudi Arabia	20,700	59
	Bahrain	34,700	30
	United Arab Emirates	55,200	7
	Kuwait	55,300	6
	Qatar	75,900	2
	United States	46,000	9

Note: Gross domestic product on a purchasing power parity basis divided by population. Data obtained from CIA World Factbook.3

Table 5. Data for Hemodialysis and Peritoneal Dialysis Activities in Selected Arab Countries

	Country	Date of First HD	Physicians Involved	No. on HD Therapy	No. of HD Centers	Patients on HD Therapy (pmp)	Date of First PD	Physicians Involved	No. on PD Therapy	No. of PD Centers
	Qatar	1979	Awad Rashed, V. Patel	350	5	439.7	1996	Awad Rashed, Elsayyed	85	1
	United Arab Emirates	1977	Avinash Pingle	800	6	190	1985	Avinash Pingle, Salahudin	80	2
	Saudi Arabia	1972	Al Ghoniemi	9,000	150	396.9	NA	Hassan Abu Aisha	750	13
	Oman	1983	F. Woods	700	12	279.0	1983	NA
	Tunisia	1967	Hassouna Ben Ayad, Fethi Hafsia, Ferid Akrout	7,500	120	747.7	NA	Aziz El Matri, Taieb Ben Abdullah	220	40
	Jordan	1968	Tarek Suheimat	2,800	>50	NA	1990	NA	23
	Syria	1976	Josef Sayegh	2,800	66	154.7	1984	Akram Khatib, Hassan Salloum	120	80
	Egypt	1958	Nagy Muhhalawi, Abulmoinem Hassaballah	30,000	300	424.5	1963	Abulmoinem Hassaballah	10
	Iraq	1967	Mahmoud Thamer	NA	27	NA	2004	Dawood Hussien, Sami Akram	25	1
	Yemen	1982	Abdulkareem Sheiban	1,053	13	50.8	1984	Abdulkareem Sheiban	0
	Sudan	1973		27	2,129	61.7	2005		77	7
	Algeria	1975	A. Drif	10,000	150	304.4	1980	G. Krouri	520	10

Abbreviations: HD, hemodialysis; PD, peritoneal dialysis; pmp, per million population; NA, not available.

Islamic and Cultural Influences 

Although it generally is believed that Arabs are all Muslims, a significant number of Arabs are Christians and a few are Jews. Nevertheless, the Islamic religion is critical to many Arabs, and in many Arab countries, laws governing areas of potential social or ethical controversy have to be in agreement with Islamic teaching. This dogma also applies to laws governing kidney transplantations. A landmark fatwa (Islamic religious opinion) in Saudi Arabia came about in Decision No. 99, dated 06-11-1402 by the Hijri calendar (1982 CE), opining that according to Islamic Jurisprudence, it is permissible to perform deceased donor transplantation, which paved the way for us to start a cadaveric renal transplant program.

Although the first kidney transplant in the Arab world was from a deceased person, deceased organ transplantation programs have been difficult to establish in many Arab countries (Fig 1). Consents for the first deceased donor kidney transplantations in both Qatar and Oman were obtained from expatriate families (Irish and American, respectively) who came forward to offer their loved ones' kidneys spontaneously.

The initial reluctance to start deceased donor kidney transplantation programs was because of a lack of fatwas regarding its permissibility. However, positive fatwas came along in many Arab counties. A progressive fatwa from the meeting of the Islamic Jurisprudence Conference in 1986 in Amman declared that the diagnosis of brain death was permissible and can be used to diagnose an irreversible process. Another landmark fatwa issued in Saudi Arabia in 1988 allowed cessation of therapy, including ventilation, in hopeless cases.

In Islam, there is no pastoral hierarchy and Muslims can ask any scholar they trust for a fatwa or can follow what their conscience dictates after obtaining all the relevant facts about a subject. It therefore follows that even in the presence of positive fatwas from “official fatwa councils,” at the end of the day, many people simply make up their own minds about whether deceased kidney donation is permissible.

All Arab countries that have deceased organ programs follow the opt-in (required consent) system. The only exception is Tunisia, which has had an opt-out (presumed consent) system since 1991. Egypt, which is the largest Arab country, has had only 2 deceased donors. The program could have been set back by the unfortunate fact that the organs were procured from criminals who were executed in Alexandria, intubated immediately after hanging, ventilated, and transferred by ambulance to Cairo, where a surgical team transplanted 2 livers and 4 kidneys. This provoked an intense ethical reaction in the media, leading to abandonment of deceased donor transplantations to date.

Renal Transplantation in Saudi Arabia 

Renal transplantation in Saudi Arabia went through 5 phases. Phase 1 entailed sending Saudi patients with renal failure abroad for renal transplantation. The majority went to the United States and some went to Europe; that was during the 1970s when it was still possible for non-US citizens to receive deceased donor kidneys in the United States. This phase was very informative for us because these patients were among the first to receive cyclosporine (and later tacrolimus) as immunosuppressive agents and thus we obtained very early experience in the use of these drugs.4 This model of sending patients abroad for transplantation was adopted by many Arab countries in the 1970s and 1980s, particularly in the Gulf region countries (which usually sent patients to the United States and United Kingdom) and North Africa (which usually sent patients to France).

The second phase consisted of living related transplantation by a visiting team from St Thomas's Hospital, London, UK. The team came every few weeks and stayed for a week or so to perform a few living related transplantations. This phase lasted for 2 years (1979 to 1981) while Saudi transplant physicians and surgeons were being trained. This model was not adopted by many Arab countries because of costs. Instead, they opted to send physicians abroad for training in transplantation, with the intention that they would come back to start the programs in their countries. Similarly, many Saudis were trained abroad during the third and fourth phases in the Saudi model.

The third phase consisted of continuing living related transplantation and also obtaining kidneys from Eurotransplant; this phase started in 1981 and continued for 3 years. During this period, we received 64 kidneys, and all transplantations were performed at Riyadh Armed Forces Hospital. This phase was of enormous benefit to us because it introduced us to the important business of organ procurement logistics and coordination. However, the only high-quality kidneys sent were from AB blood group donors when no suitable recipients were found in Europe. The vast majority of these kidneys were what today would be classified as marginal or “expanded pool” kidneys, and most had been refused by European centers and had long cold ischemic times.5 Of course, we had to use these kidneys because then, as now, we faced a shortage of kidneys. These types of kidneys are now being used by Eurotransplant and the United Network for Organ Sharing because the organ shortage problem began to take hold in Europe and the United States. Among the kidneys we used were half a “horseshoe” kidney, a “third-hand” kidney,6 and kidneys with cold ischemic time as long as 72 hours.7 In 1983, George Abouna in Kuwait used 2 kidneys from a diabetic donor with proteinuria whose baseline renal biopsy showed severe diabetic changes and proved that these changes reversed when the kidneys were placed in the normoglycemic milieu of the recipients.9 Sadly, we also had the unfortunate experience of unwittingly using 2 kidneys from a human immunodeficiency virus–positive donor. This was before human immunodeficiency virus testing or even acquired immunodeficiency syndrome became widely known. We learned of this after the fact with the retrospective testing of the stored sera of the 2 recipients.10

The fourth phase involved the use of kidneys from deceased donors procured locally. (Only a few Arab countries managed to move to this phase; see the map in Fig 1 and Table 6.) The fifth phase witnessed the establishment of the Saudi Center for Organ Transplantation (SCOT) and the spread of renal transplantation across the country with the founding of 10 transplantation centers serving all the regions of the country and the introduction by SCOT of multiorgan donation.11, 12, 13

Table 6. Data for the First Transplants/Transplantation Activities in Selected Arab Countries

	Country	Date of First LRD	Physicians Involved in First LRD	No. of LRDs to Date	First DD	No. of DD Kidneys	Physicians involved in First DD	No. of Current Transplant Centers	Year of Passage of Transplant Law
	Qatar	1986	Ali Hijazi, Awad Rashed, Abu Shalla	80	1988	90	Ali Hijazi, Saleh AbuRomeh, Awad Rashed	1	Yes
	United Arab Emirates	1985	Avinash Pingle, Abdulla Daar	40	ND			0	1993
	Kuwait	1979	George Abouna, V. Johnny	NA	NA	NA	Mustafa Mousawi	NA	NA
	Bahrain	1996	George Abouna, Ahmed Al-Arrayed	NA	NA	NA			1998
	Saudi Arabia	1979	J. Thompson, Anthony Wing, Norman Jones	3,862	1984	1,704	Al Otaibi, Chang, Al Sayyari	10	1982
	Oman	1988	Abdullah Daar, Feidhlim Woods	230	1998	15	Abdullah Daar, Nabil Mohsin	2	1993
	Lebanon	1985	Antoine Stephan	470	1990
	Tunisia	1986	Aziz l. Matri, Saadeddine Zemrli	415	1986	175	Aziz l. Matri, Saadeddine Zemrli	4	1991
	Jordan	1972	Daoud Hanania, Tarek Suheimat, Said Karmi	2,800	1972			10	1977
	Syria	1976	Maher Housami, Bachir Yafi	1,555	ND	ND		8	1974
	Egypt	1976	M. Ghoneim, M. Sobh, (Mansoura University), R. Barsoum, A. Hassaballa, M. Safwat (Cairo University)	4,000	1992	4	Khafagy, A. Hassaballah, S. Lotfy	15	1945
	Iraq	1973	W. Kayal, S. Khatab, S. Shamma		ND			2	1978
	Yemen	1998	Mansoura University group (Egypt), Ibrahim Al Nono	36	ND			1	2002
	Sudan	1974	Omar Beliel, Hassan Abu Aisha	378	ND			4
	Algeria	1986	A. Drif, Aberkane	400	2002	5	Aberkane, Bendjaballah	10	1985

Abbreviations: LRD, live related donation; DD, deceased donation; NA, not available; ND, not done.

I became directly involved in this fourth phase on December 24, 1984, when I had a call from Syd Jacobs, the intensivist at Riyadh Armed Forces Hospital, telling me that a Saudi patient had been diagnosed with brain death in the intensive care unit and asking if I would talk to the family about kidney donation. Such a request had never been made before in the strictly religious and tribal society of Saudi Arabia. We had no idea what the family's response would be and we feared the worst. The family was very gracious and responded with empathy to our predicament. The result was the first 2 kidney transplantations from a deceased donor to be performed in Saudi Arabia. The donor, a Saudi teenager, was overwhelmed by smoke from a fire at home, which also killed 2 members of his family. The brain death diagnosis was made by Chris Pallis, a neurologist from the Hammersmith Hospital, who wrote extensively on brain stem death, including a series of 6 articles in the British Medical Journal entitled “ABC of brain stem death.”14 Pallis happened to be in Riyadh as a speaker in a symposium on renal transplantation and brain death. The consent for donation was quickly handwritten. It is to the credit of the then-Director of the hospital, General Sherbini, a nonphysician, that he gave his approval for this “controversial” operation to take place.15

The 2 kidneys donated were transplanted into 2 young Saudi girls. Ketab Al Otaibi, then a consultant urologist at the Riyadh Armed Forces Hospital performed 1 transplantation, and the other was performed by Rene Chang. Al Otaibi later become the Director of the Riyadh Armed Force Hospital and is now the Director General of Medical Services of the Saudi Royal Forces; Rene Chang currently is the Director of Transplantation, St George's Hospital, University of London.

The first deceased donor kidney donation at King Faisal Specialist Hospital and Research Center, which occurred in 1985, was interesting in that the donor had a urinary tract infection caused by Escherichia coli, hypertension, and borderline high serum creatinine level. Despite the suboptimal status of the donor (especially as viewed in those days), after a intensive vigorous debate, nephrologists Saadi Taher and Osman Alfurayh decided to go ahead with the transplantation after discussion with the microbiologist, Dr Pavillard, indicated that the E coli was “manageable.” Fortunately, the recipient did extremely well. Khalid Meshari now heads this center, with the remarkable achievement of performing 150 renal transplantations annually, including some in highly sensitized patients.16 The first case of successful desensitization and transplantation from a living donor was done in this center in 2002.

The first Ministry of Health Hospital to perform transplantation was Alshaty Hospital in Jeddah in 1985. This operation was done by Nabeel Nezamuddin, who was involved in renal transplantation activities in 5 other transplantation centers in the Kingdom. Nezamuddin is a remarkable surgeon with many other firsts in the Arab world: the first non–heart-beating donor transplantation performed in King Fahd Hospital Jeddah with Faissal Shaheen; the first transplantation performed from an anencephalic donor with Faissal Shaheen; the first kidney pancreatic transplantation performed with Nawal Basri and Faissal Shaheen; and the first combined deceased donor liver and kidney transplantation, which he performed at King Faissal Specialist Hospital and Research Center, Riyadh. The first living donor combined liver-kidney transplantation was performed at King Abdulaziz Medical City of the National Guard by Abdulamjeed Al Abdulkareem with Ghormullah Ghamdi in 2005.

Other Saudis who left their marks in the history of transplantation in Saudi Arabia include Muaffak Jawdat, who worked with Mohamed Abu Melha, the first Saudi transplant surgeon. Jawdat went on to perform the first liver transplantation in the Arab world in 1990.17 Mohamed Al Sulaiman, the current Director of the Nephrology Department at the Riyadh Armed Forces Hospital, was central in the development of renal transplantation and has been responsible for all the transplantations performed in that hospital. Also at Riyadh Armed Forces Hospital was Dr Peter Little, a nephrologist from New Zealand who brought his experience during the early days of renal transplantation while he was Chief of Medicine. Little had had part of his renal training under Hugh de Wardener in Charing Cross Hospital, London, and continued the interest he developed there in urinary tract infection and loin-pain hematuria syndrome.

As listed in Table 6, the Saudi Arabian transplantation program is the most successful center in the Arab world when measured in combined numbers of living and deceased kidney donation. It is difficult to overestimate the positive influence that HRH Prince Salman bin Abdulaziz, the Governor of Riyadh region, had in the history of renal transplantation in Saudi Arabia. As is widely known, his wife developed renal failure and underwent renal transplantation. This experience gave him first-hand knowledge of the suffering of patients with renal failure and their families and the positive difference that renal transplantation makes in their lives. As a result, he worked tirelessly to champion their cause. Prince Salman was instrumental in passing a royal decree establishing the National Kidney Foundation in 1985 to act as a coordinating center for deceased donor kidney transplantation. With support from HRH Prince Salman, another royal decree was passed in 1993 replacing the National Kidney Foundation with SCOT to encompass other multiorgan donation and transplantation. SCOT has become a model and prototype for an organ procurement organization in the Muslim world.18 Since its establishment, SCOT has coordinated transplantation of 3,862 living related kidneys, 1,704 deceased donor kidneys, 83 whole hearts, valves from 389 hearts, 121 living related livers, 346 deceased donor livers, and 10 pancreases.19 In June 2007, Faissal Shaheen, Director-General of SCOT, received the Transplantation Society Award for his pioneering work for transplantation in Saudi Arabia (Fig 2). Few Arab countries have procurement organizations in existence (these include Kuwait, Sudan, and Tunisia), although many have laws governing transplantation (Table 6).

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Figure 2. Faissal Shaheen, Director-General of the Saudi Center of Organ Transplantation, receiving an award for his work in renal transplantation.

Nevertheless, there have been low points and challenges to the success of transplantation in the Kingdom. Intermingled with all the historical phases of kidney transplantation is the unfortunate “transplantation tourism” process by which many patients from the Arab countries, especially from the Gulf countries, traveled abroad to get “commercial” transplants. These were usually done in poor counties where there was much abuse of the donors and poor results for the recipients.20, 21 This led us in Saudi Arabia to consider starting noncommercial living nonrelated transplantation.22 Moreover, nephrologists in the Kingdom learned that it is vitally important to start deceased kidney programs cautiously and on sure footing to avoid a backlash. Three years ago in Saudi Arabia, an unfortunate child from a prominent family was diagnosed as brain dead after head trauma in a road traffic accident, but he still remains alive with ventilator support and normal status to the present. The electroencephalogram was misread because it showed persistent brain activity. This led his father to launch a prolonged media campaign to abolish the diagnosis of brain death.

Other Notable Pioneers in Arab Transplantation 

In addition to these Saudi physicians and the Jordanian surgeons mentioned in the introduction, there have been a number of other pioneers in Arab transplantation. Inevitably, I am bound to miss important names because of space limitations and because I depended largely on the responses to the questionnaires.

One such pioneer was the late Omar Beliel, who performed the second successful renal transplantation in the Arab world in the Sudan in 1974. Beliel was training in the United Kingdom to be a neurosurgeon when he needed a kidney transplant, which was performed in the Royal Free Hospital. When he recovered, Beliel changed his career to renal transplantation and devoted his training in the United Kingdom for that purpose. He wrote a moving account of his experience as a patient who was on the verge of death and was saved by his brother, who donated a kidney to him. The book, beautifully narrated by a British journalist, is entitled Two Lives: Death Odyssey of a Transplant Surgeon. The nephrologist who took care of this first transplant patient in the Sudan was Hassan Abu Aisha, who later moved to Saudi Arabia and was a pioneering nephrologist in the Kingdom. Abu Aisha was responsible for establishing the first peritoneal dialysis unit in the Kingdom. Currently, Abu Aisha is the Rector of National Rabat University in Khartoum. Beliel died of a heart attack (with a functioning kidney) 18 years after his own transplantation.

Abdullah Daar (Fig 3) will always have a special place in the history of Arab transplantation. He is a remarkable multitalented and multiqualified person with medical (member of the Royal College of Physicians) and surgical (fellow of the Royal College of Surgeons) qualifications from United Kingdom as well as a doctorate in philosophy in immunogenetics from Oxford University. Daar started renal transplantation programs in 2 Arab countries, the United Arab Emirates (UAE) in 1985 and Oman in 1988. In the latter country, Abdullah Daar was also the founding Professor of Surgery at Sultan Qaboos University. In both countries, Abdullah not only started renal transplantation, but also the “transplantation culture” and set up an immunology service. In 1998, he performed the first deceased donor kidney transplantation in Oman. The kidney was volunteered spontaneously by the family of an American expatriate. Also while in Oman, Abdullah Daar performed a unique transplantation from a 33-week-gestation (ie, preterm) donor with brain death into a 17-month-old recipient boy who is alive and doing well more than 10 years later. This became the official world record for the youngest ever deceased donor renal transplantation and has yet to be surpassed. The mother of the brain-damaged 33-week donor, a Dutch woman, sought the donation. A few years ago, Abdullah changed gears completely and has since become a biomedical ethicist of international repute in the Center of Bioethics at Toronto University.

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Figure 3. Abdullah Daar.

Avinash Pingle was the nephrologist responsible for the first transplant patient in the UAE. He worked for 23 years as a consultant nephrologist in Abu Dhabi and was instrumental in starting hemodialysis, peritoneal dialysis, and renal transplantation in the UAE. Unfortunately, no renal transplantations have taken in the UAE during the last 3 years.

Another major contributor to starting renal transplantation in the Arab world is George Abouna, who did the first transplantations in Kuwait in 1979 and also in Bahrain in 1996, where he was Dean of the College of Medicine of Arabian Gulf University. Abouna, who is now Professor of Surgery in Drexel University, Philadelphia, PA, also performed renal transplantations in many Arab countries, including Libya, Sudan, Syria, Tunisia, and Iraq (his native country) and performed the first pancreas transplantation from living donors and cadaver donors in Kuwait in 1987. While in Kuwait, 290 of 600 transplantations carried out by Abouna were on Arabs from other countries performed free of charge thanks to the generosity of the late Sheikh of Kuwait Jaber Al Sabbah.

A unique Arab pioneering personality who contributed widely to Arab nephrology and renal transplantation is Rashad Barsoum of Cairo. His contributions are so diverse, it will be difficult to mention all of them. Suffice to say that he was involved in the early phases of transplantation and dialysis in Egypt, developed the fellowship program in nephrology in Egypt, was a President of the Arab Society of Nephrology and Renal Transplantation and of the African Association of Nephrolology, developed an internationally accepted classification of schistosomiasis-associated glomerulonephritis,23 trained a generation of Egyptian and Arab nephrologists (especially from poor countries), and when he was the Secretary-General of the International Society of Nephrology, successfully managed to use International Society of Nephrology resources to improve Arab nephrology and nephrologists.

The Mansoura University group in Egypt warrants a significant mention. Mohamed Al Ghoneim managed to establish a center of true excellence for urology, nephrology, and transplantation. Members of the Mansoura group are prolific authors in all aspects of renal transplantation.

A unique historical event of interest to transplantation in the Arab world occurred in Aden, Yemen. A Saudi team led by Faissal Shaheen, together with doctors from Aden led by Hussein Al Kaff, organized a symposium on renal transplantation that was to be accompanied by performing the first renal transplantations in Aden. Nadey Hakim, Director of Transplantation at St Mary's Hospital, London University, led a team of surgeons from Aden. Robert Fitzgerald, an intensivist/anesthetist; Dr Felix Stockenhuber, a nephrologist; and Dr Annilies Fitzgerald, a psychologist, all from Vienna, Austria, formed the rest of the team. The operations were almost abandoned at the last minute for “political” reasons. It took much political and diplomatic skill to make this happen. This experience was beautifully and amusingly described by Nadey Hakim.24 Eventually, 5 living related transplantations were carried out in the same sitting. The 10 operations (donors' and recipients') took 20 hours, which must be a record of some kind. The operations went well and were a source of pride for the inhabitants of this ancient city.25, 26 The Arab European Foundation was established as a result of this experience and registered in Vienna with Faissal Shaheen as President, Robert Fitzgerald as Vice-President, and Annilies Fitzgerald as Secretary-General. Its mission is to help poor Arab countries, and its motto is “Poverty should not be a barrier to health or education!”27

Wars and Renal Transplantation in the Arab World 

To the credit of the team that performed the transplantations in Aden, they insisted on going to Aden regardless of the raging Iraq war in March 2003, thus showing that international cooperation can reduce the suffering of patients.8 Antoine Stephan recollects that the first transplantation in Lebanon in 1985 was timed when they thought the Lebanese civil war was over. Unhappily, a day after the transplantation, there was a “relapse” in the hostilities and he had to move the patient “from the isolation unit straight to the basement!”28

Muaffak Jawdat, who performed the first-ever liver transplantation in the Arab world in Saudi Arabia on July 30, 1990,17 received little media coverage of this important medical event because Saddam Hussein invaded Kuwait just 3 days afterward. The invasion also stopped all transplantation activities in Kuwait, which had initiated its transplantation program in 1979. From that time until March 1990, a total of 500 kidney transplantations had been performed, but activities did not resume until September 1993.29

Although Iraq was among the first Arab countries to start living donor transplantation, the transplantation activities in Iraq suffered as a result of these wars and the embargo that followed, and this continues until now because of the continuing strife there. Unfortunately, during the embargo, Iraq became the place to go to from neighboring countries to get an inexpensive “commercial” transplant. Before the Iraq war in 2003, there were 4 transplantation centers in Baghdad, and now only 2 remain. Even the existing centers work spasmodically in Baghdad because of the poor security situation. The good news is that an enthusiastic young Iraqi surgeon, Pishtewan Al Bazzaz from the Kurdish region of Iraq, has restored some transplantation activity in Erbil since December 26, 2006, and this center treats patients from all over Iraq. In less than 6 months, they already have performed 25 transplantations. Al Bazzaz is also the Rector of Hawler Medical University in Erbil.

Arab Contributions to Transplantation Literature 

Throughout this historical journey of renal transplantation, some interesting observations from the Arab region were published. In the late 1980s, we described several transplant recipients treated with cyclosporine who became pregnant and delivered healthy children.30, 31 Since then, many other groups from the region described large numbers of cases of posttransplantation pregnancies with good outcomes,32, 33, 34 with no deterioration in renal function even after repeated pregnancies.35 Infections, such as tuberculosis, nontyphoid salmonella, parasitic infections, and schistosomiasis, are common in the region, which led to the publication of a number of useful articles emanating from this region about these infections in the setting of renal transplantation.36, 37, 38, 39 The predilection of posttransplantation tuberculosis to cause loss of the allograft because of tuberculous interstitial nephritis was described.36 Appropriate cyclosporine dose adjustment when using rifampicin is another contribution from the region.40 The first case of cyclosporine-related Kaposi sarcoma was described.41 Now we know that Kaposi sarcoma accounts for 75% of all posttransplantation malignancies in the Arab world.42 It therefore is not surprising that several reports from the Arab region were produced on this condition, including its natural history and treatment42 and its involvement in children,43 the chest,44 and the gastrointestinal tract.45 Also, a novel classification was developed for posttransplantation Kaposi sarcoma,46 and its association with human herpesvirus 8 was also described.47 The first report of its recurrence after reintroduction of immunosuppression was also described.48 The first regrafting of a transplanted kidney (third-hand kidney) was reported.6 Again, because of the high prevalence of hepatitis B virus in the Arab world, a group from the Arab world established that it is safe to transplant kidneys from hepatitis B virus–positive donors to hepatitis B virus–negative patients, provided they are immune.49 The group from Mansoura, Egypt, reported good graft and patient survival in patients with amyloidosis.50 Fasting during the month of Ramadan is an obligatory duty for all adult Muslims unless fasting is deemed deleterious to their health. A few reports from this region have addressed this issue.51

Because the Kingdom of Saudi Arabia has the highest number of multiorgan donations from deceased donors in the region, useful insight into societal and religious components peculiar to the Arab world with regard to organ procurement have been provided.52 We also found that the most important factors in obtaining consent from families were not their educational, social, or economic levels, but their awareness about issues related to transplantation.53 However, there has been also extensive experience in living donors, which resulted in some interesting observations at an ethical and cultural level, such as donor motivation,54 publication of an objective scoring and grading system for donor willingness,55 and also the finding that, in contrast to the West, we have more male donors and more female recipients.56

During the Aden experience described, it was observed that Annilies Fitzgerald, the Austrian psychologist with the visiting team, developed a strong bond and could communicate for long periods with female donors and recipients by using gestures and body language. This human bond that is often seen in transplantation has been coined the “Annilies factor.”57

Conclusion 

The story of transplantation in the Arab world is intertwined and shaped by the prevailing socioeconomic and health indicators in the different countries. It is also the story of hard-working pioneers and of human endeavor against adversity, exemplified by 2 of the pioneers having received organ transplants themselves. In Saudi Arabia, the renal transplant service went through developmental phases culminating in the establishment of the SCOT, which has become the prototype of a successful multiorgan procurement center that can be emulated by Arab and Muslim countries. Arab countries have had more than their fair share of strife and wars, and this fact of life has unfortunately adversely affected transplant services and programs in the region.