Objectives: The number of patients with organ failure in Saudi Arabia is increasing annually, and transplantation offers the best outcome for these patients. However, the number of donors does not meet these needs.
Materials and Methods: A questionnaire was distri­buted to assess the behavior of participants in Saudi Arabia toward different types of organ donation. The questionnaire examined general willingness to donate, deceased donation, living donation, and refusal to donate, as well as paired-exchange donation and next-of-kin consenting.
Results: Of the 1099 participants, most were men (64%) and middle-aged (46%, 31-45 years old), with 36% of participants currently willing to donate or already registered as donors. Although 592 participants (54%) were not yet willing to donate, they believed they could consider making donations in specific circumstances (eg, when a relative is in need). In all circumstances, 10% (n = 108) of the participants refused to donate. With regard to deceased donation, 74% of participants accepted this, but only 29% (n = 322) agreed to consent for donation as next of kin. Of 1099 participants, 143 (13%) were willing to accept altruistic donation. Paired-exchange donation was widely accepted in a cohort study (n = 725, 65%), as opposed to list exchange (n = 540, 49%). Religious beliefs were the main reason behind the refusal of donation in the study cohort (n = 37, 37%). Female participants were less likely to refuse organ donation (odds ratio: 0.562; 95% CI, 0.407-0.775; P < .001), whereas older participants (> 60 years) were more likely to refuse organ donation (odds ratio: 5.457; 95% CI, 1.894-15.722; P = .002).
Conclusions: This study described the willingness of the Saudi population to donate organs in general and under special conditions, such as deceased donation, living-unrelated donation, altruistic donation, paired-exchange donation, list exchange donation, and next-of-kin consent.

Key words : Altruistic donation, Deceased donor, List exchange donation, Living-unrelated donation, Next-of-kin consent, Paired-exchange donation, Transplantation

Introduction

Chronic kidney disease is a major health care problem in Saudi Arabia. About 5% to 6% of the Saudi population has some degree of chronic kidney disease.^1,2 With the rapid increase in the incidence of diabetes in the country, this number may increase significantly.³ This leads to a massive number of the population with end-stage renal disease (ESRD), and this number has increased dramatically in recent years.

Because of the growth of this disease, ESRD has had a significant economic impact on Saudi health care institutions. From a clinical and economic perspective, transplantation is the best choice for renal replacement therapy. However, the rate of kidney transplant in Saudi Arabia remains far from meeting the demand. Kidney transplant in Saudi Arabia relies heavily on living donations, as deceased donations account for only 15% of kidney donations annually.^4,5

Organ transplant is a life-saving treatment for many organ failure conditions, including for the lungs, liver, and heart. Transplant can also dramatically improve the health and lifestyle of patients who have had kidney, pancreas, corneal, and intestinal transplant procedures. Unfortunately, the number of solid-organ transplants in most organs other than kidneys in Saudi Arabia is still low.⁵

Although several studies have previously addressed this topic in Saudi Arabia, their scope of focus varies significantly. The purpose of this study is to draw a map describing the territory of organ donation in Saudi Arabia. The study is not limited to a specific organ, and it explores the willingness of the Saudi population toward different aspects in the field of transplantation, including but not limited to living and deceased donation, paired exchange, list exchange, altruistic donation, and next-of-kin consenting.

Materials and Methods

The study was conducted in a cross-sectional design. A questionnaire was distributed to assess the behavior of people toward different types of donations in the period between December 1, 2019 and December 30, 2019. The questionnaire was composed of 27 questions, including the demographics of the participants, overall acceptance of donations, deceased donation, living donation, and refusal to donate. The questionnaire also included questions about accepting donations under special circumstances, such as paired-exchange, list exchange, altruistic donation, and next-of-kin consenting. Social media platforms were used to distribute and collect feedback. The questionnaire was distributed in both Arabic and English. Participants under the age of 18 or over the age of 75 were excluded from the study because most transplant centers do not consider donations from people in these age groups. At the time of the study, non-Saudi nationals who spent less than 2 months in Saudi Arabia were excluded to avoid the inclusion of visitors and transient residents. The design of the questionnaire and the data collection were carried out using Google Forms.

The study was approved by the Research Ethics Board of Taif University.

Statistical analyses
Statistical analyses were performed using SPSS software version 24.0 (IBM Corporation). Categorical data are shown as numbers and proportions. The chi-squared test and the Fisher exact test were used to explore the significance of differences between participant responses based on the demographics of the subgroups.

To examine the predictors of transplant rejection, a multiple logistic regression analysis was performed to estimate the odds ratios (OR) and 95% CIs of the explanatory variables, after controlling for potential confounders. All statistical tests were 2 sided. P < .05 was considered statistically significant.

Results

The total number of participants was 1132. However, 33 responses were excluded due to noncompliance with the inclusion criteria or incomplete data. More men (n = 698 [64%]) responded to the questionnaires than women. With regard to age groups, 291 participants (26.5%) were between 18 and 30 years old, 506 (46%) were between 31 and 45 years old, 246 (22%) were between 46 and 60 years old, and 56 participants (5%) were greater than 60 years old. Of total participants, 779 (71%) were married or engaged and 269 (25%) were single. Most participants were Muslims (n = 1075 [99%]) and Saudi nationals (n = 972 [89%]), and most (n = 613) were economically in the middle class or higher (monthly income > 10 000 (Saudi riyal [SR]). The complete demographics of the study population are shown in Table 1.

In general, only 394 participants (36%) were currently willing to donate or already registered as donors in the Saudi Center for Organ Transplantation (SCOT). However, of the 700 participants (64%) who indicated that they were yet unwilling to donate, 592 (54%) believed that they could consider doing so under special situations. In all circumstances, only a small minority of 10% (n = 108) of the participants refused to donate (Figure 1). Living-related donation is considered to be the most acceptable type of donation among the accepting cohort (those who are currently willing or may accept donations in the future), with an acceptance rate of 75% (n = 739), followed by deceased donation (61%). The acceptance rate of living-unrelated organ donation was substantially lower at 14% (Figure 2).

Regarding deceased donation, of the 986 participants who expressed their current or potential acceptance of donation in general, only 59 participants (5.4%) believed that deceased donation was incompatible with Islamic rules, whereas more than half of the participants (n = 524, 47.7%) believed that it was compatible with Islam. A large portion of the study cohort (n = 403, 36.7%) was unsure of the compatibility of deceased donation with Islamic rules. About 20% of participants (n = 224) who were open to the general idea of donation rejected deceased donation, whereas 69% (n = 762) accepted it, with 5% already registered in SCOT. The kidney is the organ that most participants were willing to donate after death (n = 741; 75%), followed by the liver (652; 66%) and heart (565; 57%) (Figure 3). With regard to next-of-kin consent and whether participants would consent to donating their deceased relative’s organs, only 29% (n = 322) indicated that they would consent to this type of organ donation. On the other hand, 17% (n = 186) refused such donations and 39% (n = 430) expressed uncertainty about it. Next-of-kin donation was not affected by the desperate need of the recipient (eg, a child recipient) since only 48 participants (4%) chose this option.

Regarding living donation, most participants who expressed their general acceptance of donations (n = 798/986, 90.9%) were willing to donate a kidney, whereas 65% (n = 640) were willing to be liver donors (Figure 3). Moreover, living-unrelated donation was not an option for 314 participants (32%), 403 (41%) thought they would submit to a living-unrelated donation if the recipient was a child, and 390 (40%) would consider it for a friend. Only a minority unconditionally accepted living-unrelated donation (n = 244, 25%), and 11% (n = 106) would consider it for someone who they just knew about on social media (see Figure 7). In addition, a large portion of the cohort (n = 625, 57%) did not accept the idea of an altruistic (nondirected living-unrelated) donation. However, 13% (n = 143) thought they were likely to donate altruistically; the rest were neutral to this type of donation (Figure 4).

The type of surgery (laparoscopic vs open) had no effect on the decision of living-related donation in 579 participants (53%), whereas only 100 participants (10%) would not donate if laparoscopic surgery was not available. About 27% (n = 297) preferred laparoscopic surgery but would still proceed with living-related donation if open surgery were the only available option (Figure 5). On the other hand, the responses to the same question changed significantly for living-unrelated donation: only 32% (n = 349) considered that the type of surgery would not affect their decision to donate, 35% (n = 344) were unwilling to accept living-unrelated donations regardless of the surgical type, and 11% (n = 118) would not donate unless the surgery was laparoscopic (Figure 5).

The paired-exchange donation was widely accepted in the cohort study, with 445 participants (41%) indicating that they would unconditionally accept it, 260 (24%) indicating that they would accept it if the recipient did not have other donors, 193 (18%) being unsure whether they would accept it, and 88 (8%) rejecting this type of exchange donation. Participants were less likely to accept list exchange as a solution for incompatibility. In fact, 336 participants (31%) could not be sure that they would accept this type of donation, 309 (28%) accepted list exchange, and 231 (21%) accepted it only if their recipient would have no other donors, with 110 (10%) refusing list exchange.

Of the 108 participants (10%) who refused to donate under any condition, 37 (37%) indicated that their decision was based on their religious beliefs. Twenty-one participants (21%) refused for fear of organ (kidney/liver) failure after donation, 27 (27%) were afraid of complications after donation, and 14 (14%) indicated that they had medical conditions that prevented them from donating (Figure 6). The vast majority (n = 74, 69%) of people who refused donation had never encountered any organ donor before. Financial incentives (eg, coverage of transportation and accommodations costs) did not seem to affect their donation decisions since most (n = 89, 82%) indicated that financial benefits would not change their decisions. For comparison, 6 participants (6%) answered “yes” and 13 participants (12%) answered “maybe.”

The difference in acceptance of donation in general between men and women in the cohort study was significant because the percentage of men who accepted donation, rejected it, and were uncertain was 34%, 10%, and 58%, respectively, compared with 43%, 10%, and 46% for female participants (P < .001) (Figure 1). In addition, acceptance in women of different types of donation was 63%, 65%, and 12% for deceased, living-related, and living-unrelated donations, respectively, compared with 51%, 66%, and 10% for men (P < .001) (Figure 2). With regard to deceased donation, more women were likely to accept this type of donation than men. Current and potential deceased donors in the female cohort were 83% compared with 74% in the male cohort (P = .002) (Table 2). Most men (58%) and women (61%) indicated that the type of surgery (laparoscopic vs open) did not affect their decision for living-related donation (P = .111) (Figure 5). Acceptance of paired-exchange donation among women in Saudi Arabia was also higher compared with men (49% vs 43%), whereas men were more likely to reject this donation (12% vs 5%; P = .001). Similarly, rejection of list exchange was found to be higher among men than women (13% vs 8%, respectively; P = .042) (Table 2 and Table 3).

Age of participants was also found to affect the decision to donate, since the response rate of decrease in donation increased as age advanced (Figure 2 and Table 3). Moreover, younger participants (18-30 years) displayed a higher acceptance toward deceased, living-related, and living-unrelated donation at 60%, 68%, and 14%, respectively, compared with 48%, 32%, and 7% in participants > 65 years old (P < .001). In addition, the younger group also displayed a higher acceptance of paired exchange donation (51% for the 18- to 30-year age group compared with 5% in participants > 65 years old; P < .001) (Table 2). On the other hand, there was no statistically significant difference between the age groups and the acceptance/rejection of donation based on type of surgery (open vs laparoscopic).

Educational level affected the general acceptance of donation. Although 18% of people in the lower educational scale (secondary school education or less) refused to donate, this rate dropped to 14%, 8.3%, and 8.4% for undergraduate students, college graduates, and higher education groups, respectively (P = .022) (Figures 1 and 7). There was no statistically significant difference between the different educational levels in the cohort study and the acceptance rate of deceased donation, next-of-kin consent, paired exchange, or list exchange donation (Table 4).

Economic class did not affect the likelihood of donation in general, nor did it affect the decision of next-of-kin consent, altruistic, paired exchange, or list exchange donations. However, there was a semi-U-shaped relationship between economic class and acceptance of deceased donation (Figure 2). Similarly, it formed an inverted U-shaped relationship when the economic class was correlated with living-related donation. The possibility of considering that deceased donation is compatible with Islam was higher among the high economic class, with 62% of the high economic class (> 30 000 SR/month) stating that they believed deceased donation was allowed in Islam compared with 63%, 50%, 48.3%, and 48.2% for the 20 000 to 30 000 SR, 10 000 to 20 000 SR, 5000 to 10 000 SR, and < 5000 SR groups, respectively (Table 5).

Social status was also shown to affect willingness to donate. Single participants were more likely to accept donations (43%) than married participants (33%; P = .003). They were also more likely to accept deceased donations, with rates of registered donors, willing to register after obtaining more information, and refusing deceased donations in single participants of 11%, 70%, and 20%, respectively, compared with 4%, 72%, and 24% for the married participants (P < .001) (Table 6). Neither the city of residence nor the nationality of the participants had a significant effect on willingness to donate.

Discussion

The first organ transplant surgery in Saudi Arabia was a living donor kidney transplant, which was performed in Prince Sultan Military Medical City-Riyadh in 1979. Years later, on December 23, 1984, the first deceased donor kidney transplant in the country was also carried out in Riyadh.6 In 2017, 921 kidneys, 226 livers, 37 whole hearts, 72 lungs and 18 pancreases were transplanted in Saudi Arabia. The vast majority of kidney (84%) and liver (65%) organs came from living donors.⁵

Based on the latest data from SCOT, the number of patients with ESRD in Saudi Arabia has exceeded 29 000 patients, with most being young or middle-aged (26-65 years old). Moreover, the number of new ESRD patients has also increased annually.5 Most patients with ESRD in Saudi Arabia depend on dialysis (around 20 000 patients).⁴ In Saudi Arabia, only 921 kidneys were transplanted between 1979 and 2017, with 84% from living donors (n = 776) and only 15% (n = 145 kidneys) from deceased donors. Furthermore, the number of approached families of potential deceased donors has remained stable over the past few years. In addition, only 33% of the approached families of potential deceased donors had consented for deceased donation in 2017.⁵

This study aimed to exhaustively explore the behavior of the Saudi population toward different types of donations, as well as their attitudes toward complicated donation-related issues, such as paired-exchange donation, list-exchange donation, and next-of-kin consent. This may help policymakers and organ recruitment teams understand the possibility of donations from Saudi residents.

This study showed that pools of donors in Saudi Arabia are likely to expand since only 10% of the population ultimately ruled out donation. However, most participants had not yet decided and may only consider donating if necessary. This makes educational plans, online materials, and advocacy programs much needed to increase organ donation rates in Saudi Arabia.⁷

Living donation is the main modality of organ donation in Saudi Arabia.⁴ Similarly, most participants in this study accepted living donations. This willingness seems to be unaffected by the type of surgery (laparoscopic vs open). In this study, female participants had greater willingness to be living-related kidney donors. This finding is not surprising because it has been repeatedly found that donation rates in women (especially spousal donation) are higher than donation rates in men. For instance, in Kayler and associates, women accounted for 68% of spousal and 56% of non-spousal living donations.⁸

Living-unrelated transplant has a favorable long-term allograft survival compared with deceased donation and has a comparable outcome with respect to living-related donation.9 This type of donation may increase the pool of donations and shorten the wait list for deceased donations. Living-unrelated kidney transplant is widely accepted in developed countries.^10,11 On the contrary, in 2017, only about 14% of living kidney donations and 11% of living liver donations in Saudi Arabia came from unrelated donors.5 However, although only a small minority (13%) of the study population was willing to make living-unrelated donations, people seemed to respond to the moral calls of close personal relationship and the desperate need of the recipient, demonstrated by significantly increased rates in cases where the recipient was a child or personal friend (Figure 7). Even in the Iranian model of regulated compensation for kidney donation, a considerable percentage of donors (18%) donated out of altruism and goodwill, as described by Mousavi and associates.¹² To avoid commercial living-unrelated donation, Shaheen and associates published a proposed approach in 2005 for the ethical utilization of living-unrelated kidney donations, which has been implemented and expanded by SCOT ever since.¹³ In the present study, the willingness for living-unrelated donation was found to be significantly higher among women, the younger age group (18-30 years), and those at the lowest income and educational levels (Figure 2). In Kayler and associates,¹⁴ female donation in living-unrelated transplant was slightly higher than that of men (55% vs 45%). In another study, when comparing donation rates in men versus women in living-unrelated donation to the expected proportions in the population (based on incidence rates for ESRD by sex), the proportion of male donors was lower than the expected proportions (P < .001). In contrast to the findings of the present study, where the willingness for living-unrelated donation was higher in the lower income group, Gill and colleagues15 demonstrated that the higher income group had higher living-unrelated donation rates with persistent rate growth since 1999. This may be because of lesser financial burden on donors in Saudi Arabia (eg, a prolonged period of paid time off for donation).

Deceased donation is not common in Saudi Arabia, currently accounting for less than 15% of organ donations in Saudi Arabia.5 However, > 60% of participants in this study were willing to accept this type of donation (Figure 2). This rate of willingness was close to that shown in countries with a high volume of deceased donors. For instance, Spain has a similar acceptance rate, with around 40 deceased donors and over 100 transplant procedures/million population.^16,17 This finding emphasizes the need to increase efforts of deceased donor recruitment in Saudi Arabia. The need for better education and recruitment programs were also indicated, as illustrated by more people willing to donate their kidneys after death than willing to donate their corneas. This could be due to better knowledge in the population about kidney donation versus that shown for other organs. Despite the fact that deceased donation in this study was not related to the participants’ areas or place of residence, the latest data from SCOT shows that Riyadh City has the largest source of deceased organ donors. This might reflect the advanced medical facilities in Riyadh compared with other cities in Saudi Arabia rather than a greater inclination toward deceased donation in this city.

Next-of kin consent for deceased donation is not common in Saudi Arabia.4 In this study, less than 20% indicated that they would not consent to such a donation, whereas more than one-third of the population was uncertain. There was no correlation between this finding and the respondents’ sex, level of education, or socioeconomic characteristics. This explains that only 33% of approached families of potential deceased donors in Saudi Arabia had given their consent in 2017.⁵ However, the younger participants (those 18-30 years old) were more willing to consent than older participants. In a previous study, better education and prior knowledge of donation were 2 main factors associated with higher rates of next-of-kin consent.18 Furthermore, in Rodrigue and colleagues, sex, age, marital status, educational level, and acceptance of next-of-kin consent were not significantly associated with willingness to donate. On the other hand, the next-of-kin relation to the deceased, previous donation discussions, and favorable organ donation beliefs were factors associated with a higher likelihood to consent.¹⁹ For instance, only a quarter of potential deceased donors in Saudi Arabia in 2017 had consented to donation.

The desperate need of the recipient (eg, a child recipient) does not seem to affect the likelihood of next-of-kin consents in Saudi Arabia, unlike living-unrelated donation, where the probability rate increased from 13% for living-unrelated donation in general to about 40% if the recipient was a child (Figure 2 and Figure 7).

This study showed that women in Saudi Arabia were more willing to donate their solid organs than men. This finding is consistent with findings from other countries across the globe. For instance, 65% of kidney donors in Switzerland and 87% of donors in India are women.^20,21 Notwithstanding, this study showed that the percentage of men who totally refused the donation was as low as that of women (only 10%). Most male participants in Saudi Arabia indicated that they were unsure of their willingness to donate, which gives organ recruitment teams in Saudi Arabia a large margin for potential expansion. Moreover, women were more likely to accept paired-exchange donation, whereas men were more likely to reject it, as well as to reject list-exchange donation. The relationship between donors and recipients plays a role in establishing the rate of donation. In Godara and associates,²¹ 30% of the donors were mothers donating to their children, followed by wives donating to their husbands (17%) and fathers donating to their children (16%).

Results of the present study also revealed that donation was more likely among the young population, which is an old finding in the field of transplantation.²² In this study, younger groups who accept donation were also more willing to accept indirect donations like a paired-exchange donation, which has been found repeatedly in the Saudi population.^23,24 The reason for this finding is not well understood. However, the high incidence of comorbidities (such as diabetes) in people over 45 years of age in Saudi Arabia may be the cause of this finding.²⁵

Since 1995, laparoscopic donor nephrectomy has been widely known in the field of transplantation.²⁶ Laparoscopic donor nephrectomy is more beneficial than open nephrectomy because it has comparable transplant outcomes (eg, delayed graft function, patient and graft survival) with better donor outcomes (eg, shorter hospital stay, early return to work, better cosmetic outcomes).^27,28 In a population in the United States, the availability of laparoscopic surgery has significantly increased the rates of living donation.²⁹ On the contrary, in this study population, the type of surgery (laparoscopic vs open) had no effect on the donation decision, especially for living-related donation (Figure 7). More interestingly, this finding is consistent in men versus women.

Social factors have been linked to willingness to donate since the early days of kidney transplantation. In 1984, Nolan and colleagues³⁰ discovered that people were more likely to be willing to donate when the recipient is a family member, even if they initially opposed it. Similarly, some ethnic groups may behave differently from the general population with regard to their willingness to donate.³¹ This requires that donation-promoting programs should be carefully designed based on the target audience.

In previous studies, socioeconomic factors affected the likelihood of organ donation, in which people with low socioeconomic status were shown to be less likely to donate.³² This was attributed to a number of potential factors, including the loss of an equivalent cost of 1 month’s salary for kidney donation, time away from work for pretransplant evaluation, hospitalization, and the postoperative period, in addition to other expenses, including travel, accommodation, and childcare.³² In the present study, high-income people also showed a tendency toward a higher probability of donation. However, this finding was not statistically significant. Similarly, high education was also found to be associated with a greater willingness to donate. In Prottas and associates,³³ these 2 factors (high income and high education) were associated with a higher likelihood of donation along with White race. Similarly, a lower level of education was also associated with a lower likelihood of donation among certain ethnic groups, as described in Salim and associates.³⁴

Religious beliefs play an essential role in the donation decision. Some religious groups have stood against organ donation. For instance, Orthodox Jews in Israel issued antidonation cards.³⁵ Islam is the faith of most people in Saudi Arabia. Although most Islamic bodies and institutions all over the Muslim countries endorse organ donation, many individuals in these countries are still reluctant to consider organ donation, especially deceased donation. The Islamic Jurisprudence Assembly Council in Saudi Arabia approved deceased and living donations in 1982. However, many Saudis still reject organ donation. In a study from Al-Harthi and Alzahrany, almost 60% of the study population refused to consider organ donation.²³ Moreover, in a study from Alam,³⁶ only 42% of the population under study accepted organ donation. Of these, 27.5% feared that the act of organ donation would contradict their religious beliefs.³⁶ In the present study, the majority of those who accepted donation in general believed that deceased donation was compatible with Islamic rules. However, a good proportion of participants were not sure whether Islam would allow such type of donation. In addition, the majority of those who refused donation indicated that they did so because of their religious beliefs (Figure 6). Nevertheless, people showed more willingness to donate during Islamic seasons like the holy month of Ramadan. Najafizadeh and associates³⁷ showed that Ramadan had a 154% increase in the donation rate compared with the previous month for donor recruitment teams in Islamic countries for utilizing Islamic seasons, thereby enhancing donor recruitment.

Financial compensation can enhance the willing­ness to donate to family members and strangers.³⁸ Arguments for or against financial compensation for solid-organ donors are beyond the scope of this study. In Gordon and associates, 29% of people who thought financial support would increase their willingness to donate said they needed this support to cover for some of the nonmedical expenses related to transplant. On the other hand, over 54 years of age was a factor associated with the thought that financial compen­sation would not affect their willingness to donate.³⁸ In this study, the potential financial gains did not seem to change the decision of those who refused to donate.

In a series of studies conducted in Saudi popula­tions, a number of factors have been reported to hinder people from organ donation. The most frequently reported factors were (1) fear of complications, (2) insufficient information about donation, and (3) the belief that Islam prohibits such a procedure.^23,36,39 In the present study, only a minority of the study popula­tion refused donation, and the main reason for their refusal was their religious beliefs, followed by fear of postoperative complications and fear of organ failure. However, most of the participants who refused donation have never encountered any organ donor before. This may indicate that raising awareness with regard to organ donation and its actual outcomes may move a portion of refusing people toward the acceptance end.

The donor-exchange program is an excellent modality that can expand living donations. In Saudi Arabia, most donor incompatibilities (75%) are because of HLA incompatibility.40 In Waterman and associates,⁴¹ 64% of potential donors were willing to participate in such a program. List exchange is another way to expand kidney donation. The availability of paired exchange and list donation program is estimated to increase the kidney transplant rate by 1% to 11%. However, only 37% of donors considered it as an option.⁴¹ Close family relationships and less than a college education were the most critical factors for accepting paired-kidney exchange, whereas hemodialysis initiation was the major factor for accepting list donation.⁴¹ In the present study, about two-thirds of participants eventually agreed to paired-exchange donation or in the event that their recipient had no other donor. This number dropped to about 50% for list exchange. The acceptance rate for paired exchange donation was higher in female, unmarried, and younger (< 45 years old) age groups.

Limitations
There are several limitations: (1) the response rate to the questionnaire was unknown; (2) the number of male respondents was disproportionately higher than female respondents; and (3) the number of respondents refusing donation was very low (about 10%). This did not allow running statistical tests to assess correlations between different socioeconomic groups.

Conclusions

This study described the willingness of the Saudi population for organ donation in general and in special conditions, such as deceased, living-unrelated, altruistic, paired-exchange, list exchange, and next-of-kin consent.

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