Objectives: The Organization of Islamic Cooperation consists of 57 member states whose people are mainly followers of the Islamic religion. During the past several decades, organ transplants have been increasingly used for the treatment of end-stage organ failures worldwide. This study is to investigate the current status of organ transplant in Islamic countries.

Materials and Methods: For data collection a literature, review was carried out. Information from international registries was used and key persons from some countries were contacted.

Results: In all 5 Islamic countries of North Africa, living-donor kidney transplant was performed. Tunisia was the only country with deceased-donor organ transplant in North Africa. In 22 Islamic countries of sub-Saharan Africa, living-donor kidney transplant was performed only in Sudan and Nigeria. Deceased-donor organ transplant was illegal and nonexistent in this region. In all 14 Islamic countries of the Middle East, living-donor kidney transplant was an established practice. Turkey, Iran, and Saudi Arabia had the highest rates of organ transplant activity. In 2013, Turkey performed the highest rate of living-donor kidney and liver transplants, and Iran performed the highest rate of deceased-donor kidney and liver transplants. For 7 Islamic countries of Central Asia, organ transplant was nonexistent in Afghanistan and Turkmenistan; in the other 5 countries, a limited number of living-donor kidney or liver transplants were performed. In all 6 countries located in South and Southeast Asia, living-donor kidney transplant was performed. Only Malaysia had a limited-scale deceased-donor transplant program. Albania in the Balkans, and 2 countries (Suriname and Guyana) in South America, were also member states of the Organization of Islamic Cooperation; in these countries, only few living-donor kidney transplants were performed.

Conclusions: The organ transplant rates, especially for deceased-donor transplant, in most Islamic countries were less than expected. Some of the causes of low transplant activity included lack of public education and awareness, lack of approval and support by Islamic scholars, and lack of government infrastructure and financial resources.

Key words : Central Asia, Middle East, North Africa, Southeast Asia, Sub-Saharan Africa

Introduction

Islam the world’s second largest religion after Christianity, has 1.62 billion adherents, and is the predominant religion in the Middle East, North Africa, sub-Saharan Africa, Central Asia, South Asia, and Southeast Asia.1 The highest percentage of the world Muslim population (62%) lives in South and Southeast Asia, followed by 19.9% in the Middle East and North Africa and 15% in sub-Saharan Africa. Only 2.7% and 0.3% of the world Muslim population live in Europe and the Americas.²

The Organization of Islamic Cooperation is the second largest organization after the United Nations and includes 57 member states whose people are mainly followers of the Islamic religion. These 57 Islamic countries that make a substantial portion of the world’s developing countries are located in the Middle East (14 members: Turkey, Iran, Saudi Arabia, Lebanon, Qatar, Kuwait, Iraq, Syria, Jordan, Yemen, Bahrain, Oman, United Arab Emirates, and Palestine), North Africa (5 members: Egypt, Libya, Tunisia, Algeria, and Morocco), sub-Saharan Africa (22 members: Benin, Burkina Faso, Cameroon, Comoros, Chad, Djibouti, Gabon, Gambia, Guinea, Guinea Bissau, Ivory Coast, Mali, Mauritania, Mozambique, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Sudan, Togo, and Uganda), Central Asia (7 members: Turkmenistan, Uzbekistan, Kyrgyzstan, Kazakhstan, Tajikistan, Azerbaijan, and Afghanistan), and South and Southeast Asia (6 members: Pakistan, Maldives, Bangladesh, Indonesia, Malaysia, and Brunei). Albania is a Muslim majority country in Southeast Europe, and 2 countries (Suriname and Guyana) in South America also are member states of the Organization of Islamic Cooperation.³

Many poor and developing Islamic countries of sub-Saharan Africa and South Asia are in the category of low human development index.4 Some Islamic countries of the Middle East that have remarkable material resources (such as crude oil and natural gas reserves) also are lagging far behind international averages in socioeconomic develop­ment such as education, health, and living standards.

During the past several decades, organ transplants have been increasingly used for the treatment of end-stage organ failure worldwide. The aim of this study was to investigate the current status of organ donation and transplant in these 57 Islamic countries. There is a proven correlation between frequency of organ transplant and human develop­ment index; therefore, it was anticipated that lower human development index in most Islamic countries would be associated with limited transplant activities or nonexistent transplant programs.

Materials and Methods

For data collection, a literature review was performed for organ donation and transplant in each of 57 Islamic countries. The availability of information varied markedly, and some countries had no reported data. Few countries had national registries. Information was used from international registries such as Global Observatory on Donation and Transplantation⁵ and International Registry in Organ Donation and Transplantation (Spanish group).⁶ Key persons from some countries were contacted to obtain needed information.

Results

The results of the study showed that in 5 Islamic countries of North Africa, living-donor kidney transplant was an established practice. Egypt and Tunisia had the highest rates of living-donor kidney transplant in this region: 13.8 per million population (pmp) in Egypt and 13.2 pmp in Tunisia.⁷ In Egypt, organ donation from deceased donors was legalized in 2010. However, because of ongoing religious debate about the definition of brain death, this law had not yet been activated, and deceased-donor transplant was rare in this country; transplant activity predominantly involved living-donor kidney and liver transplants.⁸ In 2013, there were 500 living-donor kidney (6.0 pmp) and 250 living-donor liver transplants (3.0 pmp) performed in Egypt (Professor M. A. Bakr, personal communication). Between 1991 and 2013, there were 2140 liver transplants performed, and only 2 liver transplants were from deceased donors.⁹ Tunisia had the highest rate of deceased-donor organ transplants in North Africa. In 2010, thirty of 132 kidney transplants (23%) were from deceased donors.⁷ Since the Tunisian revolution in December 2010, the deceased-organ donation rate declined from 3.0 pmp in 2010 to 0.6 pmp in 2011 and 0.1 pmp in 2012. However, the living-donor organ transplant rate remained stable at 10.2 pmp (in 2010), 9.2 pmp (in 2011), and 11.3 pmp (in 2012).¹⁰ In Algeria, the number of kidney transplants increased since 2007, reaching 137 kidney transplants (3.6 pmp) in 2011; only 2% of all transplants were from brain-dead donors (Dr. Benhocine, personal com­munication). In Libya and Morocco, few kidney and liver transplants were performed. In Libya, all transplants were from living donors (2.8 pmp in 2012); in Morocco, the living-donor transplant rate was 0.4 pmp and deceased-donor transplant rate was 0.1 pmp in 2011.¹⁰

In the 22 Islamic countries that are located in sub-Saharan Africa, transplants were limited to living-donor kidney transplant and were performed only in 2 countries: Sudan (186 kidney transplants in 2013) and Nigeria (14 kidney transplants in 2012). The other 20 Islamic countries of sub-Saharan Africa were lacking even a small national kidney transplant program. Deceased-donor transplant was non­existent because of a lack of minimum infrastructure and also was illegal because of great opposition from Islamic scholars. In Sudan, where the highest rate of living-donor kidney transplant of this region was performed, discussion about brain death and deceased-donor transplant showed great opposition from Islamic scholars.^11,12 In addition, organ transplant was not a health priority in Islamic countries of sub-Saharan Africa because millions of people in these countries lived in severe poverty and death caused by wars, crimes, infections, and malnutrition.¹³

In all 14 Islamic countries of the Middle East, living-donor kidney transplants were performed. Living-donor liver transplants were performed in Turkey, Iran, Saudi Arabia, Jordan, and Iraq.6,9 In several Islamic countries of the Middle East, deceased-donor organ transplant was an established practice. In 2013, deceased-donor kidney transplants were performed in Turkey, Iran, Saudi Arabia, Lebanon, and Kuwait; deceased-donor liver transplants were performed in Turkey, Iran, Saudi Arabia, and Lebanon; heart transplants were performed in Turkey, Iran, Saudi Arabia, and Lebanon; pancreas transplants were performed in Turkey, Iran, Saudi Arabia, and Kuwait; and lung transplants were performed in Turkey, Iran, and Saudi Arabia.6

Turkey had the highest organ transplant activity of all Islamic countries, especially living-donor organ transplant. In 2013, a total of 2944 kidney transplants (39.3 pmp) were performed in Turkey, including 2359 kidney transplants (31.5 pmp) from living and 585 kidney transplants (7.8 pmp) from deceased donors. In addition, in 2013, a total of 1248 liver transplants (16.5 pmp) were performed, with 959 liver transplants (12.8 pmp) from living and 289 liver transplants (3.7 pmp) from deceased donors. Since 2009, there was a marked and steady increase in the annual number of living-donor kidney and liver transplants in Turkey; in 2013, > 80% all kidney and > 75% all liver transplants were performed from living donors.⁶

Iran had the highest rate of deceased-donor organ transplant among all Islamic countries. In 2013, a total of 2670 kidney transplants (34.6 pmp) were performed in Iran; 1501 kidney transplants (19.5 pmp) were from living and 1169 kidney transplants (15.1 pmp) were from deceased donors. In addition, in 2013, a total of 592 liver transplants (7.7 pmp) were performed, including 39 liver transplants (0.5 pmp) from living and 553 liver transplants (7.2 pmp) from deceased donors. Deceased-donor organ transplant steadily increased in Iran; in 2013, > 43% all kidney and > 93% all liver transplants were from deceased donors.⁶ One of the transplant teams in Iran had the highest deceased-donor organ transplant activity. The Shiraz transplant team performed the first liver transplant and 80% all deceased-donor liver transplants in the country. This transplant team currently was performing almost all kidney transplants from deceased donors (Dr. Malek Hosseini, personal communications).

Saudi Arabia had an active organ transplant program that was under the supervision of the Saudi Center for Organ Transplantation (SCOT). In 2013, a total of 558 kidney transplants (20.6 pmp) were performed, including 462 kidney transplants (17.1 pmp) from living and 96 kidney transplants (3.5 pmp) from deceased donors. In addition, a total of 158 liver transplants (5.8 pmp) were performed in Saudi Arabia in 2013, of which 109 liver transplants (4 pmp) were from living and 49 liver transplants (1.8 pmp) were from deceased donors.¹⁴ Kuwait also had an active organ transplant program with kidney transplants from living and deceased donors. In 2013, a total of 66 kidney transplants (18.2 pmp) were performed in Kuwait, including 16 kidney transplants (4.4 pmp) from deceased donors.¹⁵

Turkey, Iran, Saudi Arabia, Lebanon, and Kuwait had more active transplant programs than other Islamic member states because all these 5 countries were in the category of high human development index and had some available infrastructure for organ transplant. The human development index significantly correlated with organ transplant activity, especially organ transplant from deceased donors. In addition, these countries had the Brain Death Law and Organ Transplant Act, and most importantly, in these countries the concept of brain death and organ donation was approved and well supported by religious leaders and Islamic scholars. The Iran transplant program was the best example. For 11 years between 1989 and 2000, deceased-donor kidney, liver, and heart transplants were performed in Iran only by Fatwa from the Supreme Religious Leader, in the absence of an organ transplant law; in Islamic countries, approval from religious leaders was superior to organ transplant law.¹⁶ In contrast, there were some important Islamic countries (Egypt, Pakistan, and Indonesia) where the Organ Transplant Act had been passed but Islamic scholars had not well supported the law, and deceased-donor organ transplant remained on a much smaller scale or was almost nonexistent.

In the 7 Islamic countries of Central Asia, organ transplant was nonexistent in Turkmenistan and Afghanistan. The other 5 countries (Uzbekistan, Kyrgyzstan, Kazakhstan, Tajikistan, and Azerbaijan) had specific transplant legislation but very small living-donor transplant programs.17 Azerbaijan had the highest transplant activity in this region, performing kidney and liver transplants from living donors. In 2013, there were 69 kidney transplants (7.3 pmp) and 19 liver transplants (2 pmp) performed in Azerbaijan.6 In Kazakhstan, in 2013, there were 130 kidney transplants (7.6 pmp) and 19 liver transplants (1.1 pmp) performed. The first kidney transplant was performed in Tajikistan in 2009, Uzbekistan in 2010, and Kyrgyzstan in 2012, and currently a very limited umber of living-donor kidney transplants were being performed (Dr. Hikmet, personal com­munication). Until several months ago, many patients from the countries of Central Asia were traveling to Iran for transplant. Iran banned transplant operations on foreigners to stop transplant tourism, and patients from these countries currently could not be transplanted in Iran.

In all 6 Islamic countries located in South and Southeast Asia, living-donor kidney transplants were performed. In Pakistan, at the Sind Institute of Urology and Transplantation (SIUT), a medical institution founded by Dr. Adib Rizvi, ethical living-donor kidney transplant was provided free-of-cost for all patients.18 By the end of 2013, a total of 4140 kidney transplants were performed in SIUT including 392 kidney transplants (2.3 pmp) in 2013. Similar transplant activity also was performed by other transplant teams. The deceased-donor trans­plant program was undeveloped and almost non­existent in Pakistan. By 2010, in addition to 26 kidneys received from Euro Transplant, only 5 deceased-donor kidneys were procured locally. Since passing the law in 2010 to stop organ commerce, commercial transplant decreased successfully but deceased-donor organ transplant remained non­existent. In Bangladesh, few living-donor kidney and some living-donor liver transplants were being performed. In Brunei, 3 to 5 living-donor kidney transplants (7.5-12.5 pmp) were performed every year. In Indonesia, the most populous Islamic country with a population of 238 million, between 1977 and 2013 a total of 689 kidney and 20 liver transplants were performed, including 79 living-donor kidney transplants (0.3 pmp) in 2013. Despite the Brain Death Law and Organ Transplant Act, only 1 deceased-donor kidney transplant was performed in Indonesia (Dr Gunawan, personal com­munication).

Malaysia had an established deceased-donor organ transplant program. In 2012, there were 52 kidney transplants (1.8 pmp) from living donors, 81 kidney transplants (2.9 pmp) from deceased donors, and 7 deceased-donor liver transplants (0.25 pmp) performed.⁶ The number of deceased-donor kidney and liver transplants started to decrease in Malaysia because of restriction of commercial organ donation in China, and the new kidney transplant rate decreased from 6 to 7 pmp in the early 2000s to 3 pmp in 2012.¹⁹

Albania, a Muslim-majority country in Southeast Europe, was a member state of the Organization of Islamic Cooperation. By 2012, Albania had not established its own national kidney transplant program and was lagging far behind neighboring Balkan countries in organ donation and transplant.20 The 2 countries Suriname and Guyana in South America also were member states of the Organization of Islamic Cooperation; in both countries, few living-related donor kidney trans­plants were performed.

Discussion

This study showed that organ donation and transplant rates in most Islamic countries were less than the expected rates. It also showed large disparities in transplant rates between countries. Some countries such as Turkey, Iran, Saudi Arabia, and Kuwait had successful deceased-donor transplant programs. Therefore, there was a question about the reasons that prevented establishing successful programs in other Islamic countries. Some of the causes of low transplant activity in Islamic countries were lack of public education and awareness, lack of approval and support by Islamic scholars, lack of government infrastructure and financial resources, and absence of the Brain Death and Organ Transplant Law. Another in-depth study is needed to evaluate the causes of low transplant activity in Islamic countries.

To adopt strategies to increase organ donation and transplant, Islamic countries should be stratified in 3 groups. (1) In countries with successfully developed deceased-donor transplant programs, such as Turkey, Iran, Saudi Arabia, and Kuwait public awareness should be increased. (2) In countries with undeveloped deceased-donor transplant programs, especially in populous countries such as Indonesia, Egypt, Pakistan, and Bangladesh, Islamic scholar approval and support should be obtained, and public awareness should be increased. (3) And in countries with severe poverty, wars, crimes, and infections such as Islamic countries of sub-Saharan Africa, a deceased-donor transplant program is not a health priority, and living-donor kidney transplant programs may be established.

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