Kidney transplants were first performed in Tunisia in 1986, and transplants soon extended to other organs including the heart, liver, and pancreas. Live-related donor and deceased-donor kidney transplants were both began in the summer of 1986. An organ procurement and transplant law was passed in March 1991, and the National Centre for Advancement of Organ Transplantation was created in 1995. The number of transplantation units has increased to 7 throughout the country, and the yearly transplant number has progressively increased to 139 in 2010, including 20% from deceased kidney donors. Despite these gains, the need continues to grow.

Heart transplants began in January 1993, and Tunisia and Jordan are currently the only Arab countries where it is practiced. However, only 16 patients have received a heart transplant as of 2004, and the number of recipients has decreased in the past 10 years. Liver transplants are rare in other Arab countries, but began in Tunisia in January 1998. Over 10 years, 38 patients benefited from this procedure. After a few years of stagnation, the number of liver transplants is increasing. While all types of transplantation are needed, kidney transplantation is a priority in Tunisia. The target is to perform 400 transplants annually, which would require a long-term strategy to provide full financial coverage using the National Health Insurance Funds in both the public and private sectors.

Key words : Kidney transplant, Liver transplant, Heart transplant, Transplantation in Tunisia

Introduction

The first organ transplantation surgeries in Tunisia were kidney transplants in 1986, followed by hearts in 1993, livers in 1998, and lungs in 2012. After the 1991 enactment of the organ procurement and transplant law, transplants spread from the Departments of Urology and Nephrology at the University Hospital Charles Nicolle of Tunis to the Principal Military Hospital of Tunis, and then to other university hospitals (Sfax, Monastir, Sousse, Marsa, and Rabta). We present here an historical overview and the current situation of organ transplantation in Tunisia.

Materials and Methods

Historical data were collected by interviewing the actors involved in the first transplants and studying the literature.^1-3 Medical, surgical, and immunologic data were mainly provided by the National Centre for the Advancement of Organ Transplantation^4,5 and the Global Observatory on Donation and Transplantation.⁶

Results

Legal and organizational aspects
When the first organ transplant was performed, the only available legal text was a decree dated July 19, 1952, authorizing the retrieval of organs from deceased donors for diagnostic or therapeutic purposes. At that time, it was promulgated to allow autopsies and authorize corneal procurement from deceased donors. However, after consultation with the legal and religious authorities including Mufti Sheik Mokhtar Sellami, who did not object, it was considered that this decree was sufficient to permit solid-organ transplants. This considerable responsibility was taken on by transplant teams and surgeons. On March 25, 1991, law No. 91-22 was passed to regulate organ donation, including procurement from both living and deceased donors based on the presumed consent principal. However, although it was not specified in the law, the medical staff decided, after a long debate, to limit living donors to blood relatives. This changed in 2000, when the medical community decided to extend the procurement to emotionally related donors.

The National Centre for Advancement of Organ Transplantation supervised by the Tunisian Ministry of Health was created after law No. 95-49 was passed in June 1995. Its aim was to promote the advancement of organ donation; supervise and coordinate organ activity in the country; and ensure effective oversight, traceability, and surveillance.

Kidney transplantation
The first kidney transplants
On June 4, 1986, a young male received a kidney donated from his brother. The surgery was carried out at the Department of Urology in the University Hospital Charles Nicolle by Prof. Sadedine Zmerli and his collaborators Mounir El Ouakdi, Mohsen Ayed, and Habib Boujnah with the attendant vascular surgeon Khaldoun Bardi and the anesthesiologist Hedi Ben Ayed. The Nephrology team of the Department of Internal Medicine chaired by Prof. Hassouna Ben Ayed and including Aziz El Matri, Taieb Ben Abdallah, and Chiheb Kechrid ensured appropriate preoperative preparation of the recipient and postoperative follow-up, including immunosuppressive treatment.

On July 10, 1986, the same team and the urologist Mohamed Chebil carried out the second living-donor kidney transplant in Tunisia. On July 16, 1986, the first kidney transplant from a deceased donor was performed in the same hospital. The head of the General Surgery Department Prof. Ridha Mzabi retrieved the organ, and Sadedine Zmerli carried performed the transplant. Since then, kidney transplants have become a routine activity.

The first renal transplant using the kidney of a deceased donor at the Principal Military Hospital was performed on November 16, 1992, by the vascular surgeons Jalel El Menaa and Tahar Sraieb with the attending anesthesiologists Mohamed Dhahri and Jalel Hmida. The first kidney-pancreas transplant was carried out in the same hospital on February 9, 1993.

Afterwards, other hospitals routinely performed kidney transplants. The University Hospital of Sfax, Habib Bourguiba performed its first transplant with a living-donor kidney on April 4, 1994. The urologists were Mohamed Nabil Mhiri and Ali Bahloul; the attending anesthesiologist was Ali Karoui; the attending nephrologists were Abdelhamid Jerraya, Jamil Hachicha, and Mohamed Ben Hmida; and the immunologist was Hafedh Makni. On July 3, 1997, they performed the first deceased-donor kidney transplant. On October 11, 2004, the first preemptive transplant in Tunisia was carried out. The University Hospital of Monastir began its living donor kidney transplant program on September 22, 1995. The Urologist was Hamadi Saad, the Anesthesiologist was Mourad Gahbiche, and the Nephrologist Abdelatif Achour was from the Department of Nephrology headed by Prof. Mezri El May. The University Hospital Sahloul of Sousse started a living-donor kidney transplant program in November 2007. The team included urologists Faouzi Mosbah and Faouzi Limaiem, anesthesio­logists Rachid Said and Souad Chelbi, and Nephrologist Abdelatif Achour. The living-donor kidney transplant program at the University Hospital of Tunis La Rabta was started in November 2010. The team included Urologists Y. Nouira and Mohamed Khamas, Anesthesiologist Ali Cherif, and the Nephrologists Fatma Ben Moussa and L. Ben Fatma.

Current situation
During the last 28 years, 1 492 kidney transplants have been carried out in 6 units, including 79% and 21% from living- and deceased-donors. The program has been progressing slowly, with a mean rate of 10.5 per million individuals and a peak of 13.2 per million in 2010 (Figure 1). The donors were 53% female and 47% male with a mean age of 40 ± 11.3 years. Most living donors were mothers, brothers, sisters, and fathers of the patients. The recipients were 66.4% men and 33.4% women, with a mean age of  30.4 ± 11.5 years. The patient and graft survival rates at 20 years were 50% and 42%.⁴

Heart transplantation
The first heart transplant took place at the Principal Military Hospital of Tunis, on January 15, 1993. The surgical team included the late Prof. M. Fourati and his collaborators H. Thameur, T. Mestiri, A. Iouaz, and J. Menaa; the Anesthesiologists M. Dhahri, J. Hmida, and S. Cheour; and the Cardiologists M. Gueddiche and H. Chaouch. The first transplant was successful, and the patient survived 8 years. In the following 12 years, the same team carried out 16 transplants with good outcomes.⁴ However, the program has been stagnating since 2011 (Figure 2).

Liver transplantation
Tunisia’s first liver transplant was performed on January 18, 1998 at the university hospital Sahloul in Sousse by the surgeon R. Bel Haj Hamida and the attending anesthesiologist Rachid Said. They performed 2 additional transplants before the program was transferred in December 1999 to the University Hospital of La Marsa, Mongi Slim in the suburb of Tunis. The surgeon T. Khalfallah and the anesthesiologist M. S. Ben Ammar and their teams regularly carried out regularly an average of 3 transplants per year. In a 10-year period, 38 patients have received transplants, including 6 livers from living donors (Figure 3).⁴

2013 update
Tunisia counts 12 officially registered transplant centers including 6 for kidney, 2 for liver, 3 for heart, and 1 for lung, but few are regularly active.⁶ During the year, 127 kidney transplants were performed (18 and 107 from deceased and living donors, respectively, including 8 pediatric patients). There were also 1 liver and 1 lung transplant from deceased donors.⁶

The waiting list of the year counts 9000 patients, with 1257 ever active. A total of 121 patients were included for the first time, and 22 died before receiving an organ.

Discussion

The first organ transplants in Tunisia were kidneys and coincided with the implementation of transplantation in other Arab countries in the region.⁷ Transplant surgeries were quickly decentralized to other institutions and began to be performed for other organs. For renal transplants, the number of units has increased from 1 to 6. The annual number of transplants stagnated around 40, until 2005, but thanks to the extension to emotionally related living donors, the efforts of all the teams, and the coordination of the National Centre for the Advancement of Organ Transplantation, the annual number of kidney transplants reached nearly 132 in 2010, with only approximately 20% from deceased donors. However, the need for transplants continues to grow and the waiting list is longer than ever. Costs associated with dialysis have increased annually to reach near 5% of the total national health expenditure.

Tunisia and Jordan are the only Arab countries that perform heart transplants.⁸ However, few are performed. There are many reasons for the low number of heart transplants, but the obstacles are not insurmountable.

The first Arab country to perform liver transplants was Saudi Arabia in 1990.⁹ Although a program has been developed in Tunisia, liver transplants are only carried out by a single team.

Undoubtedly, all types of organ transplants are important, but kidney transplants are a priority because of the high incidence of end-stage renal disease and the associated socioeconomic impact in a developing country. To meet the needs of the population, a target to perform 400 transplants per year would require a long-term strategy within the framework of the total reimbursement for all renal replacement therapies by the National Health Insurance Funds. This would require the expansion or creation of units, more equipment, highly motivated personnel, and the planning of an adapted budget. New ways to approach the question need to be considered such as incentive measures to motivate the medical personnel and staff, the creation of public centers specialized in transplants, and inclusion of the private sector.

Conclusion

The history of organ transplants in Tunisia demonstrates the competence of the professional specialists and the determination of public authorities to initiate organ donation programs. However, it is time to adopt new approaches to meet the needs of the patients and improve their quality of life.

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