EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Here, we describe the current situation regarding organ transplant in Uzbekistan. The legalization of paired-kidney exchange programs for donors with incompatible blood types in Uzbekistan will allow more opportunities for organ donation. The phased implementation of the transplant program with that of deceased-donor organ transplant can be carried out only with the involvement of public, cultural, and religious figures, and not only health professionals, to permanently shift the paradigm in the population.

Key words : Brain death, End-stage renal disease, Renal transplant

Organ donation offers life-extending opportunities for people with terminal stages of organ failure. Organ donation is a medical, economic, social, religious, and even political problem. Unfortunately, worldwide, the number of patients with organ failure is higher than the number of donor organs. Approximately 120 000 organ transplants are performed each year; however, the World Health Organization estimates this number of transplants only resolves 10% of the annual worldwide transplant needs.¹ Many factors may be affecting organ donation, including educational attainment, socioeconomic status, religious factors, legislation, economic factors, and cultural issues.²

The concept of “brain death” was introduced in the 1970s. Since then, this concept has been accepted in developed countries because organ donation from brain-dead patients saves many lives.³ Legal aspects of brain death were first considered and passed in the United States and other western countries; after a long delay, the laws were ratified in some Asian countries.^4,5 Deceased-donor organ donation is the main issue in transplant surgery worldwide.¹

Materials and Methods

A total of 212 patients with end-stage renal disease and their related potential donors were admitted to the Republican Research Centre of Emergency Medicine, in Tashkent, Uzbekistan, from April 2018 to December 2020. We collected data on patient and donor age, sex, family ties, and on indications and contraindications to donor nephrectomy, including body mass index, glomerular filtration rate, blood compatibility, the existence of arterial hypertension, transmissive infections, oncologic disease, and decreasing glucose tolerance. Donors younger than 18 years and older than 65 years were excluded. We also reviewed information on patients who underwent kidney transplant surgery and those who did not.

Data were analyzed with SPSS software, version 25.0 for Windows (IBM Corp). All continuous data are expressed as mean ± standard deviation, and 1-sample nominal data were analyzed by nonparametric Kolmogorov-Smirnov and binomial tests.

The donors’ mean age was 42.8 ± 10.4 years (range, 23-65 years; P = .014); 112 (52.8%) were men and 100 (47.2%) were women (P = .450). Family ties of recipients and donors are presented in Figure 1. Most donors were siblings (n = 106; 50%) or parents (n = 73; 34.4%) of the patient (P < .001).

All potential donors were examined for nephrectomy candidacy. If there were any contraindications for nephrectomy, the donor was declined. Of 212 potential donors, 102 (48.1%) were selected for donor nephrectomy: 67 donor-recipient couples (31.6%) underwent kidney transplant surgery and 35 recipients (16.5%) needed preoperative preparation because of severe anemia, polyserositis, and complicated forms of cardiovascular diseases. During the stages of the donors’ examinations, 6 recipients (2.8%) died and 16 donors (7.5%) refused to donate. Contraindications to donor nephrectomy were found for 88 donors (41.5%) during their examinations. Among recipients, only 8 (9.1%) submitted other family members as potential donors and received a kidney transplant. Most recipients (n = 80; 90.1%) did not submit family members as potential donors. The reasons for donors’ nephrectomy rejection are shown in Figure 2. The main contraindications were the presence of arterial hypertension (n = 29; 33%) and blood group incompatibility between potential donors and recipients (n = 22 [25%]; P < .0001).

The number of deceased-donor organ donations has exceeded that of living-donor organ donations worldwide in recent years. According to the World Health Organization, in 2017, 84 483 renal transplants were performed worldwide, of which 42.3% of kidneys were from living donors.6 In 2016, 20 161 renal transplants were performed in the United States, of which 28% of kidneys were from living donors. As of December 31, 2016, in the United States, the total number of recipients with a functioning kidney was 215 061, whereas the wait list consisted of 81 418 patients undergoing hemodialysis; 15% of these patients need retransplant surgery.⁷ According to the register of the Russian Transplantological Society, the prevalence of renal transplants in 2018 was 9.3 per 1 million population, which is 19.2% more than in 2017, reaching a level of 1361 renal transplants per year. The average frequency of use of living donors was 14.7% of the total number of renal transplants (in 2017, 17.1%).⁸

In October 2017, after a long delay, surgeons in Uzbekistan were first able to perform kidney transplant procedures but only from living related donors.⁹ Recent data on deceased-donor organ donation are not available in Uzbekistan due to lack of legislation. Transplantation in Uzbekistan developed in 4 stages. In stage 1 (1972-1991), in what was then the United Soviet Socialist Republic, legislation on organs and tissue transplants was issued in 1970, and the first kidney transplant (via a living donor) in Uzbekistan was performed on September 14, 1972. In stage 2 (1991-1998), transplants were not performed, due to its prohibition by law. During stage 3 (1998-2017), the Ministry of Health of the Republic of Uzbekistan issued an order on the provision of transplant care (n = 48 kidney transplants from a living related donor). Finally, during stage 4 (2017-present), a Resolution of the Cabinet of Ministers No. 859 was issued on October 17, 2017 that approved provisional regulations for kidney transplants and sharing of liver between related donor-recipient couples. In the short period from October 2017 to December 2019, 310 renal and 4 liver transplants from related living donors were performed in Uzbekistan.¹⁰

The population of Uzbekistan is 31 967 745 people (n = 15 903 552 male and n = 16 064 193 female). In 2019, there were 734 822 births and 221 423 deaths. Life expectancy at birth for boys and girls is 73 and 77 years, respectively. The frequency of dying (per 1000 live births) when younger than 5 years was 21 and the frequency of dying between 15 and 60 years of age was 160 for men and 96 for women.11 The main cause of death of young people in Uzbekistan is severe trauma due to car accidents and falls from heights.^12-15 Total expenditure on health per capita in 2018 was US $410, and total expenditure on health was 5.9% of the gross domestic product.¹⁶

The number of patients currently with chronic kidney disease in Uzbekistan is still high, at 12 567.10 As of this writing, 3067 patients are receiving hemodialysis, and there are only 48 dialysis centers, which include 326 hemodialysis devices. In 2018, the renal transplant incidence in Uzbekistan was 3.7 per 1 million people. Thus, the number of patients who need donor organs is high in Uzbekistan, and most patients in need of a kidney transplant are severely or moderately disabled.

Hemodialysis sessions are covered by the state budget. The annual cost for 1 patient receiving hemodialysis is ≤ US $50 000, state allocation for hemodialysis procedures (for consumables) is US $8.0 million, the coverage of hemodialysis procedures (ie, equipment maintenance, procurement of spare parts, salaries of medical workers involved in hemodialysis) is only one-third of the total amount needed, and the amount required to fully cover the hemodialysis procedures of all patients in the country is approximately US $7.0 million.

Our results showed that only half of the recipients in our study group (n = 110; 51.9%) had related donors for kidney transplant, and only 75 of them (35.4%) underwent the transplant procedure. The presence of severe complications of end-stage renal disease requiring preoperative preparation in 35 recipients (16.5%) and the deaths of 6 patients (2.8%) during donor examinations suggest that the quality of dialysis of these patients was inferior and they presented for kidney transplant at late stages of chronic renal disease. That many patients (n = 96; 45.3%) were unable to receive kidney transplant surgery because of donor refusal during donor examinations (n = 16; 7.5%) and the presence of contraindications for donor nephrectomy (n = 80; 37.7%) demonstrate the major problems of donation in Uzbekistan.

Although the rate of organ donations from both living and deceased donors has increased over the past few years, the current rate of organ donation is still not enough, by far, to meet the demand. Living donors are the main option for transplants in Middle Eastern countries, but this is only viable for kidney transplants and, to some extent, for liver transplants.^2,17 Kidney-exchange transplant is a well-established modality to increase the number of living-donor kidney transplants. Reasons for joining kidney-exchange programs are ABO blood group incompatibility, immunological incompatibility

(eg, positive crossmatch, donor-specific antibody), human leukocyte antigen incompatibility (ie, poor human leukocyte antigen matching), chronologic incompatibility, and financial incompatibility.¹⁸

Legal and religious issues are the main factors with regard to consideration of organ donation in Uzbekistan. The WIN-Gallup International’s 2012 Global Index of religiosity and atheism¹⁹ noted that 79% of the respondents from Uzbekistan who took part in the survey considered themselves religious, another 16% stated they were not religious, 2% reported being convinced atheists, and 3% had checked the “no response” box. Most people in Uzbekistan are Islamic (n = 31 033 499; 96.8%), 769 426 (2.4%) report being Christian, and 256 475 (0.8%) are atheists.¹⁹ Some of the influencing factors concerning organ donation are related mainly to limited information, which is not only limited in the society at large but also with regard to health care professionals. Religious aspects, fear, and prejudices about organ donation are other factors mentioned by participants as hampering organ donation.²⁰

Islam is the second most practiced religion globally, and the number of Muslims in Western countries has been increasing due to recent trends in migration. Studies have shown that Muslims in the Western world have more negative attitudes toward organ donation and transplantation compared with individuals from other religious backgrounds. Multiple barriers have been postulated that may prevent Muslims from exploring organ donation or transplantation. Key factors or concerns identified have included lack of information regarding organ donation, mistrust of the health care system, family opinions, sacredness of the body, lack of clear understanding of religious rulings, and opinions of religious leaders. Studies have suggested that partnering with religious leaders to address these concerns may help foster positive attitudes toward organ donation and transplantation.²¹

Religious beliefs also play an important role in living-organ donation programs.²² Health workers are often unaware of the religious beliefs of relatives of deceased patients and often avoid discussing organ donation with them. Transplant teams, donor coordinators, intensive practitioners, and nephrologists need to be more aware of religious beliefs to help relatives make informed decisions about organ donation. Also, educating the general population about the importance of organ donation for saving other people’s lives will help foster a positive perception of this issue among relatives in the event of the loss of their loved one.

Donation is a major problem globally for organ transplantation, particularly in Uzbekistan. The main reasons for the rejection of potential donors in Uzbekistan are their accompanying diseases and blood-group incompatibility between donors and recipients. The legalization of paired-kidney exchange programs for donors of incompatible blood types in Uzbekistan will allow more opportunities for donation. Organ donation from a relative affects only a small portion of patients needing kidney transplants or part of the liver. At the same time, patients who need transplant of other organs, as well as patients needing a kidney or liver transplant but who do not have a donor, are forced to receive treatment abroad or, much more often, to suffer and eventually die of organ failure. The phased implementation of the transplant program with the implementation of deceased-donor organ transplants can be carried out only with the wide involvement of not only health professionals but also public, cultural, and religious figures to permanently shift the paradigm in the population. The role of the state should be dominant; there is no doubt that only complete transparency of the process can earn the trust of the population and lead to the desired result.

Volume: 18 Issue: 1 July 2020 - Supplement - 2

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