Key words : Deceased donor pediatric kidney transplant, Organ shortage, Renal transplant

Introduction
Kidney transplantation is currently the best option for children with end-stage renal disease (ESRD). Updates in surgery and modern immunosuppression have led to excellent results, with excellent results also shown in children who are seen at pediatric centers with experience in the management of all aspects of pediatric kidney transplant (PKT). However, these therapeutic options are not accessible to all children in the world because of political, religious, economic, and cultural issues in developing countries. Most developing countries lack national kidney foundations and insurance systems, and, although renal transplant is more cost-effective than dialysis, some governmental strategies are still not in favor of promoting transplantation.

In contrast to the increasing availability of information pertaining to PKT from large-scale observational and interventional studies, epidemiological information on PKT from Arab countries and from other developing countries is currently limited, imprecise, and flawed by methodological differences between the various data sources.^1-5

Materials and Methods
The Arab population comprises a population of around 350 million; 35% of this population is less than 15 years of age according to the World Health Organization (WHO) 2010 report, which has estimated the Arab pediatric population to be around 122 million. About one-fourth of Arabs live in Egypt, 60% live in Africa, and the remainder live in Asia.

A questionnaire was mailed to all kidney transplant centers in Arab countries in which centers were asked to provide the following information on kidney transplant activity over a single year of available data: total number of kidney transplants (both living and deceased donor transplants) for adults and children and the total number of PKT (both living and deceased donor transplants). Missing data were obtained from the Global Observatory on Donation and Transplantation data.⁶

Results
Table 1 shows data over a single year obtained from the 17 Arab countries where kidney transplant procedures are available; data show total kidney transplants, kidney transplants per million population (PMP), total deceased donor kidney transplants if any, percent of total deceased donor kidney transplant (when applicable) of total kidney transplants, total PKTs, percent of PKTs of total kidney transplants, PKT PMP, PKT from deceased donors when available, and percent of deceased donor PKTs of total PKTs (when applicable).

The data show that 3309 kidney transplants were performed for all ages in the Arab countries over a single year. Thus, the average kidney transplant PMP, per year, in the Arab world was 9.5 cases.

There were 298 total PKTs performed in Arab countries over a single year among the total 3309 kidney transplants (9.0%). Thus, the average PKT PMP per year was 0.87 cases (from 0.0 in Yemen to 3.1 in Jordan). Figure 1 shows the most recent data (2008 to 2011) on total kidney transplant PMP versus the PKT PMP in Arab countries in a single year. The PKT rate ranged from 2.7% in Lebanon to 24% in Algeria.

Of total kidney transplants, 3097 were from living donors (rate of 93.5%) and 212 transplants were from deceased donors (rate of 6.5%). Kidney transplant from deceased donors is only available in 8 Arab countries: Algeria, Kuwait, Kingdom of Saudi Arabia (KSA), Lebanon, Morocco, Oman, Qatar and Tunisia. In these countries where a deceased donor program is available, the rate of transplant was about 22% (212/965 cases). Deceased donor kidney transplant PMP per year in all Arab countries and in the countries where a deceased donor program is available were around 0.6 (212/348 million) and 1.8 (212/117 million), respectively.

Deceased donor PKT procedures are available in only 3 countries: KSA, Tunisia, and Kuwait. Together, these countries performed 29 deceased donors PKTs in a single year, with 3 of 3 total PKTs in Kuwait (100%), 21 of 43 total PKTs in KSA (49%), and 5 of 12 total PKTs in Tunisia (42%).

Discussion
The rate of kidney transplant activity varies between and within countries; for instance, Sudan, Algeria, and Morocco, where one-third of Arabs live, together performed only about 7.3% of the total kidney transplants among Arab countries (240 of 3309 cases) and about 13.8% of all pediatric cases (41 of 298 cases).

The average PKT rate of 9.0% of total kidney transplants in Arab countries seems to be acceptable and exceeds the European rate shown in 2005, where the average pediatric transplant rate ranged from 4% to 5% of the combined adult and pediatric activity, as reported by Cochat and colleagues in a collaborative survey on pediatric renal allograft allocation practices.⁸ This could be attributed to several factors. First, according to a 2010 report from the WHO, 35% of the population in the Middle East are less than 15 years old, compared with 18% in Europe. Thus, one could expect that the PKT share in the Middle East countries to be at least twice that of Europe. Moreover, the presumed higher incidence of certain inherited kidney diseases in Arab countries due to the prevalence of consanguineous marriages, the lack of facilities and expertise for early detection, and/or inadequate management options for pediatric patients with kidney diseases in most parts of this region may suggest that Arab children have a higher incidence of ESRD and thus there is a higher need for kidney transplant procedures in Arab children versus European children.

The survey results showed that the 3 most active Arab countries in terms of total kidney transplants PMP per year were Jordan (29.2 cases PMP), Kuwait (20 cases PMP), and KSA (19.3 cases PMP). Together, the average PKT share of total transplants performed in these 3 countries was 8.6% (66/765), which was even lower than that drawn from all Arab countries together (9.0%), although their average kidney transplant PMP was 21.2 cases PMP, which is higher than that of all Arab countries together (9.5 cases PMP). These results indicate that the PKT share was not better even in the countries where the overall kidney transplant rate was higher. However, it is worthwhile to mention that the incidence of pediatric ESRD may differ among Arab countries, especially in countries with a high expatriate population like KSA, Kuwait, and the United Arab Emirates (UAE), not only because expatriates are generally of different ethnicity but, more importantly, because most expatriates are adults. In Kuwait, for example, two-thirds of the population are expatriates, and this can at least partially explain the smaller number of PKTs in some of these countries such as Kuwait compared with Syria, for example, and not necessarily because Kuwaiti children are neglected.

Over a single-year period, Egypt, with a population accounting for 24.3% of the Arab world (85 of 350 million), performed 42.3% of the total PKTs in the Arab world (126/298 cases). Four countries (Algeria, Egypt, Saudi Arabia, and Syria) performed 75.5% of the total PKTs in the Arab world (225/298 cases), although their population accounts for 48.6% (170 of 350 million), indicating large differences in rate of PKT PMP per year among Arab countries. Jordan seemed to be the most active country with 3.1 PKT PMP per year, followed by KSA with 1.6 and Egypt with 1.5; however, some of the transplants performed in Jordan may have been for non-Jordanian children and for children coming from Yemen and other Arab countries to receive procedures in private hospitals and then leaving the country. These PKT rates may not actually reflect the real status of PKT rates versus those shown in other countries, especially with regard to Jordan and Egypt, which are known to perform transplants for foreigners.

Morocco chose to refer selected patients to developed countries for transplant procedures and therefore was the least active, with only 2 children receiving transplants from a total of 18 kidney transplants in 2011; with a population of 32 million, the PKT PMP rate thus is extremely low and less than 0.1 cases (Figure 1). Yemen is the only Arab country where there are no PKTs, although some improvement was shown after the recently launched kidney transplant program at the Al Thaoura Hospital in Sana’a. In 2010, 33 adult kidney transplants were performed for a population of 24 million. Some of the “fortunate” Yemeni children with ESRD are being transplanted abroad, especially in neighboring Arab countries.

The rate of 0.87 PKT PMP per year in the Arab countries is quite low compared with rates shown among many developed countries. Spain/Catalonia has the highest pediatric transplant rate among Western countries, reaching 15 patients PMP, followed by a rate of 12 patients PMP in the United States and Finland (Figure 2).⁹

In the United States, approximately 1200 children (that is, those from 0 to 19 years old) develop ESRD each year.¹⁰ This represents approximately 16 cases per 1 million children. In the Arab world, with a population of 122 million children, nearly 2000 children are expected to develop ESRD each year if we assume Arab children have an incidence of pediatric ESRD similar to US children. From this assumption, we could therefore also suggest that only about 15% (298/2000) of the need for PKT in Arab countries is being met. Hence, although data from the Arab world on the estimated prevalence and incidence of pediatric ESRD and the estimated number of children in need for kidneys are still unclear, the actual rate of PKT being currently performed is clearly lower than what it is supposed to be in all Arab countries, including the most active countries such as Jordan and KSA. These concerns also apply to adult kidney transplantation.

In general, organ transplant is an expensive procedure and can be regarded as a public health challenge. The use of living donors is by far the most used source for kidneys in Arab countries (93.5%) for several reasons, mainly because it is less expensive than the development of a national network for organ allocation based on deceased donors. The cost of transplant is of special importance in certain countries, including Arab countries, where access to transplant often depends on familial recourses due to the absence of a national health care system versus private insurance. The need to exclusively rely on living donors has led some Arab countries (for example, Egypt, Syria) to legalize unrelated kidney donation, which rapidly led to this becoming the main source of transplanted kidneys. More critically, the practice of kidney donation from unrelated donors fell into commercialism (that is, purchase of “donated” organs), even though kidney selling is prohibited by law in these countries.¹¹

The problem of insufficient access to kidney transplant for Arab children with ESRD is even wider than in adults. The most important causes preventing the development and/or enhancement of PKT programs in Arab countries probably are age at ESRD (treatment withdrawal may be applied for infants and young children), type of primary disease when identified (inherited inborn error of metabolism), transplant procedure (need for a combined liver and kidney transplant), associated morbidities (mental retardation), lack of facilities and expertise, and sometimes even cultural reasons that may weaken interest in providing the best care for children with ESRD.^12,13 The rate of PKT PMP shown in some Arab countries such as Kuwait, Lebanon, and Iraq does not seem to follow rates shown for adult kidney transplant; however, these finding must be interpreted with caution, especially in countries with a large adult expatriate population. Nevertheless, further investigations in each country are needed. With these disparities between adult kidney transplant and PKT rates in most Arab countries, there is concern of possible “discriminatory” practices against children as being a cause behind this unacceptably low PKT rate. Having said this, pediatric nephrologists in developing countries should make a strong plea for the elimination of discriminatory practices against children12 and should continue to claim “the same rights for subjects who were living in the same country but with only a difference of age and size.”¹³

A stable deceased donation program is found in KSA, Tunisia, and Kuwait, where the rates of deceased donor transplants are 31%, 22%, and 14% and the PMP rates of deceased donor transplants are 6, 2.9, and 2.9, respectively. In contrast, the remaining 5 countries where deceased donor transplant is also available (Algeria, Lebanon, Morocco, Oman, and Qatar) only perform a few transplants (Table 1).

The results reported here are only over a single year, which may not reflect average activity over several years. In Kuwait, for example, the single-year rate for deceased donor transplants of 14% was low compared with the average taken from several years (30%), suggesting that analysis and averaging of data over several years may be better.

Deceased donor kidney transplant rates in KSA, Tunisia and Kuwait, which ranged from 14% to 31% of the total kidney transplant activity, were still much lower than rates shown in European countries, which average 80% (Table 2). Thus, more efforts are needed from Arab countries to establish well-functioning deceased donor transplant programs.

Of note, deceased donor PKT was only available in the 3 countries that had stable deceased donor transplant programs (KSA, Tunisia, and Kuwait). In these 3 countries together, the average deceased donor PKT share of all PKTs was 50.0% (29/58), which is comparable to US data, where 49.2% of PKTs were from deceased donors according to a 2010 report14 and lower than that of European countries, which averaged 69% (Table 2).⁶ Among Arab countries, KSA alone performed 72.4% (21/29) of all deceased donor PKTs.

The upper age limit for pediatric renal care differs among countries, ranging from 13 years in Oman to 18 years in Sudan and Libya. This difference is a limitation in this study and could result in variations in results. However, one can conclude that, with renal transplant as the most favored ESRD treatment modality in children, the lack of health care resources and the lack of deceased donor transplant programs in most Arab countries have limited the provision of renal transplant in children. Some countries have inactive PKT programs and are not responding to the increasing demand for kidneys. Cooperation is needed among developing and developed countries/centers to provide assistance to developing Arab countries.

References:

1. Saeed MB, Sherif S. Pediatric renal transplantation in Syria: a single center experience. Saudi J Kidney Dis Transpl. 2005;16(3):342-347.
   CrossRef - PubMed
   
2. Al-Ghwery S, Al-Asmari A. Chronic renal failure among children in Riyadh Military Hospital, Riyadh, Saudi Arabia. Saudi J Kidney Dis Transpl. 2004;15(1):75-78.
   CrossRef - PubMed
   
3. Kamoun A. Spectrum of pediatric renal diseases in Tunisia. Saudi J Kidney Dis Transpl. 1997;8(3):317-319.
   CrossRef - PubMed
   
4. Abou-Chaaban M, Al Murbatty B, Majid MA. Spectrum of pediatric renal diseases in Dubai. Saudi J Kidney Dis Transpl. 1997;8(3):310-313.
   CrossRef - PubMed
   
5. El Aun M, Hazza I, Qudah E, Najada AH, Khairi Y. Causes of chronic renal failure in children in a single hospital in Jordan: A 10 years retrospective study. Saudi J Kidney Dis Transpl. 1995;6(3):290-293.
   CrossRef - PubMed
   
6. World Health Organization and the Spanish Transplant Organization. Global Observatory on Donation and Transplantation (GODT) Data. http://www.transplant-observatory.org.
   CrossRef - PubMed
   
7. 5th Symposium France, Maghreb transplantation of organs, tissues and cells. Nice, France, March 23-24, 2012.
   CrossRef - PubMed
   
8. Cochat P. Collaborative survey. Presented at the 39th Annual Meeting of the European Society for Pediatric Nephrology, Istanbul, September 10-13, 2005.
   CrossRef - PubMed
   
9. US Renal Data System 2005 Report. Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2005.
   CrossRef - PubMed
   
10. United States Renal Data System. http://www.usrds.org/
    CrossRef - PubMed
    
11. Saeed B. Current challenges of organ donation programs in Syria. Int J Organ Transpl Med. 2010;1(1):35-39.
    CrossRef - PubMed
    
12. Saieh-Andonie C. The management of end-stage renal disease in underdeveloped countries: a moral and an economic problem. Pediatr Nephrol. 1990;4(2):199-201. doi:10.1007/BF00858841
    CrossRef - PubMed
    
13. Grunberg J. The challenge of care of children with renal disease in developing countries: A Latin American outlook. Indian Pediatr. 1996;33(2):91-94.
    CrossRef - PubMed
    
14. Smith JM, Martz K, Blydt-Hansen TD. Pediatric kidney transplant practice patterns and outcome benchmarks, 1987-2010: a report of the North American Pediatric Renal Trials and Collaborative Studies. Pediatr Transplant. 2013;17(2):149-157. doi:10.1111/petr.12034
    CrossRef - PubMed