Key words : Brain death, Kidney transplant, Liver transplant, Middle East and North Africa region

Introduction
Egypt is situated in North East Africa and the Middle East. In Africa, Egypt is the third largest country by population, with 113 million people. In Egypt, stage 5 chronic kidney disease is attributed to hypertension, diabetes, glomerular diseases, collagen diseases such as systemic lupus erythematosus, and hereditary diseases as polycystic kidney disease.¹ These diseases are responsible for 70?000 patients on regular hemodialysis, with an annual increase of 10%, with constitutes 0.0006 of Egypt’s population. In Egypt, 750 dialysis centers are mainly distributed in the capital and large cities, with two-thirds of these funded by the government and insurance

The issue of transplant of human organs is a vital issue, which has preoccupied Egyptian scientists since transplant was introduced by modern science to human civilization. In 1966, the Egyptian Council released a law on the transfer and transplant of corneas. The first living donor kidney transplants in Egypt were in 1976, at the Cairo University and Mansoura Center. Partial liver transplants started in 1981, with initial support from Professor Tanaka and a Japanese team.²

Egyptian Law of Organ Transplantation
Since 1999, debates have been continuous about organ transplant regulation. The draft law took 12 years of debates to discuss the nature of transplant and whether transplant is associated with any religious bans. Debates and dialogues were among doctors, religious scholars, and opinion makers before a final version of the law was reached in 2011. Organ trade had been present in Egypt before the law, necessitating visits from the Istanbul Declaration committee members to Egypt’s Minister of Health in 2008. After the 2011 law was finalized, a big advantage was the cut in organ trade.³

Example of some articles of the Egyptian law are presented here. Article I prohibits the conduct of the transfer of organs and tissues through removal of any organ or tissues from the human body of a living or a dead person with the purpose of being transplanted in the body of another person, except as outlined in the law and its bylaws.

Article II bans all mentioned in article I except for the need to preserve the life of the donor or for the sake of treatment and provided that no harm or life-threatening event will affect the person who donated the organ or tissue. Procedures should conform to health standards. In addition, article II bans that the resulting transplant mixes lineages (ie, direct descent from an ancestor).

Article III prohibits transplant from Egyptians to foreigners, except spouses for at least 3 years with proper documentation. Transplantation is also allowed between children of these couples. Transplantation between foreigners from the same nationality is allowed upon a request from their nation, as outlined in bylaws.

Article IV bans transfer of any part of the human body except as a donation between Egyptian relatives. Donations between nonrelatives are allowed in extreme critical conditions after approval from a special committee nominated by the Minister of Health.

Article V requires donations to be made by free will and with written consent. Article V also acknowledges that organ and tissue donations are not accepted from children and those lacking legal capacity. Stem cells could be procured in special conditions. Under article V, the donor has the right to refrain from donation and cancel their consent before the transfer process. Regulations of donation are detailed in bylaws.

Article VI bans transplant of any part of the human body through buying or selling or when transfer of organs or tissues has any positive implications, whether moral or in kind, to the donor’s heirs. Article VI also prohibits any doctor from beginning a process of transplant if he or she is informed of the above.

Article VII prohibits transplant until both the donor and recipient are briefed about the transplant procedure and the associated risks. The briefing committee is composed of 3 experts, and they must obtain documented approval and informed consent from both the donor and recipient and/or from their deputy or legal representative if the donor or recipient does not have legal capacity. The report of the committee should be signed by the donor and recipient (or their representatives).

Article VIII, when needed for preservation of human life and treatment, approves the transplant of organs or tissues from deceased patients between Egyptians, but only under the condition that the deceased person had recommended donation before death in a documented request according to steps in bylaws.

In the Egyptian law, chapter IV consists of 11 articles (from 16 to 26) that concern penalties when provisions of the law are violated.

Obstacles to Deceased Donor Transplantation
Heart, lung, pancreatic, and other organ transplants requiring deceased donors have so far not been performed in Egypt. Some causes of resistance are explained below.

First, many religious authorities have stressed that organs cannot be taken from a person with brain death because, in their view, life ends with death of all organs. However, the definition of death is still being debated. As early as 1997, al-Azhar Grand Sheikh Mohamed Sayed Tantawy issued a fatwa, or Islamic decree, allowing organ transplants and vowed to donate his own organs after death. Some religious Muslims in Egypt, however, believe that death occurs only when the heart stops beating.

Second, sustainable improvements in health cannot be achieved by imposing change on people; rather, active participation is needed. “People have a right and duty to participate individually and collectively in the planning and implementation of their health care,” according to the 1978 Declaration of Alma-Ata.⁴

Third, the media has played a role in communicating contradicting and sometimes misleading health care information. False fears from journalists and film makers may have frightened the public by suggesting that deceased donations could exacerbate organ trade. Most people believe that death occurs only when the heart stops beating; thus, organs cannot be taken from a person with brain death because life ends only with death of all organs.

Fourth, many intensivists disagree over the definition of death, which states that death of the brain stem is a disease and is not death. They request for a definition that would guarantee that the soul has permanently left the body. This argument has been supported by cases of prolonged coma.

Fifth, the Egyptian Pharos’ traditions of mummification, which is rooted in Pharos practice, is linked to religious beliefs. After death, next steps were to remove the internal organs, the lungs, liver, stomach, and intestines, and place these in canopic jars. The canopic jars had lids shaped like the heads of the 4 sons of Horus (Imsety, Hapy, Duamutef, and Qebhseneuf). Imsety was human-headed and guarded the liver. Hapy was ape-headed and guarded the lungs. Duamutef was jackal-headed and guarded the stomach. Qebhseneuf was hawk-headed and guarded the small and large intestines. The 4 canopic jars were buried with the mummified body. The ancient Egyptians believed that the practice of burying the deceased with their organs allowed the dead to be rejoined with them in the afterlife. Sixth, 60% of health care expenditure is out of pocket. This means that significant efforts are needed to move from individualistic participation in health care to a societal model of participation and national insurance coverage.⁵

Plans to Overcome Obstacles to a Deceased Donor Program
Communications are needed with politicians highlighting that end-stage organ mortality could be saved (180 thousand/year in Egypt). More collaborations are needed with international transplant bodies, such as The Transplantation Society. Extensive training courses on deceased donor transplant are also needed. Campaigns that include doctors, politicians, and celebrities are needed on donating organs after death, focussing on both religious (Thawab) and humanitarian (media focus on new life of recipients) aspects.

Recent Steps in Egypt
Although living donation can be a safe and acceptable source of organs if performed within ethical and legal guidelines, our aim as the transplant community should be to work toward a system of meeting the organ demand as much as possible with deceased donation. This action will result in a decrease in unethical transplant activities. Having a deceased donor program will also make an enormous difference to patients on transplant waiting lists.

The lack of deceased donor programs is a particularly substantial problem for organ transplant in the Middle East and Africa. Therefore, it is essential to support ongoing education, legal, regulatory, ethical, and public health challenges in collaboration with the Ministries of Health and Education, as well as with national medical societies related to and involved in transplantation to achieve these goals.

In October 2022, according to Bassam Rady, the presidential spokesperson, President Abdelfattah El Sisi directed the government to establish a regional center for organ transplantation aiming to be the biggest in the Middle East and North Africa region. The new center will be part of a new medical city that will replace Nasser Medical Institution in Cairo.

The government has also recently prepared an official form to be signed by a person before death accepting use of organs, giving hope and support to other patients in need.

In February 2023, Egypt signed a Memorandum of Understanding between African Association of Nephrology, Egypt, and the European Society for Organ Transplantation to promote deceased donor transplantation in the region. After which, Donation and Transplantation Institute officials gave talks in June 2023 on how to implement a deceased donor program.

Since October 2023, Egyptian deceased donor transplant guidelines are being prepared, which consider the international guidelines, but also respect the environmental and socioeconomic circumstances. The latter is dominated by a rich bioecological environment, specific demographics, social constraints, limited financial resources, and the shortage of living donor transplantation.

Conclusions
Guidelines on a deceased donor program are actively being prepared, which aim to integrate recent international guidelines and which respect the bioecological environment, specific demographics, social constraints, limited financial resources, and the shortage of living donor transplantation. Although the guidelines and immunosuppression protocols are focussed on adult recipients, they touch on general issues related to children, pregnant women, and elderly patients; the guidelines are kept brief and cite selected comprehensive position statements that provide more details on these special populations.

References:

1. The Center for Economic and Social Rights. Egypt social progress indicators: health. Accessed November 11, 2021. https://www.cesr.org/Egypt-social-progress-indicators-health
   CrossRef - PubMed
2. Hassaballa M, El-Wakil H, Elsharkawy M, et al. Egyptian renal data system (ERDS) 2020. An annual report of end-stage kidney disease patients on regular hemodialysis. J Egypt Soc Nephrol Transplant. 2022;22:1-28.
   CrossRef - PubMed
3. Farag YMK, El-Sayed E. Global dialysis perspective: Egypt. Kidney360. 2022;3(7):1263-1268. doi:10.34067/KID.0007482021
   CrossRef - PubMed
4. World Health Organization. Report of the International Conference on Primary Health Care. Alma-Ata, USSR, September 6-12, 1978.
   CrossRef - PubMed
5. World Health Organization. World Health Statistics 2012. http://www.who.int/gho/publications/world_health_statistics/EN_WHS2012_Full.pdf
   CrossRef - PubMed