Transplantation Society Regional Perspectives

Status of Liver Transplantation in the Arab World

Hatem Khalaf,1,17 Ibrahim Marwan,2 Mohammed Al-Sebayel,3 Mahmoud El-Meteini,4 Adel Hosny,5
Mohamed Abdel-Wahab,6 Khaled Amer,7 Mohamed El-Shobari,6 Refaat Kamel,4 Mohammed Al-Qahtani,8
Iftikhar Khan,8 Abdulla Bashir,9 Saeb Hammoudi,9 Sameer Smadi,10 Mohamad Khalife,11 Walid Faraj,11
Kamel Bentabak,12 Tahar Khalfallah,13 Assad Hassoun,14 Asem Bukrah,15 and Ibrahim Mustafa16
Keywords: Arab, Egypt, Saudi Arabia, Doha Donation Accord, Deceased donation, Living donation.
(Transplantation 2014;97: 722Y724)

he liver transplantation experience of 11 countries in

the League of Arab States is presented in this Regional
Perspective and provided in an ongoing series of such perspectives through the auspices of The Transplantation Society (1Y3). The history and current experience of 27 liver
transplant centers throughout these 11 countries is a seminal recording of both deceased (DDLT) and living donor
(LDLT) liver transplantation in the Arab World. The data of
this report were assembled by responses to an email questionnaire from 26 of the 27 centers with information regarding the date of the first liver transplant (LT), the total
number of LT (including DDLT and LDLT), and the most
common indication for LT in those centers.

The authors declare no fundng or conflicts of interest.

1
Hamad Medical Corporation, Doha, Qatar.
2
National Liver Institute, Minoufiya University, Minoufiya, Egypt.
3
King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
4
Ain Shams University, Cairo, Egypt.
5
Cairo University, Cairo, Egypt.
6
Mansoura University, Mansoura, Egypt.
7
International Medical Center (IMC), Cairo, Egypt.
8
King Fahad Specialist Hospital, Dammam, Saudi Arabia.
9
Jordan Hospital, Amman, Jordan.
10
King Hussein Medical Center, Amman, Jordan.
11
American University of Beirut, Beirut, Lebanon.
12
Centre Pierre et Marie Curie, University of Algiers, Algiers, Algeria.
13
Mongi Slim University Hospital, Tunis, Tunisia.
14
Zheen International Hospital, Erbil, Iraq.
15
National Organ Transplant Program, Tripoli Central Hospital, Tripoli,
Libya.
16
Theodor Bilharz Research Institute, Cairo, Egypt.
17
Address Correspondence to: Hatem Khalaf, M.Sc., Ph.D., F.E.B.S.,
Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar.
E-mail: hatem@khalaf.us
H.K. initiated the research and wrote the article. All other authors
participated in data analysis and performance of the research.
From the Pan Arab Liver Transplantation Society (PALTS).
Received 27 December 2013.
Accepted 8 January 2014.
Copyright * 2014 by Lippincott Williams & Wilkins
ISSN: 0041-1337/14/9707-722
DOI: 10.1097/TP.0000000000000062

722

www.transplantjournal.com

The Arab World is composed of 22 countries in the

League of Arab States founded in 1945. It has a combined
population of approximately 350 million people and is united
by Arabic language, culture, Islamic religion, and geographic
contiguity. Additionally, certain Arab countries share a high
prevalence of viral hepatitis with an increasing need for LT
in those countries (4, 5). The first DDLT in the Arab World
was performed in 1990 at Riyadh Military Hospital in Saudi
Arabia (6). The first LDLTwas performed in 1991 at the National
Liver Institute in Egypt (7). Between 1990 and August 2013,
3,804 liver transplants (3,052 [80%] LDLT and 752 [20%]
DDLT) were performed at the 27 in 11 Arab countries (Table 1).
The largest percentage of liver transplantation has been performed by 13 transplant centers in Egypt (56%) followed by four
transplant centers in Saudi Arabia (35%) and two transplant
centers in Jordan (5%). In the remaining eight Arab countries,
liver transplant activity has been limited to one program in
each country. The most common indication for LT in this series was end-stage liver cirrhosis caused by hepatitis C virus or
hepatitis B virus, with or without hepatocellular carcinoma.
More than 70% of the LDLT in this series were performed by the transplant centers in Egypt (Table 2) with five
living donor deaths reported (0.2% rate of mortality) (8Y12).
Egypt has the highest prevalence of hepatitis C virus (HCV)
worldwide, estimated to be 15% and 26% of the population
(13). More than 90% of the DDLT in this series were performed
in Saudi Arabia; four liver transplant centers in Saudi Arabia
have collectively performed 1,338 LT (52% DDLT and 48%
LDLT), including 13 split LT procedures. There were no reported living donor deaths in Saudi Arabia (14, 15). A small
number of transplants have been performed in Algeria, Tunisia, and Lebanon (16, 17). The initial transplant programs
in Libya, Kuwait, and United Arab Emirates performed a
few liver transplants, but they were subsequently suspended
because of logistical and technical reasons. A program for
LDLT has recently been developed in Iraq with a potential
of performing 15 LDLT per year; also, a DDLT program has
begun in Qatar with four transplants performed to date (18).
Missing in this report are the current annual data of patient and allograft survival. The progress of liver transplantation
Transplantation

& Volume 97, Number 7, April 15, 2014

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Khalaf et al.

* 2014 Lippincott Williams & Wilkins

TABLE 1. Liver transplant activity in the Arab world until

August 2013 arranged according to date of the first
liver transplant
Country

First LT

LDLT

DDLT

Total

Saudi
Egypt
Tunisia
Lebanon
Algeria
Jordan
Libya
UAE
Kuwait
Iraq
Qatar
Total

1990
1991
1998
1998
2003
2004
2005
2007
2010
2011
2011

648
2,138
8
4
36
174
21
2
V
21
V
3,052

690
2
31
19
V
4
V
V
2
0
4
752

1,338
2,140
39
23
36
178
21
2
2
21
4
3,804

35%
56%
1%
0.6%
1%
5%
0.5%
0.1%
0.1%
0.5%
0.1%

LT, liver transplantation; LDLT, living donor liver transplantation;

DDLT, deceased donor liver transplantation; UAE, United Arab Emirates.

in the Arab world will ultimately necessitate such data to validate the ongoing expertise of the transplant programs. The
Pan Arab Liver Transplant Society intends to develop a
registry of outcome data and also include a recording of a
relationship of the living donor to the recipient. This relationship is an important concern throughout the region but
especially in Egypt, considering the high poverty rates in the
country and noting that the largest percentage of LDLT has
been performed by the transplant centers of Egypt (19, 20).
Consequently, the Egyptian parliament has recently enacted
a law banning the sale of human organs, imposing restrictions on transplant operations for foreigners, and stipulating jail sentences and fines for violation of the law. The
absence of deceased organ donation in Egypt is troublesome
but not surprising in view of the cultural barriers and the
current political unrest (21).
The Saudi Center of Organ Transplantation (SCOT)
is a well-recognized national organ donation agency that
has collaborated with the liver transplant programs of Saudi
Arabia in propelling deceased organ donation (22). Because
almost all of the deceased donors are derived from expatriate workers residing temporarily in Saudi Arabia, there
have been ethical concerns that the inducement to donate is
a result of a cash payment to the next of kin of the donor
provided from the Saudi government and administered
through SCOT (23). SCOT has responded that such payments constitute an expression of gratitude to the family for
their donation.
The assessment of deceased organ donor potential by
the WHO Critical Pathway that was developed with SCOT
leadership will be another component of data that will be
a helpful reflection of Saudi contribution to the practice of
deceased donation in the region. The SCOT program is to
be commended for the opportunity of expatriate patients to
undergo liver transplantation in Saudi Arabia. The transparent display of a waitlist with specific allocation to patients on the list based upon medical urgency becomes an

important model of ethical propriety for Saudi Arabia, for

the region, and the rest of the world.
The Qatar Center for Organ Donation is working
closely with The Transplantation Society and the Declaration of Istanbul Custodian Group to develop a donation
system that fulfills global standards in accordance with
WHO Guiding Principles. This combined effort has led to
the Doha Donation Accord in an attempt to encourage deceased donation and increase consent rates. The Accord provides a government sponsored support to the families of all
potential deceased donors (3).
The survey of this report clearly reveals the current
necessity for both deceased and living donor liver transplantation to meet the patient needs of each country. The
best rate in the region is being achieved by Saudi Arabia but
only providing 25% of the demand. The high prevalence of
HCV, for example in Egypt, also impacts both the deceased
and living donor pool. Thus, patients from Arab countries
are still traveling to foreign destinations to undergo transplantation entailing much cost and resulting in inadequate
care. Poor outcomes are well known to be associated with
commercial liver transplantation (24).
In conclusion, both DDLT and LDLT are now routinely
and successfully performed in the Arab World. As elsewhere,
the organ shortage remains the biggest hurdle facing the increasing need for LT in most of the Arab countries. Although
deceased organ donation has been legalized, implementation
remains limited because of cultural and logistical barriers.
The increasing demand and scarce supply of organs in the
Arab World has generated appropriate concern related to organ
trafficking and transplant tourism. These shared challenges can
only be faced through continued collaboration between the
liver transplant programs in the Arab World and the international transplant community.

TABLE 2. Liver transplant activity in Egypt until August

2013 arranged according to date of the first liver transplant
Center
National Liver Institute
National Cancer Institute
Wadi El-Nile
Dar El-Foad
Maadi Hospital
Cairo University
Al-Mansoura University
nternational Medical Center
El-Sahel Hospital
Egypt Air
Al-Azhar University
Ain Shams University
Other
Total

First
LT LDLT DDLT Total
1991
1992
2001
2001
2003
2004
2004
2005
2007
2007
2008
2008
V

205
V
400
350
131
129
267
170
115
160
25
155
31
2,138

V
2
V
V
V
V
V
V
V
V
V
V
V
2

205 9.6%
2 0.1%
400 18.7%
350 16.4%
131 6.1%
129
6%
267 12.5%
170 7.9%
115 5.4%
160 7.5%
25 1.2%
155 7.2%
31 1.4%
2,140

LT, liver transplantation; LDLT, living donor liver transplantation;

DDLT, deceased donor liver transplantation.

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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Transplantation

ACKNOWLEDGMENT
The authors wish to express their appreciation to Francis
L. Delmonico, President of The Transplantation Society, for
his editorial review and suggestions and his support for the
Pan Arab Liver Transplant Society.

11.

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