1. Altruistic Living Non-Related Kidney Donation Program in Syria Facts & Difficulties Bassam Saeed Kidney Hospital, Damascus, Syria bassam.said@gmail.com 4 th SSN Congress Riyadh, April 27, 2009

2. Introduction  The kidney transplant program in Syria has been exclusively relying on living related donors and remained sluggish for more than three decades  In 2003, There has been discussion in the country about the possibility of accepting unrelated living kidney donors  From an ethical point of view, there is no conclusive argument that could justify a general exclusion of unrelated donors (1-3) 1-Daar AS, Land W, Yahya TM, Schneewind K, Gutmann Th, Jakobsen A. Living donor renal transplantation: Evidence-based justification for an ethical option. Transpl Rev 1997;11:95-109 2- United Network for Organ Sharing 1991 Ethics Committee. Ethics of organ transplantation from living donors. Transplant Proc 1992; 24:2236-2237 3-Spital AL. Unrelated living donors: Should they be used? Transplant Proc 1992; 24:2215-2217

3. Sequential Legislations In consideration of the widening gap between demand and supply of kidneys and other organs: In January 2008, the government of Syria issued a pronouncement restricting kidney Tx to the public sector with a new national regulatory oversight of Tx practices In November 2003, a new national Syrian legislation has been enacted and authorized the use of organs from both volunteer strangers and deceased donors providing the donation to be altruistic and between nationals to avoid transplant tourism

4. ESRD in Syria  The estimated incidence of ESRD in Syria:100 pmp/yr *  2000 new ESRD case /yr*  Prevalence of ESRD patients undergoing dialysis: 143 pmp*  Prevalence of ESRD ≈ 200 pmp** *Saeed B, et al. Organ failure in Syria: initiating a national deceased donation program. SJKDT 2007;18(2):270-276 **Saeed B, et al. Volume of organ failure in Syria and obstacles to initiate a national cadaver donation program. IJKD 2007; 2 (2):65-71

5. Aim of The Study To examine the donor characteristics of kidney transplants in Syria To examine the impact of national Syrian legislation on the evolution of kidney transplantation activities in the private and public sectors

6. Methods Retrospective analysis of numbers of all kidney transplants performed in the private and public sector hospitals in Syria and abroad for Syrian nationals from 1990 to 2008 with a focus upon transplants since 2003 We reviewed the medical records of all donors from kidney transplant centers in Damascus over a period of 3 years (2005 to 2007) and recorded the donors and recipients' 1.Genetic relationship if any 2.Ages 3.Genders 4.Difference in age 5.Different barriers to donate kidney from potential related donors

7. Results

8. Increasing Rate of Kidney Tx

9. Substantial Decrease in Kidney Tx abroad

10. Results  A total of 856 kidney donors were enrolled  454 donors (53%) in public hospitals  402 donors (47%) in private hospitals

11. Related versus Non-related Donors 2005-2006-2007 71% 29%

12. Gender Distribution in Related Compared to Non-Related Donors

13. Donor Age Groups Related versus Non-Related

14. Kidney Selling Despite the prohibition to buy a kidney in Syria, vendors had found ways to sell their kidneys through disreputable brokers especially in the private sector

15. Why Potential related donors were not inclined to donate kidneys to their relatives 1.kidneys could be bought from a non-related donor! 2.Fear of not being able to maintain family and raise children 3.Fear of developing kidney failure 4.The non-acceptance of their senior influent relatives 5.Fear of anesthesia, surgery, cosmetic complications 6.Fear of doing something against the religion 7.Fear of losing their job if any miss happening 8.Fear of losing the chance to get married

16. Live kidney donation : a balance Donor Recipient Selection Follow-up Care DONATION

17. The hidden kidney donor Donneur Recipient Selection Suivi Prise en charge DON Kidney selling conceal the donor

18. A Step of Ethical Propriety On January 17, 2008 The government of Syria issued a pronouncement restricting kidney transplantation to the public hospitals On January 17, 2008 The government of Syria issued a pronouncement restricting kidney transplantation to the public hospitals

19. Evolution of Kidney Transplant Activities in Syria 2000 - 2009

20. Number of Public Transplant Centers

21. Evolution of Kidney Tx Activities In Public Hospitals

22. -26%

23. Kidney Tx Number in Public Hospitals +55%

24. Evolution of Kidney Transplantation in Public vs Private Hospitals

27. Conclusion  The recommendations of the Istanbul Declaration and the Revised Guiding Principles of the WHO have yet to be implemented in Syria  The expansion of kidney transplants in the public sector is an important initial step to initiating a deceased organ donation program as an essential component of a comprehensive approach to the problem of the organ shortage

28. Thank you for your attention