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Research Article
Trends in Transplantation
Trends in Transplant, 2020 doi: 10.15761/TiT.1000281 Volume 13: 1-7
ISSN: 1887-455X
Transplantation Model- Analytical Review: A Strategic
Proposal and Moral Obligation
Issa Al Salmi1*, Fatma Al Rahbi1, Ehab Mohammed1, Dawood Al Riyami2, Salima Al Alawi1 and Suad Hannawi3
1The Renal Medicine Department, the Royal Hospital, Muscat, Oman
2Nephrology Unit, Medicine Department, SQUH, Muscat, Oman
3The Medicine Department, MOHAP, Dubai, UAE
Abstract
Chronic kidney disease is rising worldwide in parallel to that of non-communicable disease. Kidney transplantation is the gold standard of care. We aim to provide
a model for Oman transplantation and its health system
is is a situational analysis of the incidence and prevalence of end-stage kidney disease in Oman. Also, we examined the transplantation trends and the health
system. We review the local transplantation and the commercial transplantation. Further, we reviewed few transplantation models to provide some insight into Oman
model of transplantation.
Oman facing a tsunami of end-stage kidney disease. Its one-o a few countries around the world where almost people with functioning kidney transplant equal
number on hemodialysis. However, majority of kidney transplantation were procured commercially outside the country. Upon their return home, these patients
receive their full management at tertiary hospital without any further diculties or issues of concern.
Oman health system needs to further strengthen its health services. is requires a strong political lead with full logistic and nancial incentives. Both citizens and
residents need to receive the necessary health requirements for ESKD. Transplantation, both deceased and living donation, need to be improved with strong tie with
World Health Organization and Istanbul Declaration rules adherence.
*Correspondence to: Issa Al Salmi, MD, BA, BAO, Bch, MB (Trinity College),
FRCPI, MRCP (UK), FRCP, MIPH, PhD (AUS), FASN (USA), e Royal
Hospital, 23 July Street, P O Box 1331, code 111, Muscat, Oman, Tel: 968
92709000; Fax: 968 245 99966; ORCID: 0000-0002-3443-5972; Research ID:
J-4622-2014; E -mail: isa@ausdoctors.net
Key words: transplantation, health system, medical tourism, chronic kidney
disease, Oman
Received: September 14, 2020; Accepted: October 12, 2020; Published: October
15, 2020
Introduction
Oman is the second largest country in the South East of Arabian
Peninsula that has a total population of 3, 831 553. e burden of non-
communicable diseases including chronic kidney disease is a serious
health care issue in Oman. Almost 40,000 persons aged 40 years, or
more were screened for chronic kidney disease (CKD) in a preliminary
survey performed in 2009 throughout Oman [1-3]. Of the individuals
screened, 0.9% had severe renal failure, with an estimated glomerular
ltration rate of less than 30 ml/min/1.73 m2; 9% had moderate renal
failure with estimated glomerular ltration rates between 30 and
59 ml/min/1.73 m2; and 29% had mild renal failure with estimated
glomerular ltration rates of 60 to 90 ml/min/1.73 m2 [3]. ere is a
gradual increase in the prevalence of end-stage kidney disease (ESKD)
and outpatient’s morbidity caused by CKD in Oman [3].
All citizens have easy and free access to health services all over the
country [2,3]. At the beginning, the number of patients with ESKD
was very small, and they were sent to India for dialysis and lived there
for the rest of their lives. In 1983, those patients who were still living
in India were brought back to Oman when the rst dialysis unit was
established. e number of patients was small, and a single dialysis unit
was enough for all patients across the country. In addition, all services
were provided for them, including transportation [2,3]. However, with
the increasing number of patients and rising prevalence of citizens
with ESKD, Ministry of Health built new units to cope with the
rising number of patients. e location of new units was built in close
proximity to the majority of patients in each area [3].
Statistics of the ESKD incidence showed that during 1983,
there were 34 patients, and in 2015 there were 230 patients per total
population. e incidence reported by the end of the year 2018 was 350
patients per country per annum. All 24 hemodialysis centres are fully
operated 24 hours a day and many patients are only on twice weekly
dialysis sessions [3]. Oman ESKD patients are very young compared
to those in Europe or North America. DOPPS study has revealed that
these patients despite being young have developed major morbidity
and mortality. Hence, improvement of kidney transplant service is
demanded.
If this high CKD incidence is to be followed by a rapid rate of
progression, with short duration in each stage of CKD, it is probable
that we are seeing only the tip of the iceberg of ESKD with RRT. e
nature of the relationship between CKD and ESKD is multifaceted,
and many risk factors interact in a complex way that may ultimately
determine its incidence and prevalence and the progression toward
Issa Al Salmi (2020) Transplantation Model- Analytical Review: A Strategic Proposal and Moral Obligation
Volume 13: 2-7
Trends in Transplant, 2020 doi: 10.15761/TiT.1000281
ESKD across various populations. However, based on our data showing
the continuing large increase in the prevalence of treated ESKD in
Oman, the picture looks grim, with a high prevalence of CKD at the
present time [1-3].
We noticed an uncommon observation that the number of ESKD
patients living with a kidney transplant is almost equal to the number
of patients treated with hemodialysis. In Oman, which has exclusively
a living-related kidney transplant donation program, this program
contributes 22.7% of the kidney transplantations for all the ESKD
patients living with a kidney transplant within Oman. is has been
the result of commercial transplantation from various developing
countries. Deceased donor programs contributed to only 1.3% of
total transplanted cases in Oman. However, 76% of kidney transplant
cases are commercial transplantations that are being done abroad.
is illegal pathway has led to an almost equal number of transplant
cases and hemodialysis cases in the country. is has been driven by
various socioeconomic and cultural beliefs. is manuscript aims to
review several transplantation models and provide an insight for Oman
to overcome its organ shortage and transplantation need and curtail
transplant tourism [3-5].
Method
We reviewed Saudi Arabia, Israel, Iran, Pakistan and United State
transplantation system or model and their history. We elaborated the
situation of the transplantation program. en, we discuss the issues
and concerns of transplantations in Oman. Later on, we provided
an insight into taken to achieve a reasonable success. At the end, we
proposed a comprehensive transplantation model program for Oman
to improve the care of people inside the country and curtail the
transplant tourism from neighboring countries.
Organ Transplant Models- worldwide
Saudi Arabia Model
In Saudi Arabia (SA), transplant centers are performing both
living related and deceased kidney transplantation. However, living-
unrelated kidney transplantations is prohibited.
e rst Living related kidney transplant was done in 1979 [6], and
the rst deceased kidney transplant was in 1981 which started as Euro-
transplant. During this period of time, SA hospitals were receiving
kidneys from Europe where it was been rejected due to various
reasons such as anatomical abnormalities, prolong ischemia time or
unacceptability for the transplant. So, these kidneys were suboptimal
in their functions. e nephrologists worked as coordinator to nd the
recipients for those kidneys.
During the same period, they worked very hard to obtain religious
approval (Fatwa) [6], for cadaveric transplant which was approved
in1982 [6].
For cadaveric transplantations, national kidney foundation was
established in 1985. One of its main function was to establish the
transplant waiting list where all patients with ESKD were registered
and to organize the kidneys from cadaveric kidney transplantation.
Later, the foundation was renamed as Saudi Center of Organ
Transplantations (SCOT) when other organs like heart, lungs, livers
and cornea were utilized for transplantations [6,7].
ere were regional coordination oces in all major hospitals
throughout SA, which are working under SCOT. e function of these
oces is to identify cases with brain death from emergency rooms and
ICUs and obtain consent for donation [6,7].
e kidney allocated to national patients whenever a suitable
patient is available. If there are no suitable national patients, and aer
obtaining consent, the kidney may be transplanted to a non- national
patient with priority for residents followed by visitors. Moreover,
kidneys could be exchanged with other countries according to an
agreement established between the SCOT and similar institutions in
other Gulf countries [8].
It was noted that the numbers of identied brain-dead patients are
more than the consent obtained from families. Patients are going for
commercial kidney transplantations and come with complications that
needed to be managed. For which, media and religious leaders through
SCOT play a major role in educating the society and make them aware
about the diseased kidney program and hence, the kidney donation
increased since 1990 and onward [6,7]. In addition, the unlimited
governmental support of all transplantation activities, e.g., cadaveric
donor’s families are oered nancial support and free transportation of
the donor’s body to their country of origin in the case of expatriates [6,7].
For the living kidney transplantations, the donor should be
blood- related or must be the breast-feeding mother and that must be
conrmed by ocial specialized institutions. And emotionally related
and non-directed non-commercial donation can be accepted. SCOT
is a distinguished model for the region and especially the GCC, where
there are very close similarities between such countries such as patients
demography and health systems [8-10].
United State Model
Living related, living unrelated and diseased kidney transplantations
are conducted in USA to help patients with ESKD.
ere are multiple kidney transplantations centers in USA and
each center has its own criteria for kidney transplantations. Moreover,
not all centers doing all the type of transplantations [11-13]. It is the
duty of the patient to choose the center of kidney transplantations for
which patient should consider the following:
1- Insurance and cost
2- Location of the transplant center to ease to access
3- If patient has living donor, he needs to make sure that center is
doing Living kidney transplant.
4- Centers is doing kidney paired exchange program.
In 1950s, each center was working alone and if the kidneys from
cadaver transplant does not match for any patient from that center,
it will be discarded. Hence, United Network for organ sharing
(UNOS) was established in 1984 and all patients who are waiting for
kidney transplantations will be registered and diseased kidneys will be
organized and distributed equally among all centers.
Patients can be register in the waiting list once they started to have
eGFR <20 and on dialysis. Initially the program was accepting diseased
kidney and living related kidney transplantation. But between 1998
and 2008, it was noted that the numbers of patients in waiting list are
increasing in comparison to available kidney donors and there was a
signicant reduction in the number of living related donors since 2003
[14,15]. Also, aging transplant candidate population and concurrent
medical unsuitability of prospective donors as well as nancial
disincentives [12,15,16]. Moreover, the concerns of the nephrologists
that most donors lost follow- up aer 1-year post-kidney donation.
Because the outcome of living kidney transplantation was better
than deceased donor, the following actions were taken:
Issa Al Salmi (2020) Transplantation Model- Analytical Review: A Strategic Proposal and Moral Obligation
Volume 13: 3-7
Trends in Transplant, 2020 doi: 10.15761/TiT.1000281
1. e establishment of kidney paired donation (KPD) programs, in
this system living donors who are incompatible with their intended
recipients either because of ABO incompatibility or because of
sensitization (leading to a positive cross-match) participate in a
“donor pool,” resulting in an expanded availability of organs.
2. Permission of a non-directed live kidney donor (sometimes referred
to as altruistic donors). ese individuals oer to donate a kidney,
but do not identify the specic recipient [2-4].
In regards of increasing the diseased kidneys, it was thought to
increase diseased transplantation by using donors at extremes of age,
double kidney transplants from marginal donors and extended-criteria
donors [12,14,17,18].
Israel Transplantation Model
Kidney transplantation has been available in Israel since the mid
of 1960’s. e rst two kidney transplants, one from a living related
donor and the second from a deceased donor, were performed at
approximately the same time at two dierent hospitals. Aerwards,
kidney transplantation began to be performed in several hospitals
throughout the country, but the overall numbers remained small [19].
In 1994, e National Transplant Center was established as an
Israeli governmental organization. e objectives of the organization
were to: promote organ transplantation, maintain a central list of
potential transplant candidates, and select recipients as organs become
available as well as to provide guidelines for various functions, such as
selection of patients and collection of data.
Despite of these eorts, the number of kidney transplantation
remained less than 150 per year in the early 2005. As a result of this,
many Israelis with kidney failure travelled to other countries for kidney
transplantation. Organ tracking led to sever legislation and sanctions
based on the adoption of Istanbul declaration [20].
In 2008, e Israel Knesset enacted 2 laws [21,22], the 1st dened
brain death and provided the criteria for diagnosis brain death [23], the
2nd law, the transplantation law, dened the conditions for performing
transplants using deceased and live donors in Israel [24,25].
By these laws’ direct payment to donors and reagents were regarded
as illegal, remuneration for loss of income was permitted and regulated
and the regulations regarding the requirements for the use of organs
from living donors were published [24,25].
e attitude of Jewish religious leaders regarding organ
transplantation: Historically, many, but not all, rabbinic authorities
rejected the use of organs from deceased donors for transplantation
[23,26,27]. e main objection was related to the denition of brain
death, which is not considered acceptable to many rabbinical authorities,
as opposed to cardiac death, which was universally accepted [19,22,25].
Matnat Chaim encourages live kidney donation among Orthodox
Jews in Israel: A non- prot organization, Matnat Chaim (“Gi of life”
in Hebrew), a faith-based initiative, has emerged as a major force for
organizing Living Donor Kidney Transplantation mainly by facilitating
altruistic living un-related transplantation with an emphasis on donors
from the Orthodox Jewish community through:
A- Increase the awareness in the media, both traditional media, such as
newspapers, magazines, radio and television, as well as new media,
such as internet and social media sites, especially Facebook.
B- e organization produces magazine supplements that disseminate
stories describing the life and suering of dialysis patients, as well as
inspiring stories of kidney donors.
C- Group meeting.
e organization helps donors navigate the health system and refers
them to the Physician with particular experience in advising kidney donors.
e organization does not interfere with matching or donor selection.
Related donors are required to receive the approval of an independent
committee in the hospital of transplant center whereas altruistic non-
related donors are referred to an independent national committee.
Potential donors can choose specic characteristics of the recipient
like a child, a mother of small children, a non-smoker or a member of
a specic religious group. But donors are not permitted to choose a
specic recipient [19,22,25].
Matnat chaim organization eects: e total number of live
kidney donation facilitated by Matnat Chaim since its founding in
February 2009 until the end of 2017 was 494. e mean age of these
kidney donors was 41 years (range between 23 and 66 years), 73% were
male and 27% were female. In 2011, only 27% of live donors were referred
by Matnat Chaim whereas by 2016 it has increased to 55% (Figure 1) [19].
rough Matnat Chaim organization, the number of deceased
donors had increased from a maximum of 87 until 2010 to 117 in
2013 and 115 in 2016. Also, the number of live kidney donor increased
from 78 in 2010 to 222 in 2016. Matnat Chaim facilitated 4 live donor
kidney transplantation in 2009, 11 in 2010, 32 in 2011, 37 in 2012, 33
in 2013, 49 in 2014, 89 in 2015, 127 in 2016 and 112 live donor kidney
transplants in 2017 [19].
e increase in the number of transplants has resulted in a plateau
in the number of patients on the transplant waiting list [19,22,27].
Iranian Model of Transplantation Model
e rst kidney transplant in Iran was done in 1967, it was the rst
organ transplant in the Middle East Society for Organ Transplantation.
In 1988, because of the long waiting list, the Iranian Ministry of
Health for kidney transplant, regulated living-unrelated donor kidney
transplant program was approved [28]. In addition, in 1989, a religious
approval (fatwa) from the Supreme Religious Leader was achieved that
recognized brain death and allowed deceased-donor organ transplant [29].
By 1999, the kidney transplant waiting list in Iran was eliminated.
Subsequently, transplant centers created performing deceased-donor
kidney, liver, and heart transplants [30].
Figure 1. Shows the Matnat Chaim facilitation of 4 live donor kidney transplantation in
2009, 11 in 2010, 32 in 2011, 37 in 2012, 33 in 2013, 49 in 2014, 89 in 2015, 127 in 2016
and 112 live donor kidney transplants in 2017
Issa Al Salmi (2020) Transplantation Model- Analytical Review: A Strategic Proposal and Moral Obligation
Volume 13: 4-7
Trends in Transplant, 2020 doi: 10.15761/TiT.1000281
In 2000, the Brain Death and Organ Transplantation Act was
approved by the Iranian parliament, legalizing deceased-donor organ
transplant. e transplant team at Shiraz began performing more
deceased-donor kidney and liver transplants and became a fruitful
deceased-donor organ transplant model in the country [28-31].
In 2011 and 2012, Iran was ahead of all country members of
the Middle East Society for Organ Transplantation in performing
deceased-donor kidney and liver transplants [31] and graded as
number 33 among the 50 most active countries worldwide.
By the end of 2012, there were 34166 kidney (including 4436
deceased-donor) and 2021 liver (including 1788 deceased-donor), 482
heart, 147 pancreas, 63 lungs, and several intestine and multi-organ
transplants performed in Iran.
Organ Transplantation in Iran before and aer 2008
Istanbul Declaration
In 1979, the period previous to the revolution, random transplanted
cases were done, but despite the high expenditures and cultural and
language barrier, most of the 114 transplantations performed in this
period, were carried out abroad, especially in the United Kingdom,
were using imported organs from Euro transplant organ sharing
network with large payment. e limited kidney transplantation
activities were totally stopped two years aer revolution and the
expertise transplantation surgeons le the country [32,33].
In 1984 and despite the grim circumstances, the rst kidney
transplantation aer a temporary stop, was carried out in Tehran with
minimal facilities and support, but excellent outcome [34]. e organ
was donated by a brother to his sister. Fiy such transplants, all from
live related donors, were carried out in various setups.
is eventually led to the expansion of the National plan for kidney
transplantation, which was ocially well-known in a hospital devoted
to nephrology and urology patients. e hospital was university-
aliated, and a multidisciplinary team was assigned to manage
and govern the program. e excellent success rate, low cost and
remarkable outcome encouraged all patients to join the waiting list for
transplantation [31,35-37].
To prevent transplant tourism, in 1992 the high council of organ
transplantation in the Ministry of Health and Medical Education ruled
the prevention of foreign nationals to be transplanted in Iran, except
they present a live donor of their own nationality. Since April 2010,
following Istan bul Declaration, and to respect its contents, kidney
transplantation of foreign individuals was entirely removed from
transplantation activities in Iran [37].
Despite the eorts to motivate and support deceased organ
donation, still the large gap between available donors and demand,
makes the unrelated donation an alternative. To support the donors
and recipients, a state-regulated system was started, and a recompense
was oered to the volunteer donors following the donation service.
ough this reward was satisfactory at the beginning, but year by year
it slowly lost its real worth due to rise each year and situ ation evolved
to present day, where the additional demand is compensated by the
recipients [38].
However, e Bio ethics Committee of the Academy of Medical
Sciences of IR Iran conrmed that the act of kidney donation from
living related and unrelated volunteers is generally acceptable,
and oering a re ward as appreciation, gi or compensation is not
considered unethical and should not discourage this honorable act
provided. Various strategies of Iranian model to solve the dilemma of
sale vs. donation is shown Table 1.
• Saving lives of many ESKD patients especially before the Brain
• Death Act
• Waiting list omission
• Complete medical and psychological examination of donors in the hospital, in addition to routine outpatient
evaluation process
• No middleman/broker or travel to the country to buy kidneys
• No financial benefit of transplantation team
• Development of BDD program and its progression (increasing experience of transplantation centers)
Legal approval of compensation for donor and transplantation expense in the hospital
• Donors cannot seek the highest possible price (no foreign patient can enter the system)
• Rich and poor can be transplanted
Same nationality of donor/recipient:
• Getting informed written consent from donor and next of kin
• No coercion of donors
• No exploitation of the poor
• Donor age 18
• Separation of scientific responsibilities from ethical ones
• Protection of fundamental doctor–patient relationship
Supervision of Patients’ Foundation on donor motivation:
• Decrease donor harm to the least
• Development of newer and safer approaches possible (e.g., laparoscopic nephrectomy)
• Complete medical and psychological examination
Transplantation centers in academic hospitals licensed by the MOHME:
• Direct financial connection between donor/recipient (negative point)
• Donors do not like to be known (negative point)
• Transparency of system (no abuse in the system)
• Development of BDD program and its progression (by redirection of the budget)
• Lack of protracted/long-term follow-up of donors
Supervision of Patients’ Foundation on donor motivation:
Table 1. Shows various strategies of the Iranian model to solve the dilemma of sale vs. donation
Issa Al Salmi (2020) Transplantation Model- Analytical Review: A Strategic Proposal and Moral Obligation
Volume 13: 5-7
Trends in Transplant, 2020 doi: 10.15761/TiT.1000281
Pakistan Model of Transplantation Model
Kidney transplantation in Pakistan begin in 1979 from living
related donors in public sector hospitals. e activity was as low as less
than 50 cases per year but slowly rose to more than 100 per year by the
mid-1990s [40].
Shortage of donors for lack of a de ceased donor program along
with rapidly developing skill in transplantation principal to unrelated
commercial trans plants in the private sector where the poor were
exploited to donate kidneys for US$ 1000 to 2000 [40,41].
By the year 2000, the number of transplants per year ex ceeded
1000—more than 70% of which were unrelated commercial donors [42].
Although, most of the recipients were local, which lead Pakistan
to become the largest center of transplant tourism by the year 2005—
where almost 1500 foreigners received transplants every year in private
sector hospitals [42].
By the year 2007, of 2500 trans plants performed annually in
Pakistan, 2000 were unrelated commercial transplants, 1500 of which
were for foreigners. Of the 500 living related transplants, 50% were
performed in one center in Karachi, southern Pakistan [42].
Dialysis and transplantation service were available for few select
people who could a ord it with >90% of population disfranchised
[40-42]. is situation made transplantation irrelevant to the com-
mon people and consequently for it to gain ground as a successful
management , it had to be made avail able to this population and
thereaer the soci ety could be asked to support transplantation,
declaration of law and organ donation from living and deceased [42].
A single institute in Karachi started a combined dialysis and
transplant program. In addition, all services were oered free of
charge to all patients to include recipient and donor follow-up and
post-transplant immunosuppressive drugs. is program was based
on a philoso phy of public-government partnerships with the public
donating up to 60%–70% and the government the rest [42-44].
Excellent results of the Institute established reliability overseas and
lead to the rst cadaver kidney transplant in Pakistan by the courtesy of
Euro-trans plant Foundation [42]. Aer transplantation of 26 deceased
do nor kidneys from Euro-transplant becomes the rst resident
deceased donor in 1998 followed by another in 2005.
e Transplant Law in Pakistan in 2010: e beak on
transplantation was accessible in the legislature almost 15 years ago
in the early 90s. It remained inactive for the rst decade in numerous
specialist committees from government to government mainly due to non-
acceptance of transplantation by the so ciety as a therapeutic modality
due to social, cultural and religious concerns [42]. is lack of facilities
in the presence of skill moved transplantation in the private sector largely
depended on living related donation. SIUT, however, established itself as
the best transplant institution in the country, started a campaign against
organ sale and transplant tourism [40,42,44].
Feature of the Transplant Ordinance in Pakistan: e transplant
rules excluded commercial unrelated transplantation of locals as well
as foreigners. It allowed donation only from living donors who are rst
degree relatives and legally related. But in case of unavailable of donor,
a “non-rst degree relative” can donate aer getting approval by an
assessment committee. In addition, the regulation permitted donation
from “brain death” donors who gave consent in life to be donors or
with the consent of their head of kin [40,42,44-46].
Finally, punishment for breaking the ordinance was 10 years
custody and a ne of U$ 15,000 [41,42].
Discussion
ere is no perfect system or model of transplantation worldwide.
However, the IR of Iran Transplantation Model seems the most suitable
model in the region and world-wide. Oman may need to adopt such a
model if to be successful in its provision of necessary transplantation
care for various end-stage organ failure. Treatment of patients with
ESKD is one of the major health care challenges in Oman, as the
number of ESKD patients is continuously increasing. e prevalence of
patients receiving RRT at the end of 2013 was 2382 with an incidence of
120 per million population, and it was more frequent in young patients,
as 86% of them were of 64 years and below. e prevalence and
incidence of treated ESKD patients reported in 2013 in dierent Asian
and Middle East countries with some similarities in the geographic and
socioeconomic patterns as in Oman. ese countries have prevalence
rates of treated ESKD patients ranging between 200 and 3000 patients
per million population. As well as an increase in ESKD prevalence,
as expected, a gradual increase in the outpatient morbidity caused by
CKD has been observed. In 2014, for example, a total of 1280 males and
3150 females per 100 000 population had evidence of kidney or urinary
tract disease. Additionally, surgical procedures related to the kidney
and urinary tract constitutes a considerable economic burden [1-3].
Transplant regulations were established in Oman in 1994 and were
supported by formal ministerial decision. e brain death criteria have
been accepted by civil authorities and religious authorities but have not
yet been accepted by the public at large, possibly due to poor educational
programs and media advertisements. As the deceased donor program
is still in its infancy, we anticipate that it will increase and hence curtail
the use of commercial transplantations. Implementing comprehensive
central strategies to consolidate the living related donor kidney
transplantation and supporting kidney organ donation is the way
forward in treating people with ESKD [3,4].
A survey was carried out in 2010 to evaluate the attitude of our
population toward organ transplantation and the results showed
great public acceptance of kidney donation during life and very low
acceptance of aer death donation. Religious and sociocultural
factors have to be further addressed and regulations and laws have to
be strengthened to further improve the service and to curtail organs
commercialism practices.
Although Oman deceased donor transplants program was among
the earlier programs in the Gulf region, it was not fully sustainable,
and the transplantation program turns now to be mainly living related
donor transplants program. e absence of resources to establish a
committed organizational unit for deceased donor transplants was the
major challenge causing its unsustainability compared to neighboring
countries. e program requires a good network of donors’ coordinators
throughout all intensive care units. Similarly, the absence of kidney
support societies is an important hurdle that the government must
tackle and to ease the establishment of such important public services
to further improve the care of people with ESKD. e disturbing eects
caused by unregulated commercial transplants performed outside the
country, which is called transplant tourism, contributed to some extent
to the unsustainability of this program. Interestingly, the support of the
Declaration of Istanbul, in which the ethical guidelines and framework
for transplantation was established, had led to immediate decrease
in commercial transplants and a noticed increase in the number of
transplants performed in Oman during the period of 2007 to 2009
Issa Al Salmi (2020) Transplantation Model- Analytical Review: A Strategic Proposal and Moral Obligation
Volume 13: 6-7
Trends in Transplant, 2020 doi: 10.15761/TiT.1000281
(from 12 to 23 operations) [3,4]. However, in recent years, there is an
increasing trend towards commercial transplantation, especially from
Pakistan and China, as well as countries that suer from political unrest
and natural disasters, where the poor being targeted for their organs in
exchange for a nancial gain.
Previously, we reported that Oman has exclusively a living-related
kidney transplant donation program, but this program contributes
22.7% of the kidney transplantations for all the ESKD patients living
with a kidney transplant. is has been the result of commercial
transplantation from various developing countries. Deceased donor
programs contributed to only 1.3% of total transplanted cases in
Oman [3]. However, 76% of kidney transplant cases are commercial
transplantations that are being done abroad. A recent paper found
that 3% of their participants paid only $15,000 to $30,000, 33% paid
between $30,000 and 45,000, and 52% of the participants stated that
they had paid more than $45,000 for KT; 65% of them had paid before
the operation and aer the agreement was made with the broker on the
price for the obtained kidney [4].
e brain death concept is still distant in the Omani public. e
meaning is that an individual is dead, according to medical denition,
while the heart is still beating causing a lot of confusion between the
patient’s career and the caring doctor. is misunderstanding of the
concept of brain death avoids the use of these individuals as potential
organ donors, which is a problem in an era where the needs for organs
exceeds their availability.
In Oman, despite the permission from religious and legal
authorities to use organs from deceased donors we are now practicing
almost solely with living related donors. e public attitude toward
donation is essential in all transplantation programs. Furthermore, a
survey was carried out in 2010 to assess Omani populations’ attitude
towards organ transplantation, showed great public acceptance of
kidney donation during life and very low acceptance of aer death
donation. However, religious and sociocultural factors have to be
further investigated and regulations and laws have to be strengthened
to further expand the facility and to prohibit organs commercialism
action [4].
A common thread that binds all faiths of the world is that the
saving of life overrides all objections, and no religion is against organ
donation. In KSA and Kuwait, have successful kidney transplantation
programs, which might notify the kidney transplantation program
in Oman to assume some variations to the present system to make
the program more active. However, the MOH has provided all the
resources for successful kidney transplantation program in Oman such
as the transplant coordination unit and kidney donor clinic [1,3-5].
Oman, similar to countries in the regions, and various other
countries around the world must empower their citizens, provide the
care required to improve their lives, and preserve dignity and human
values. Eorts must therefore be directed towards strengthening the
national program with full logistic, nancial, and strong legislation to
protect human lives locally, regionally, and globally and must collaborate
with international eorts to combat organ tracking and commercialism
and to encourage the notion of humanity’s best interest [3,4].
ough Oman deceased donor transplants program was among the
earlier programs in the Gulf region, it was not fully supportable, and the
transplantation program turns now to be mainly living related donor
transplants program. e major challenge causing the unsuitability of
this program in Oman compared to the neighboring countries was the
absence of resources. e brain death criteria have been accepted by
civil authorities and religious authorities but have not yet accepted by
the public at large, possibly due to poor awareness programs and media
announcements [3,4].
A clear guideline related to the diagnosis of brain death and
subsequently guidelines related to the withdrawal of life support
in these patients and been approved by the primary health services.
However, we as health care professionals and physicians have failed
to bridge the gap that exists between medical knowledge, legality of
brain death, religious views, and the education of our community in
this regard [3,4].
In order to resolve this, dierent institutions, most importantly
RH and SQUH, across the country need to come together to form a
committee in order to deal with this important and critical subject.
Secondly, we need to arrange and conduct a forum, including religious
and legal authorities, to discuss organ donation and come to a
consensus on policies and guidelines relating to the process of organ
donation. Finally, we also need to educate the public on sensitive issues
such as this and increase their overall awareness of brain death as a
medical condition. Religion plays an important part in the public live
of the population and hence a proactive religious approach is needed
at a regular pace to inform our citizens especially during the Friday
prayers where thousands of people attend it on a weekly basis. Media
must do a similar task as well to better approach young people and
educate them of the importance of organ donation.
In Oman, the decision to donate organs is a crucial step in the
process of transplantation. Moreover, Arab countries have poor
transplant rates because of multi factors. Which might include, have
low levels of infrastructure, an inadequate trained professional sta lack
of a legal structure leading the brain death program, religious, cultural
and social constraints, patient anxiety, physician bias, commercial
encouragements that favor dialysis and geographical remoteness. It is
based on personal or familial opinions that are strongly inuence by
many factors, including education, socioeconomic status, religion and
cultural characteristics [3,4].
Al Alawi, et al. stated that the DD program needs a good network
of donors’ coordinators all over intensive care units [1,2]. In the same
way, the absence of kidney association support is an important obstacle
that the government must challenge and to comfort the launch of such
important public services to improve the care of people with [1,3,4].
In addition to deceased program, Oman will need a few parallel
strategies for a successful organ transplantation, the full support of live
organ transplantation, both related and non-related. ese pathways
require logistic and nancial support of both government and NGO.
Presently, Oman uses, through its patients, other countries citizens
to provide organ, i.e. commercial transplantation. is need to stop!
Legally and ethically, it is unacceptable to continue with such an act in
the twenty rst century. If at all, there is a need to utilize live unrelated,
then it must stay within the country and no need to cross borders to
other countries. Morally, if there is a need for live unrelated, then every
country could provide some strategy to have a fair and acceptable
system within the community to enable such a strategy. Any citizen
individual willing to be live unrelated kidney donor would be registered
in a general donor pool and may avail for a nancial compensation of
15,000-20,000 OMR. In addition, the donor is also would be provided
with follow up medical care for the rest of his live. e donation cannot
be specied to individual, but it would be in a general pool of donor.
is would ensure a fair and equitable system where the general criteria
Issa Al Salmi (2020) Transplantation Model- Analytical Review: A Strategic Proposal and Moral Obligation
Volume 13: 7-7
Trends in Transplant, 2020 doi: 10.15761/TiT.1000281
Copyright: ©2020 Issa Al Salmi. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
for recipient is utilized in this pool. Recipient need to wait for at least a
year to avail for such a service.
Hence, these three major strategies, deceased, living related and
living unrelated, would be able to overcome shortage of organs (kidney)
in the country. Importantly, it would curtail the transplant tourism and
ameliorate all the suering of its endeavor. However, only time and
experience shall prove its success or failure [1,3,4].
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