Kidney exchange in the UAE, with the assistance of the Alliance for Paired Kidney Donation (AKPD), took another step forward, with a three way exchange.
Here is the press release fron the Cleveland Clinic Abu Dhabi:
"Cleveland Clinic Abu Dhabi, a Mubadala Health partner, played a major role in a groundbreaking triple ‘kidney swap’ transplant case in the UAE where three patients received life-saving organs under Abu Dhabi’s Paired Kidney Donation Program."
Yesterday, March 10 was World Kidney Day, whose theme was "Kidney health for all."
I couldn't help noticing that reports in honor of WKD reflect some of the considerable controversy that exists about kidney transplants.
Here are two with opposite points of view on increasing access to kidney transplants, with special attention to kidney exchange.
First, from Abu Dhabi:
World Kidney Day: SEHA Kidney Care leads the way in ensuring kidney health for all
"A key area that SKC is spearheading is investing in opportunities to increase transplant activities, for patients locally and further afield. SEHA’s recent collaborations with international organizations and the Department of Health – Abu Dhabi have ensured that it is prepared for an influx in transplant volumes, with an increased deceased donor activity from 3 donors in 2017 to 39 donors in 2021, and more opportunities for live donation with the start of a paired kidney exchange program in partnership with Alliance for Paired Kidney Donation. Through these partnerships, kidney transplants, often resulting in enhanced quality of life, are now a viable option for many patients here in the UAE. SEHA’s Transplant Program has performed more than 52 pediatric kidney transplants and almost 393 transplants in total since its inception.
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And here, from the Pakistani newspaper Dawn, is an editorial that bemoans the prevalence of black market kidney transplants in Pakistan, and worries that increasing access to kidney exchange will only increase the black market (as opposed to giving patients a safe and legal alternative to the black market). This is an opinion that seems to underlie the policies of a number of international transplant organizations.
"IRONICALLY, the Punjab government’s recent step in the effort to stop organ trafficking may well end up providing a shot in the arm to the illegal transplant racket. At a meeting chaired by the Punjab health minister, the provincial government has given its approval to a swap transplant plan which expands the living donor pool beyond immediate family members.
...
"Organ swap transplants, or paired exchanges, work by matching a recipient-donor pair that is medically incompatible, with another pair in a similar predicament. An organ ‘swap’ can then take place between the two pairs. However, these are only the bare bones of the procedure. It must be carried out according to strict ethical and clinical guidelines if it is not to open the floodgates for illegal transplants. Among these is the requirement that each recipient-donor pair must meet the eligibility criteria laid out in the law.
...
"Thus, while paired exchanges are an accepted method of addressing donor-recipient incompatibility, the level of oversight mechanisms needed to prevent abuse are daunting — even more so in an unequal society riddled with corruption. The first paired kidney exchange in Pakistan was performed in 2015 at the Sindh Institute of Urology and Transplantation in Karachi; only seven more have taken place since then — all at SIUT — partly because of the extreme diligence that the process calls for. The troubling fact is that most illegal transplants take place in Punjab; some were found to have been carried out surreptitiously in KP and Azad Kashmir by doctors from Punjab. The situation in recent years had improved considerably after several organ trafficking gangs were busted, again mostly in Punjab. Does the province have a system in place to ensure that unethical individuals do not use the organ swap programme as a cover for illegal transplants?"
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And here's a recent BBC video, "Kidneys for Sale?" on the controversy about compensation for donors. I just saw it yesterday (HT David Klinowski) but was produced earlier this year. A number of people are interviewed, and Sally Satel makes the point that increasing access to legal, safe kidney transplants is a way of competing with and reducing the prevalence of black markets.
From the Abu Dhabi Government Media Office, this Oct. 7 announcement:
SEHA, Alliance for Paired Kidney Donation Formalize Partnership to Promote Paired Kidney Donation
"Abu Dhabi Health Services Company, (SEHA), the UAE’s largest healthcare network, and Alliance for Paired Kidney Donation (APKD), a non-profit organization based in Ohio, U.S, have signed a Memorandum of Understanding (MoU) following their recent collective success in facilitating paired kidney donations.
"With both organizations sharing a common goal to elevate opportunities for donation and transplants for both local and international patients with kidney disease, this strategic agreement will see SEHA and APKD working closely together to build a paired kidney donation program in the UAE, as well as facilitate transplant opportunities for patients with kidney failure seeking the right match kidney from the UAE or abroad.
"Dr. Tarek Fathey, Group Chief Executive Officer, SEHA, said: “A fundamental element of our constant growth and development as SEHA is building fruitful partnerships and relationships with global pioneers. Collaborating with APKD strengthens our position to significantly add to the UAE’s healthcare ecosystem and will introduce ample opportunities for us to transform kidney care locally, regionally and internationally.”
"As part of the agreement, SEHA Kidney Care (SKC), part of the SEHA network and Abu Dhabi’s go-to for kidney disease and treatment, will benefit from the opportunity to engage in training modules in health information technology systems applications (including Kidney Match – APKD’s paired organ exchange software), develop educational and scientific research papers and studies, and the exchange of medical, technical, and administrative experience.
"Dr. Ali Al Obaidli, Chief Medical Officer, SKC & Chairman of the UAE National Transplant Committee, said: “The key to the success of paired kidney donations is collaboration, locally and internationally. Thankfully, in the UAE, we boast a robust foundation of healthcare stakeholders and partners who will be integral in the build and roll-out of such a program. Building on our support, we are pleased to formalize a long-term partnership with APKD – by strengthening our relationship, we are unlocking pathways into countries across the world that will facilitate life-saving solutions for kidney disease patients across the globe, as well as build and bolster a paired kidney program here in the UAE that will benefit our citizens and residents.”
The APKD provides a powerful matching platform... that works with governments and hospitals around the world to match living kidney donors with patients in need within and across borders.
On a recent visit to the UAE, ... Dr. Alvin Roth, said: “Kidney disease is a global problem that requires a global solution. The UAE, with its diverse population and solid healthcare infrastructure, is well positioned to lead the charge. ....”
Dr. Michael Rees, MD PhD, Chief Executive Officer, APKD, said: “.... We are thrilled to partner with the UAE’s largest healthcare network in efforts to elevate the country’s infrastructure to not only heal its residents, but to contribute to the global healthcare landscape in terms of cross-country paired donations and transplants and research.”
If you're just tuning in, you can follow the story of the kidney exchange between the UAE and Israel here. The pairs who exchanged kidneys were an Israeli Arab husband and wife, a Jewish Israeli mother and daughter, and a mother and daughter who wish to be identified only as Arab residents of the United Arab Emirates. (I joined their family at their home for a meal when I was in Abu Dhabi, but won't say more about them.)
It isn't a surprise that the donor in each pair couldn't donate to the intended recipient, because in each pair the recipient was a highly sensitized mother ( i.e. for whom it was hard to find a compatible kidney, because she had many antibodies against human proteins). During childbirth, mothers can develop such antibodies to the father's proteins that the children inherited. So the father and the daughters were incompatible donors, since the mother had antibodies against the paternal proteins (human leukocyte antigens) in their kidneys. Together with the fact that the mothers were quite hard to match, and that Israel and the UAE are both small, each with populations of around ten million, they had to look across national borders.
Cross border kidney exchange requires some diplomacy, particularly when the countries involved are getting together for the first time (and don't necessarily have a long history of cooperation). The key medical diplomats were Dr. Tamar Ashkenazi* the director of Israel Transplant and Dr Ali Abdulkareem Al Obaidli, Chairman of the UAE National Transplant Committee. (Other key collaborators in the complicated logistics were Itai Ashlagi at Stanford and Atul Agnihotri and Mike Rees of the Alliance for Paired Kidney Donation.)
So this was the plan:
And here's a picture of the Abu Dhabi kidney packed for shipping (masked in the picture are Sue and Mike Rees, who have a lot of experience with packing and shipping kidneys, another nurse whose name I don't know, and Dr. Muhammad Badar Zaman the UAE transplant surgeon who transplanted the kidney that was on the way.
The little box taped to the top of the shipping container allows the kidney to be tracked in transit, via an app that gives you a picture of where it is at it travels:
And here's the swap of the two kidneys in shipping containers in the airport in Abu Dhabi (Tamar Ashkenazi and Dr. Ali are in the center, Atul and Mike are at the two ends...). Dr Ashkenazi was on both legs of the flight above--she flew in with the Israeli kidney and flew out with the UAE kidney.
On my last night in Abu Dhabi I had dinner with a lot of the docs. Across from me in the picture below are the two surgeons most actively involved in this exchange on the UAE side, transplant surgeon Dr. Zaman and the nephrectomy surgeon Dr. Hamid Reza Toussi. Next to me is the nephrologist Dr. Mohamed Yahya Seiari.
There are excellent hospitals in the United Arab Emirates that can perform kidney transplants, and they are prepared to do kidney exchange, both domestically and internationally. My post today is about why the UAE would be a natural international center for kidney exchange.
International hubs for kidney exchange are needed because hard-to-match patient-donor pairs may need to find compatible exchanges outside the borders of their own countries. This is particularly true for citizens of countries with relatively small populations of potential compatible donors, and of countries that don't yet have widespread kidney exchange. But even a big country like the U.S., in which kidney exchange is a standard mode of transplantation, can sometimes be too small to find compatible kidneys for the hardest to match patients. (The U.S. itself is a natural hub for global kidney exchange, about which I've written elsewhere. But so far, bureaucratic obstacles have prevented us from integrating kidney exchange even with Canada...)
The UAE itself is already quite international, as only about 10% of its approximately 10 million residents are Emirati citizens; the rest, largely foreign workers and their families, are citizens of other countries. The biggest of the Emirates, Abu Dhabi, provides medical care for its residents that includes dialysis and transplantation for kidney failure, which is prevalent there (perhaps due in part to the very hot weather and the perils of frequent dehydration in outdoor work). Most of those patients are on dialysis, although the national health insurance will pay for transplants for those who have willing donors either in the Emirates or in their home country. The UAE is wealthy, and many of the home countries are not, so my understanding is that the UAE is prepared to assume the costs of bringing family members to the UAE and providing the necessary medical care. This is cost effective as well as good for the patient, because in the UAE as elsewhere, transplantation is much cheaper than dialysis, as well as being the best treatment. So taking a UAE resident off dialysis via transplant saves a life and pays for itself.
Of course, sometimes the UAE resident's family member who is willing to donate a kidney isn't compatible with the UAE resident. So kidney exchange makes a lot of sense in this case. But with a resident population of only 10 million, there are severe limits on how much kidney exchange can do for hard-to-match patients. So international, global kidney exchange makes sense, in which patient-donor pairs from other countries could also be transplanted in the UAE through kidney exchange with UAE residents (or, eventually, with other international pairs).
It helps a lot that the UAE is also an air transit hub, with two international airlines. Emirates has a hub in the Emirate of Dubai, and Etihad has a hub in Abu Dhabi. So a big portion of the world's population is within a few hours of direct air travel to the UAE. (When I went to the UAE this summer in connection with the UAE-Israel kidney exchange, I took a direct flight from San Francisco to Dubai, but that takes sixteen hours...)
My main goal in the UAE was to meet with various mostly government bodies engaged in an effort, in collaboration with the Alliance for Paired Kidney Donation, to make domestic and international kidney exchange a regular part of medical care there. To that end, we met with the Ministries of Health in Dubai and in Abu Dhabi, with the national health insurance, with the Red Crescent (which is able to get involved in care of patients and donors after they return home), and others.
The key player in organizing this collaboration, and in transplantation generally in the UAE is Dr Ali Abdulkareem Al Obaidli, transplant nephrologist and Chairman of the UAE National Transplant Committee. Two other key figures from the APKD are Mike Rees and Atul Agnihotri. Many of our meetings ended in photos, and I'm with those three in all pictures below.
I expect to write some more about this. In the meantime, here are related posts.
And this older one:
Here's a Stanford story celebrating Itai Ashlagi's role in this summer's UAE-Israel kidney exchange. (His matching software is embedded in the software suite of the Alliance for Paired Kidney Exchange (AKPD) which is a partner with a remarkable Abu Dhabi effort to further kidney exchange.)
Stanford engineers develop algorithm to aid kidney transplant exchanges. A historic and complex kidney exchange between Israel and Abu Dhabi put a spotlight on the Stanford algorithm that made it all possible. BY ANDREW MYERS. AUGUST 12, 2021
"A historic kidney transplant exchange recently took place in the Middle East, but it might never have transpired without an algorithm developed at Stanford by Itai Ashlagi, a Stanford associate professor of management science and engineering, and his graduate student Sukolsak Sakshuwong. In all, three ailing recipients received life-sustaining transplants while three healthy donors gave kidneys.
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"“One of the nice things in the software we developed is the user interface. We collect all the relevant patient data, but then we let the user play with the various thresholds that determine successful matches to see what works for them,” Ashlagi said as he explained the team’s game-like approach to matching. The software acts as a platform and allows different organizations to easily collaborate and create more possibilities for exchanges. “Just a few days ago, I was looking for matches and found an unexpected exchange between pairs from Israel and other European countries. Hopefully, this will lead to new collaborations.”
“Itai’s software was used on both sides of that historic exchange between Abu Dhabi and Israel,” said Alvin Roth, Nobel Laureate and Ashlagi’s mentor and frequent collaborator, who was in Abu Dhabi in connection with the exchange.
"Roth says Ashlagi exemplifies the concept of scientist-engineer and is now a driving force in contemporary kidney exchange through both his deep understanding of the immunological issues of matching kidneys to patients and his intimate appreciation of the needs of transplant centers.
“He’s turned those practical theoretical insights into widely deployed digital tools with the power to change lives,” Roth added. “Having the chance to collaborate with him has been among the best experiences of my intellectual career.”
I spent a week in the UAE this summer, in connection with a three-pair kidney exchange between the UAE and Israel. (The UAE is a natural hub for kidney exchange, something I'll say more about in subsequent posts.) Because there were some sensitivities about how it would be publicized, I've refrained from blogging about it until now, but yesterday's front page story in USA Today met with just about everyone's approval, and so over the next few days I'll post some observations. Today I'll start with the USA Today story, which is gated, but can also be found ungated on Yahoo, here:
How three Jewish and Arab families swapped kidneys, saved their mothers and made history by Marco della Cava, USA TODAY, Wed, September 29, 2021 AM
"At a time when the world seems rife with division and discord, what happened on July 28 reminds how mutual survival often depends on shared humanity triumphing over historical differences.
"In this case, with the assistance of organ transplant experts in the United States, Israel and the United Arab Emirates, three pairs of kidney donors and recipients in Israel and the UAE saved each other in a series of choreographed, pay-it-forward surgeries known as a cyclic exchange.
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"Just consider the logistics involved in the UAE-Israel exchange. A UAE daughter who was not a match for her mother volunteered to give her kidney to a stranger. An Israeli Arab woman was a match for that kidney, so her husband agreed to donate his kidney to save an Israeli Jewish mother – whose daughter in turn gave her kidney to the sick mother in UAE.
"“The reason we are excited about this is simply because the bigger the pool, the more likely you are to find matches,” says Dr. Michael Rees, a surgeon and founder of the Alliance for Paired Kidney Donation, a Toledo, Ohio-based nonprofit instrumental in making this politically groundbreaking kidney transplant chain a reality.
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"Those communications, however, remain politically sensitive. When asked for comment, officials in the UAE focused less on the partnership with Israel and more on a general need for international cooperation.
"We are pleased that our innovative partnership with the Alliance for Paired Kidney Donation has allowed us to help our patients,” says Dr. Ali Al Obaidli, chairman of the UAE National Transplant Committee. He added that a collaborative spirit between countries can be used to “close the gap” for those in need of kidneys.
"The UAE donor daughter and recipient mother asked not to be identified by name or religion. Conversations with those involved in the cyclic exchange say kidneys donated outside the UAE generate negative reactions among some Emirati.
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"This unique transplant chain began when the 60-something mother in the UAE found out in fall 2020 that she had kidney failure and would soon need to start dialysis or find a new kidney.
"Because her family members were not matches, Rees and his Alliance for Paired Kidney Donation team got to work finding a match, which also involved seeing where her daughter’s donor kidney might go.
"The first step was to plug all the relevant medical details into an algorithm ...
"Also crucial to the process was Roth's Israeli colleague Itai Ashlagi, who had developed software that could instantly mine his native country’s kidney database. While Israel had started to develop transplant relationships with Austria and the Czech Republic, he was excited about this new involvement with the UAE.
“Better to exchange kidneys than bombs,” says Roth, adding that using computers to search the world for medical solutions radically increases the chances of patients getting help. “International boundaries are artificial markers. Kidney disease doesn’t care about that.”
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Here's the picture on the USA TODAY front page: Tamar Ashkenazi flew from Israel to UAE with an Israeli kidney, and flew back with the UAE kidney...
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Here's a USA Today 1-minute video collage of pictures and video accompanying the story:
Daughters from the UAE and Israel put differences aside to save lives in kidney exchange. Three pairs of kidney donors and recipients in Israel and the UAE saved each other in a series of pay-it-forward surgeries known as a cyclic exchange. by Harrison Hill, USA TODAY
I'll have more to say soon, and will link back and forth between posts to make the whole story accessible.
Here's a chapter on transplantation in a book about liver cancer. The countries in the Middle East that can do liver transplants can also transplant kidneys, with living donors being the majority of donors across the region.
Liver Transplantation in the Middle East by Sezai Yilmaz, In: Carr B.I. (eds) Liver Cancer in the Middle East. Springer, Cham. https://doi.org/10.1007/978-3-030-78737-0_12
It contains some interesting summaries by country. Here is the summary of the transplant situation in the UAE (about which I expect to be able to say more soon).
"6 LT in the United Arab Emirates
"The United Arab Emirates (UAE) is an Arabian Gulf country located at the southeast end of the Arabian Peninsula with a population of about 9.3 million. It has made great strides in healthcare over the past several years and has among the highest life expectancy in the region. However, one of the key lacking areas of medical care in the country was the availability of solid organ transplantation. Collaborative efforts began a few years ago aiming to establish thoracic and abdominal solid organ transplantation from deceased donors in addition to continued development of the existing program on kidney transplantation from living donors. The UAE played an important role in efforts leading up to the declaration of Istanbul on organ trafficking and transplant tourism in 2008, the groundwork for which was laid in a steering committee meeting organized by the Transplantation Society and the International Society of Nephrology in Dubai in December 2007. This landmark declaration helped establish a framework of ethical principles to guide the practice of transplantation worldwide. The legal definition of brain death in the UAE was confirmed in May 2017, paving the way for deceased donor organ transplantation [42].
"The Cleveland Clinic Foundation was instrumental in the accelerated path to establishment of a multi-organ transplant center at Cleveland Clinic Abu Dhabi. Cleveland Clinic Abu Dhabi, which began clinical operations in early 2015, was established as a partnership between Mubadala Healthcare, Abu Dhabi, and Cleveland Clinic Foundation in Cleveland, Ohio. A meticulous and thoughtful collaborative approach, which began with identifying key operational needs, resulted in the establishment of transplant services within 2.5 years with the establishment of Cleveland Clinic Abu Dhabi. The first multi-organ procurement and transplant from a brain-dead donor in the UAE occurred at Al Qassimi Hospital in Sharjah on July 15, 2017 [42]. Also noteworthy was a regional organ sharing agreement with SCOT that enabled the utilization of deceased donor grafts for potential recipients in Saudi Arabia while awaiting full operational readiness for thoracic and LT at Cleveland Clinic Abu Dhabi. The overall organ donation rate remains low in terms of the number of organs recovered (3.66) and transplanted (3.57) per donor.
"Shortage of deceased donors remains one of the primary challenges facing the transplant community in the UAE. This mandated establishment of LDLT to complement ongoing efforts to improve DDLT. An extensive collaborative effort, with Cleveland Clinic’s main campus in Cleveland, Ohio, resulted in the first successful LDLT in the UAE on July 29, 2018. Since that time, an additional 13 LDLTs were performed (overall: four right lobe and ten left lobe grafts) over the past year and a half [42]."
The Guardian has the story:
UAE decriminalises alcohol and lifts ban on unmarried couples living together--Country also ends lenient punishments for ‘honour’ killings as part of reforms by Emma Graham-Harrison and agencies
"The United Arab Emirates has ended lenient punishments for so-called “honour” killings, lifted a ban on unmarried couples living together and decriminalised alcohol, in reforms to personal laws.
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"The country, where citizens are outnumbered nine-to-one by migrants, has long branded itself internationally as a modern business and tourist destination and has not always strictly implemented its own law.
...
"Emirati judges have until now been allowed to hand down lighter sentences when a woman was attacked or killed by a relative because she has acted in a way he considers to have affected the family reputation, or “honour”. That can include eloping or fraternising with men not related to them.
"Kenneth Roth, the executive director of Human Rights Watch, described the changes as “positive steps for women’s rights” but also raised concerns about the daughters of Dubai’s ruler, Sheikh Mohammed bin Rashid al-Maktoum.
"A UK family court this year found he had orchestrated the abductions of two of his children – one from the streets of Cambridge – and subjected his youngest wife to a campaign of “intimidation”.
...
"The reports did not mention other behaviour outlawed by Emirati law, which has previously landed foreigners in trouble, including homosexual relationships, cross-dressing and public displays of affection.
"Although alcohol is available for sale in restaurants and bars in Emirati cities, individuals needed a licence to buy booze or keep it in their homes. The new laws would apparently allow Muslims, who have not been able to get licences, to drink alcoholic beverages freely."
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