Manjusha Yadla, MBBS, MD, DM, MISN, F
Vincent Boima, MBChB, FWACP,aTggeHd1 ransplant: The Success of Renal Transplant
ugdigFegaTer eEgnTdgad Programs FdnEdeggdTgaTgeaigureTaggedEndaTgdgneEd*Dialysis and Transplant U
TagdgneEdyDepartment of Nephrolog
Telangana, India
TaggedEndzDepartment of Medical C
Sciences Center, Guadala
aTgdgneEdxDepartment of Medicine
Medical School. P.O. Box
||
TanggEedd Child And Adolescent Hea
Sciences, University of Z
are, Zimbabwe
agTgedEnd{Department of Paediatric
Children’s Hospital, Uni
Africa
dndgggaendTEgTeaEdFinancial disclosure and co
angdgeTEdAddress reprint requests to
Medicine and Therapeut
P.O. Box 4236, Accra, Gh
0270-9295/ - see front matte
© 2023 Elsevier Inc. All rig
https://doi.org/10.1016/j.se
Seminars in Nephrology, VTaeggdEP bun L. Bamgboye, MBBS, FWACP, FRCP, FNAN *
ISN † Guillermo Garcia-Garcia, MD, FACP ‡
FGCP, MPH, Cert Nephrology (SA) §
Privilage D. Makanda-Charambira, MBChB (Zim), Mmed Paeds (Zim), DCH (Aus), Cert Paed
nephrology (SA), MPhil Paed Nephrology (SA), Fellow ISN/IPNA ||
Mignon I. McCulloch, MBBCh (Wits), DCH (SA), DTM&H (UK), FRCPCH (Lon), FCP Paeds (SA) ¶
and Dwomoa Adu, MD, FRCP§TadgEgdenTaegPgdSummary
In the absence of malignancy or other severe comorbidity, kidney transplantation offers better survival rates and
quality of life than dialysis. Despite this survival advantage, many lower- and upper-middle−income countries do
not offer adequate kidney transplant services. This is particularly troubling because end-stage kidney disease often
is more common in these countries than in high-income countries and overall is less costly in the life of a patient.
We describe the contrasting levels of provision of kidney transplantation in Mexico, India, Nigeria, Ghana, and Zim-
babwe, and kidney transplant services for children in Africa.
Semin Nephrol 42:151312 
 2023 Elsevier Inc. All rights reserved. TagdgeEdn
TaggeKdP eywords: Kidney transplantation, sub-saharan africa, india, mexicoTadgEgdenhronic kidney disease is common worldwide, but
Cthe use of kidney replacement treatment (KRT) islimited in most low-income and middle-income
countries. The extent of KRT correlates with income,
and it is estimated that there are 1.2 million premature
deaths per year owing to a lack of access to kidney
replacement therapy.1 In mos countries the major modal-
ity of treatment is hemodialysis,1 although survival and
quality of life are better with a kidney transplant than
with ongoing dialysis.2,3TAEGGD1H FRICA TGAGEEDND
TaggPedIn Africa, countries with a high level of transplantation are
Tunisia, South Africa, Sudan, Algeria, Egypt, and Morocco.
Currently, there are 8 countries in sub-Saharan Africa wherenit, St Nicholas Hospital, Lagos, Nigeria
y, Gandhi Medical College, Hyderabad,
linics, University of Guadalajara Health
jara, Jal. Mexico
and Therapeutics, University of Ghana
4236, Accra, Ghana
lth Unit, Faculty of Medicine and Health
imbabwe, PO Box A 178, Avondale, Har-
Nephrology, Red Cross War Memorial
versity of Cape Town, Cape Town, South
nflict of interest statements: none.
Dwomoa Adu, MD, FRCP, Department of
ics, University of Ghana Medical School.
ana. E-mail: Dwoms15@gmail.com
r
hts reserved.
mnephrol.2023.151312
ol 42, No 5, September 2022, 151312successful kidney transplants are performed.4 The estimated
number of transplants performed, the dates when the first
transplant was performed, the average number of transplants
performed in the past 3 years, and the number of transplant
centers available in each of these countries are described in
Table 1. The majority of these countries perform live-donor
(LD) kidney transplants exclusively, and in Africa only
Morocco,Algeria, Tunisia, and SouthAfrica have a deceased
donor (DD) kidney transplant program. Setting up a kidney
transplantation service requires substantial infrastructure in
addition tot surgical, medical, nursing, and anesthetic skills,
and a major barrier is the cost of immunosuppression.5 Addi-
tional barriers to kidney transplantation include the lack of a
legal framework for organ donation, clinical expertise, lack
of clinical protocols, inadequate laboratory infrastructure
especially for HLA testing and crossmatching, and a robust
ethical framework.6 There is also a requirement for an ethics
board to ensure that organ donation is performed without
coercion or inducement and is in compliance with the Decla-
ration of Istanbul.7TaggendEd
TaeggdSP everal centers and groups in high-income countries
provide support for the initiation of kidney transplantation
in Africa, including Transplant Links, a non-governmental
organization based in the United Kingdom.8 Similarly, the
University of Michigan has an outreach program in Ethio-
pia.9 Ethical transplantation requires a legal framework
and ethical committees. Most African countries have an
ethical framework for clinical care, but few have specific
legislation to cover transplantation.10TadgEgdenTAEGHGD1NIGERIA TAGDGNEED
aTgdgePIn Nigeria, kidney transplants first became available in
2000 at St Nicholas hospital in Lagos. Since then, 151
deEggdn2Ta E.L. Bamgboye et al.
EdeTgdnga
Table 1. Countries With Transplant Capacity in sub-Saharan Africa, India, and Mexico
Country Date of First Transplant Number of Number of Transplants Number of Transplants
Transplant Centers Performed Until 2022 Performed in Past 3 Years
Africa
South Africa 1966 15 9,011 750
Kenya July 5, 1978 7 400 160
Mauritius December 17, 1980 ?? 389 0
Nigeria March 6, 2000 16 1,132 546
Cote d’Ivoire September 24, 2012 3 75 7
Ethiopia 2015 1 137 102
Ghana 2008 1 21 4
Cameroon November 9, 2021 1 4 4
Mexico 1963 571 55,916 5,873
India January 1971 550 50,844 27,237other centers have acquired the capacity to perform kid-
ney transplantation in both public and private health
facilities. The more active centers, however, are the pri-
vate centers, accounting for more than 90% of trans-
plants, and they are located in large urban areas. Public
hospitals generally are bedeviled with various problems
mitigating against consistency with their clinical pro-
grams. These include frequent strikes, interprofessional
rivalry and conflicts, poor work ethic, and poor mainte-
nance culture. These also are challenges similar to many
other countries in the subregion. Payment for kidney
transplantation and other forms of KRT in many of these
countries remain out of pocket, with the exceptions being
South Africa, Mauritius, and Kenya, where the govern-
ments of these countries have actively supported the
KRT programs. These countries also have the best-
resourced and fastest-growing kidney transplant pro-
grams in all of sub-Saharan Africa, and together with
Cote d’Ivoire, Nigeria, Angola, and Uganda are the only
ones that have enacted human organ transplantation leg-
islation. dgTgaeEnd
gTagdeP he coronavirus disease-2019 (COVID-19) pandemic
had a devastating effect on the kidney transplant pro-
grams in all units in Nigeria. All units suspended trans-
plantation during the first year of the pandemic, with
some resuming in December 2020 when the pandemic
numbers decreased. Since then, with better knowledge
and experience with managing COVID-19 infections
and with the availability of vaccines, the numbers of
transplants have increased to pre-COVID levels.TadgEgdenATGDGEH1ZIMBABWE TGAGEEDND
TaggeCdP urrently, Zimbabwe does not have a kidney transplant
program. However, after initial workup the patient and
donor are sent abroad, either to India or South Africa, for
their transplant. This is true for many other countries in
sub-Saharan Africa. The patients then are followed up
after transplantation in Zimbabwe. Very few patients can
afford the costs of this life-saving surgery and there is no
government subsidy for renal transplantation. ETeadgdgnTAEGGD1H HANA TAEGGDNED
TaggPedIn 2008, LD kidney transplantation commenced in Korle
Bu Teaching Hospital in Ghana 6 The program was sup-
ported by a team of transplant surgeons and nephrolo-
gists from the University Hospital in Birmingham and
by the Transplant Links Community.6 Twenty-one trans-
plants were performed between 2008 and 2019, with a 1-
year patient and graft survival of 95.2% and 90.5%,
respectively, and the 5-year patient and graft survival
were 76.2% and 71.4%, respectively.6 All the donors are
currently in good health. Since then, clinical and surgical
expertise was attained locally and through training pro-
grams in South Africa and the United Kingdom. The
main challenge confronting the sustainability of this pro-
gram is the lack of a legislative framework to guide
organ donation and transplantation. A community survey
in Ghana showed that approximately 50% of Ghanaians
were willing to donate their kidneys and more than 70%
will do so when dead.11 Even though Ghanaians are will-
ing donate their kidneys, without a legislative frame-
work, it is difficult to establish a DD transplant program.
The legislative framework was drafted by the Ghana
Attorney General’s office with the assistance of the
Ghana Kidney Association in 2016 and it currently is
awaiting approval by legislators. TaggendEd
aTggePdKidney transplantation was suspended temporarily in
Ghana after December 2019 because of the COVID-19
pandemic. Seven of our kidney transplant recipient
patients developed COVID-19 infection and two of these
with severe COVID-19 pneumonia died. The transplant
team are planning to resume the transplant program in
2023.TadgEgdenTAEGGD1H FRICAN PEDIATRIC TRANSPLANT PERSPECTIVE TADGEGDEN
TagdgeP ediatric kidney transplantation is the definitive treat-
ment for infants, children, and adolescents who have
end-stage kidney disease.12 Furthermore, pre-emptive
kidney transplantation from a living-related donor before
dialysis is superior for children in terms of growth and
development as opposed to spending a long time on
aTgSgneEdd uccess of renal transplant programs 3dialysis with the associated negative effects, including
disruption in school attendance.13 Prioritization of chil-
dren on the transplant waiting list also is important
because it allows children to thrive. Unfortunately, in
low-resource settings such as Africa, children with kid-
ney disease often come from a long distance from the
kidney center, present late, and have very few symptoms
apart from poor growth and anemia. This means that the
diagnosis of kidney failure is delayed.14TaggdeEnd
eagTgdCP ongenital abnormalities of the urinary tract often are
responsible for infant end-stage kidney disease. How-
ever, in many regions, maternal antenatal scans are not
performed routinely, resulting in patients presenting late
with obstructed renal systems (eg, posterior urethral
valves) in need of urologic care. Access to KRT is lim-
ited in adults and even more so in children.14,15 Efforts
by nephrology organizations such as the International
Pediatric Nephrology Association, the International
Society of Nephrology, the International Society of Peri-
toneal Dialysis, and the International Pediatric Trans-
plantation Association have supported and expanded
training programs of health care professionals. TaggEednd
TaggdePIn addition, access to kidney transplantation is limited
for children in low-resource settings, especially for those
younger than age 12 years. Such patients often are sent
to countries such as India for transplantation at great
cost.16 Rates in Europe for pediatric transplants range
from 0 to 13.5 per million children population, compared
with very poor rates of less than 4 per million children
population in lower-middle−income countries.17-19
Pediatric kidney transplantation are mostly associated
with an adult transplant unit as this gives access to histo-
compatibility laboratories, radiology, surgeons—both
transplant and urology, as well as immunosuppressant
drugs. Living donors also need assessment, including
careful tissue typing and surgical management for those
donating a kidney to pediatric cases. Specific pediatric
workup requires input from a multidisciplinary team
including pediatricians, pediatric trained nurses, dieti-
tians, and social workers.19 Before transplantation, it is
important to complete a full childhood vaccination pro-
tocol, as well as monitoring viral markers post-trans-
plant, such as the Epstein-Barr virus, which is
responsible for post-transplant lymphoproliferative dis-
order. The drugs used for pediatric kidney transplanta-
tion are the same as those used for adults, but the
metabolism of these may be different in children, making
close monitoring of kidney function and drug levels
important. Postoperative high dependency care or inten-
sive care facilities for children are needed for careful
hemodynamic and fluid monitoring as well as emergency
dialysis. There is also a need for post-transplant avail-
ability of kidney biopsies in children to assess for rejec-
tion, drug toxicity, and viral infections. Adolescent
compliance remains a major challenge worldwide and
requires a champion for both adults and children togetherwith psychological support.20 Adult renal and transplant
registries are developing in lower-middle−income coun-
tries and also are important in pediatric nephrology to
assess in future planning of pediatric-specific facilities
and governmental advocacy.21 The future of KRT and
transplantation in low-resource regions seems brighter
not only for adults but also for children, with an increase
in trained pediatric nephrologists, but a lot of work still
is needed.22,23 Roadmaps looking at the way forward for
kidney disease care for patients of all ages remains
important.24TaggEednd
TgagePd he COVID-19 pandemic impacted the living-related
kidney transplant program because the increased need for
availability of adult beds in the hospital meant that donors
could not be admitted. Pediatric DD transplantation, how-
ever, continued during the COVID-19 pandemic.TadgEgdenATGDGEH1INDIA TGAGEEDND
TaeggdPIn India, organ transplantation is regulated by the Trans-
plantation of Human Organs Act, 1994, and amended in
2011 to expand the donor pool.25 The act prohibits unethi-
cal unrelated transplants, and to increase the donor pool
made provisions for deceased organ donations. According
to Indian law, explicit consent is required for organ dona-
tion. The consent of the next of kin is mandatory after
death.27 Presumed donation is not practiced in India. The
concept of mandatory brain death declaration has been
proposed and practiced legally in some Indian states.EaeggTdnd
TaeggdPIn India, LD kidney transplants are 10 times more fre-
quent than DD transplants.26 Despite being the second-
most populous country in the world, India has a low
deceased organ donation rate at 0.5 per million popula-
tion.27 Sociocultural and religious beliefs are the major
reasons for low deceased donations in India.28 Organ
donation after a cardiac death is rare in India.28 India has
approximately 550 transplant centers, and 140 non trans-
plant organ retrieval centers are officially registered with
state-appropriate authorities. According to 2020 data,
approximately 30,000 patients are on the waiting list for
a kidney transplant.26 TaggendEd
aTgdgePIn 2019, of 9,994 kidney transplants, 11% were from
the DD pool and only a meager 2% constituted a pediat-
ric transplantation.26 Gender disparity was predominant,
with 28% of kidney recipients being women and 72%
men. ABO-incompatible transplantation and paired-kid-
ney-exchange kidney transplantations are performed in a
few canters with reasonably good graft and patient sur-
vival rates. Financial support is given to patients under-
going organ transplantation in the public sector and this
includes the transplant surgery cost and free life-long
post-transplant immunosuppression. Most state schemes
support kidney transplantation to people living below the
poverty line. aTgdgeEdn
TgagedPIn India, rates of death-censored kidney allograft sur-
vival at 1, 3, and 5 years after transplant are 94%, 90%,
aTgdgeEnd4 E.L. Bamgboye et al.and 79%, respectively, and the patient survival rates are
92%, 87%, and 83%, respectively. Similar rates of graft
and patient survival are reported in elderly patients, with
a 5-year survival rate of 82% to 86%.29,30ETeadgdgn
TagdgePBarriers for organ transplantation include equity of
access, socioeconomic factors, and inadequate health lit-
eracy. Similarly, for deceased organ donation, the cul-
tural and religious beliefs, lack of awareness, advocacy
among the physician community regarding the declara-
tion process, and misconceptions about utilization are
the major factors.31-33 TaeggdnEd
TaggPedLive donor kidney transplantation of foreigners is
legal and regulated by the Transplantation of Human
Organs Act. Permission for transplantation is obtained
from the appropriate authority and clearance from the
Embassy is obligatory. No incentives are sanctioned for
either live or deceased donation. Organ trafficking and
commercialization are prohibited. Directed organ dona-
tion or deceased donor chains are not practiced in India.TaggEednd
TgagePdDuring the COVID-19 pandemic, India had the sec-
ond largest number of cases. The first case of COVID-19
infection was reported on January 30, 2020. The
COVID-19 pandemic had a significant negative impact
on both live and deceased donor kidney transplants in
India. There was a sharp decrease in the number of kid-
ney transplants from 9,751 in 2019 to 5,486 in 2020.
There was also a reduction in the number of transplants
during the second wave of COVID-19 infections in
2021.34,35 Consensus guidelines were issued by the
Indian Society of Transplant regarding the selection/
preparation of recipients and donors.36 With theTaegFgdigure
Figure 1. Unadjusted transplant rates per million population
RD, related donor; URD, unrelated donor. Reprinted with permavailability of vaccination, the rate of renal transplants
increased to pre-COVID levels. High mortality rates
were observed in renal transplant recipients admitted
with COVID infection.36TadgEgdenTAMGHGDE1 EXICO AGTGEDEND
agTgePd he first kidney transplant (LD) in Mexico was per-
formed in 1963 followed by a DD kidney transplant in
1966. The lack of infrastructure, trained personnel, high
costs, and the absence of legislation regulating organ
donation and tissue transplantation resulted in low trans-
plant activity over the following decade. In 1973, regula-
tion on organ and tissue transplantation was introduced
for the first time in the Mexican Health Code. In 1984,
legislation on organ and tissue donation and transplanta-
tion was passed by the Mexican congress, followed by
the creation of the National Transplant Registry in
1988.37 In 2000, the transplant registry was replaced by
a central coordinating center, the National Transplant
Center, and by the establishment of a network of nation-
wide transplant coordinating centers.38,39 In 2003, the
Federal Commission for the Protection against Sanitary
Risks took over the surveillance and control of transplant
activities in the country. Finally, in 2011 and 2013, legis-
lation on organ and tissue retrieval and distribution was
passed by congress, delegating this responsibility to the
internal transplant committee of each hospital authorized
for the practice of transplantation.38,40 By law, living
organ donation is restricted to adults age 18 years and
older, and deceased organ donation requires the(pmp), by (A) donor type, (B) gender, and (C) insurance.
ission.38EdeggTdan
aTgSgneEdd uccess of renal transplant programs 5authorization of the next of kin, even if the deceased per-
son had explicitly expressed their wish to donate their
organs in case of death. These activities resulted in an
increase in kidney transplantation in the country.
Between 1984 and 2019, the transplant rate increased
from 1.57 to 23.2 per million population (pmp), and the
proportion of deceased-organ donor kidney transplanta-
tion increased from 12% to 27%.38 By 2019, more than
53,000 kidney transplants had been performed in
Mexico. dgTgaeEnd
PTeaggdA recent analysis of more than 34,000 kidney trans-
plants performed between 2007 and 2019 reported that
73% of transplants were from LDs, 27% from DDs, and
9% from living-unrelated donors (LURDs) (Fig. 1A).38
In 2020, the estimated LD graft survival at 1, 2, 3, and
4 years was 95%, 92%, 87%, and 74%, whereas DD graft
survival was 88%, 82%, 75%, and 69%, respectively. For
recipients of a LD kidney transplant, patient survival at
1, 2, 3, and 4 years was 97%, 96%, 94%, and 87%,
whereas for DD recipients patient survival was 90%,
88%, 87%, and 79%, respectively.41 According to recent
data, there are more than 17,000 patients on the national
waitlist. TgagednEd
TaggedPAmong the identified barriers to kidney transplanta-
tion in Mexico, the most important is the lack of health
insurance. Uninsured patients represented only 26% of
all transplants and transplantation rates remained signifi-
cantly lower among the uninsured population (9.3 versus
41.7 pmp) in comparison with patients with health insur-
ance (Fig. 1B)TaggdeEnd
aTggePdSimilarly, uninsured patients were less likely to be
registered on the national transplant waiting list. Only
12% of patients listed in the study period belonged to
this population. Uninsured patients must bear the cost of
transplant surgery, as well as the cost of maintaining the
immunosuppressive therapy. TaggedEnd
S 42-46TegdPga imilar to reports from other countries, gender
disparities are prevalent in kidney transplantation in Mex-
ico. Transplant rates were significantly lower in women
than in men (30.7 versus 16.4 pmp) (Fig. 1C), and less
than 50% of the patients listed in the national transplant
list were women. On the contrary, females represented
the majority of LD (53.1% versus 46.9%).38 It is known
that Mexican women are more likely to be donors, a deci-
sion probably driven by economic dependency. In addi-
tion, organ donation is identified as another form of
nurturing, leading to what has been described as the femi-
nization of organ donation in Mexico.47TadgEgden
TgagedAP n additional barrier to transplantation is the bureau-
cracy of the Mexican public health care system. Success-
fully navigating the health care system in Mexico
requires a combination of favors, personal connections,
and political pressure to speed up the work-up for trans-
plantation. Patients who do not have enough economic
and intellectual resources to facilitate their access to
transplant candidacy seldom receive a transplant.45 Inaddition, patients without health insurance must often
manage a wide range of formal and informal (paper-
work) health information.48-50 TagegdEnd
TagegdPDD kidney transplantation (7.2 pmp) and deceased
organ donation (3.2 pmp) rates are among the lowest in
Latin America.51 The cause of these lower rates is multi-
factorial. Traditionally, the shortage of deceased organ
donors in Mexico has been attributed to public ignorance
about organ donation and family refusals to donate. In a
recent report, family refusal ranged between 62% and
75%.52 However, in a prospective report of potential
deceased donors, an overall consent rate of 50% was
found, similar to the rate reported in the United
States.47,53 Furthermore, in two surveys on organ dona-
tion in Mexico, 80% of the interviewed persons knew
about organ donation, and 75% to 89% would authorize
organ donation from a deceased relative.54,55 The short-
age of deceased organ donors has resulted in an increase
of LURDs, especially in private transplant facilities,
where LURDs represented 20.2% of all the transplants
performed in this setting, in comparison with 6.4% in
public facilities, raising concerns of organ
commercialization.38,56TaegEgdnd
TaegPgdFinally, COVID-19 pandemic health policies in Mex-
ico were associated with an important reduction of kid-
ney transplantation, largely in public institutions
compared with private facilities (90% versus 42%,
respectively). In March 2020, all kidney transplantation
activity was suspended, and only life-saving procedures
(liver and heart transplants) were allowed. In late June
2020, the program was reactivated using a traffic light
system, with increasing levels represented by different
colors to regulate public health restrictions. Only trans-
plant facilities with an appropriate number of health care
workers, and hospitals with intensive care unit beds, and
COVID-19−free zones were allowed to perform trans-
plants.57 As a result, kidney transplantation decreased by
89% at public facilities versus by 57% at private. Like-
wise, an 83% decrease in kidney procurement occurred
during the study period. Waiting list additions also were
reduced by 82% during the pandemic. Hospital reconver-
sion, a shortage of health care workers low intensive care
unit capacity, uncontrolled viral transmission in the com-
munity, and the lack of exclusive transplantation and
donation centers were identified as the most important
factors limiting the number of transplants at public insti-
tutions.57 Similar to elsewhere, Mexican chronic kidney
disease patients have been identified as a high-risk popu-
lation for COVID-19 infection and mortality.58 How-
ever, they have never been considered a priority to
vaccinate by Mexico’s health authorities. daegEgdTnATGDG1EHCONCLUSIONS GTEAGDNED
agTgePdWe describe kidney transplant services in Mexico, India,
Ghana, Nigeria, Zimbabwe, and South Africa, the latter
aTgdgeEnd6 E.L. Bamgboye et al.with a focus on children. Access to kidney transplanta-
tion is limited in these low- and middle-income coun-
tries. In sub-Saharan Africa, only eight countries have
kidney transplant programs. Children and women are
disproportionately disadvantaged in these programs
because of a lack of expertise regarding pediatric care
and because women are the predominant donors, not
recipients. Most kidney transplants in low- or low-mid-
dle−income countries are from live donors, and the lack
of legislation often precludes DD, thus further work is
needed to enable donation. The COVID pandemic had a
deleterious effect on transplant activity, however, the
availability of vaccinations and treatments should facili-
tate transplantation. Transplantation programs in low-
resource settings require considerable effort to start and
maintain. In the long term, kidney transplantation is the
most cost effective and life-sustaining kidney replace-
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