Appendices Responsibilities of SCOT 78 Regulations of Organ Transplantation in KSA 79 Memorandum by the Minister of Health on Deceased Organ 80 Donation Official Statement of the National Committee for the Diagnosis 81 of Death by Neurological Criteria and Ventilator System Purport of the Senior Ulama Commission 82 Resolution of the Council of Islamic Jurisprudence on 83 Resuscitation Apparatus

Glossary 84 Abbreviations 85 Index Tables 86 Figures 87

Health Statistics Annual Book, p.18; www.moh.gov.sa

Health Statistics Annual Book, p.14; www.moh.gov.sa

Health Statistics Annual Book, p.16; www.moh.gov.sa 1

Renal Replacement Therapy

Preface

The Annual Report of 2014 highlights the present status of ESRD patients in Renal Replacement Therapy in the Kingdom of Saudi Arabia. SCOT as the central coordinating body in renal replacement therapy have taken all necessary steps to ensure accuracy of all the information and data in this annual report.

The incidence rate of patients suffering from ESRD in the kingdom has been consistently increasing. Currently, 136 incidences of ESRD patients per million populations (PMP) were recorded and were expected to grow to the upcoming years. From 1971 since the first dialysis center was erected in the Kingdom, rapid advances have been made in the field of renal replacement therapy to cater the growing numbers of patients with ESRD. Currently, Hemo- dialysis (HD) and Peritoneal Dialysis (PD) were the most prepared modality of treatment for patients with renal failure, with 187 HD & 35 PD hospitals and dialysis centers in the Kingdom catering to 15,782 of patients.

ANNUAL REPORT 2014 2

Hemodialysis Introduction

In 2014, a total of 187 hospitals and dialysis The proportion of hemodialysis patients centers Units from Ministry of health, Gov’t treated with Erythropoietin ranges from 10 Non-MOH & Private sector hospitals were and 100% with average of 86%. Vitamin D’s catering the needs of ESRD patients, were also used with 51% given orally while utilizing 5732 hemodialysis machines with 13% of the patients are receiving via 4428 number of outlet connections injectable route. Other medications such as combined. insulin and oral hypoglycemic were also utilized with 21% of patients receiving By the end of 2014, a total of 14366 patients insulin, 9% on oral hypoglycemic and 11% on Hemodialysis were recorded by SCOT, of were put on diet control. these 3687 were new patients. Blood group among dialysis patients were also noted Active HD patient’s blood levels such as with type O group averaging 52% and the Hematocrit, albumin and calcium were also least were those of blood group AB with monitored. In which, 21% of HD patients 4%. Age Distribution of patients reveals have Hct level of < 30%, 14% have albumin that most were in the productive age group of <30 g/dl, 27% have phosphorous levels of 26-65 years with a total of 75%. Sexes greater than 1.9 µmol/L and 22% have were also recorded showing that male calcium levels of less than 2.1 µmol/L. patients composed 57% of patients and female with (43%). By nationalities, Saudis Of the 14,366 patients on HD, 20% are in on HD are 84% compared to Non-Saudi the active waiting list or those patients counterparts with 16%. Vascular access evaluated and are ready for renal among dialysis patients shows that AVF or transplantation. While, the mortality rate arteriovenous fistulas were the most among HD patients by the end of 2014 were preferred site with 67% of the patients 11% having them. It was estimated that the numbers of Hepatitis B and C infection has been a Dialysis patients will be increasing constant challenge among health care continuously and numbers are expected to provider in stopping the contamination climb up to 20,000 patients by the end of amongst patients undergoing Hemodialysis. 2020. Hepatitis B infections were in good control averaging 3.4% per year, while patients diagnosed with Hepatitis C it is worth mentioning that it has been contained for the last five years with the current average of 15.5% this year. Among Patients on Hemodialysis, 59% were found to be hypertensive, while 44% are diabetic.

ANNUAL REPORT 2014 3

HD Hospitals Region Wise by Sector

Central Region MOH Hemodialysis Centers in Riyadh Region N Hospital 1 Childrens Hospital (RMC) 2 Dawadmi General Hospital 3 Shagra General Hospital 4 Thadiq General Hospital 5 Afif General Hospital 6 Al Aflaj General Hospital 7 Al Ghat General Hosptal(PNSSH) 8 Al Iman General Hospital 9 Al Muzahimiya General Hospital 10 Al Qawaeyah General Hospital 11 Al Sulayel General Hospital 12 Al Zulfi General Hospital 13 Artawiya General Hospital 14 Hotat Bani Tamim General Hospital 15 Hotat Sudair General Hospital 16 Huraimala General Hospital 17 King Khalid Hospital- Al Kharj 18 King Khalid Hospital- Majma'ah 19 King Salman for Kidney Disease Riyadh 20 King Salman Hospital Riyadh 21 Nafee General Hospital 22 Prince Salman Bn Mohd- Delim 23 Rumah General Hospital 24 Ruwaidah Hospital 25 Sajir General Hospital 26 Tumair General Hospital 27 Wadi Dawasir General Hospital 28 King Saud Medical City- Riyadh Prince Mohammad Bin Abdulaziz Hospital Hospital- 29 Riyadh* *Diaverum

ANNUAL REPORT 2014 4

HD Hospitals Region Wise by Sector

Central Region Govt. Non-MOH Hemodialysis Centers in Riyadh Region N Hospital 1 Al Kharj Military Industrial Corp. Hospital, Riyadh 2 King Faisal Specialist Hospital- Riyadh 3 King Abdulaziz Medical City, Riyadh (KFNGH) 4 King Khalid University Hospital- Riyadh 5 Prince Sultan Military Medical City - Riyadh 6 King Abdullah Hemodialysis Project-Riyadh South Center* 7 Security Forces Hospital – Riyadh** *National Guard **Diaverum

Private Hemodialysis Centers in Riyadh Region N Hospital 1 Al Khawalid kidney & dialysis Center- Riyadh 2 Arab Medical Dar Dialysis Center- Riyadh 3 Dar Al Shifa Hospital- Riyadh 4 Dr. A. Al Mishari Hospital- Riyadh 5 Demas Dialysis Center 6 Dr. Ali Lahibi Dialysis Center, Riyadh 7 Dr. Suleiman Al Habeeb Medical Center- Riyadh 8 Riyadh Care Hospital 9 Riyadh National Hospital 10 Saudi German Hospital- Riyadh

11 Specialized Medical Center Hospital- Riyadh 12 Sultan B.A. Humanitarian City- Riyadh 13 Al Hammadi Hospital- Riyadh 14 Kingdom Hospital- Riyadh

ANNUAL REPORT 2014 5

HD Hospitals Region Wise by Sector

Central Region MOH Hemodialysis Centers in Qassim Region N Hospital 1 King Fahd Specialist Hospital- Buraida 2 King Saud Hospital Unaiza* 3 Al Asyah General Hospital 4 Al Bukariya General Hospital 5 Al Midnab General Hospital 6 Al Rass General Hospital 7 Ayun Al Juwah General Hospital 8 Buraida Central Hospital** 9 Dhariyah General Hospital 10 Oklat Al-Sugour General Hospital 11 Qiba General Hospital 12 Riyadh Al Khabra General Hospital *Diaverum **MOH Outsourcing Dialysis Program Davita

ANNUAL REPORT 2014 6

HD Hospitals Region Wise by Sector

Western Region MOH Hemodialysis Centers in Makkah/Jeddah/Taif Region N Hospital 1 Adhum General Hospital 2 Al Laith General Hospital 3 King Abdul Aziz Hospital - Jeddah** 4 King Abdul Aziz Specialist Hospital- Taif 5 King Faisal Hospital Makkah 6 King Fahad Hospital- Jeddah 7 Al Khurma Hospital 8 Al Noor Specialist Hospital 9 Al Qunfudah General Hospital* 10 King Abdul Aziz Hospital- Makkah 11 Messan General Hospital 12 Rabiq General Hospital 13 Raniah General Hospital 14 Turabah General Hospital 15 Prince Abdul Majid Dialysis Center* *Diaverum **Davita

Govt. Non-MOH Hemodialysis Centers in Makkah/Jeddah/Taif Region N Hospital

1 Al Hada Armed Forces Hospital- Taif

2 King Abdul Aziz University Hospital- Jeddah

3 King Abdulaziz Medical City- Jeddah (KFNGH)

4 King Fahad Armed Forces Hospital- Jeddah 5 King Faisal Specialist Hospital- Jeddah 6 King Abdullah Hemodialysis Project-Jeddah* *National Guard

ANNUAL REPORT 2014 7

HD Hospitals Region Wise by Sector

Western Region Private Hemodialysis Centers in Makkah/Jeddah/Taif Region N Hospital 1 Abdulakrim Bakr Medical Center, Jeddah 2 Al Bir Clinic 1 Charity D.C, (Al Kandara) Jeddah 3 Al Faisal Polyclinic- Jeddah 4 Al Mustagbal Hospital- Jeddah 5 Al Takaful Al- Khairy K.D.C Makkah 6 Asia Dialysis Center - Makkah 7 Charity Community Dialysis Center- Makkah 8 Dr. Abdurahman Baksh Hospital- Jeddah 9 Dr. Erfan and Bagedo- Jeddah

10 Dr. Suleiman Al Fakeeh Hospital- Jeddah

11 New Jeddah Clinic Hospital 12 Prince Mansour Charity Dialysis Center- Jeddah 13 Taibah Dialysis Center- Makkah 14 Al Bir Charity Dialysis Center (2)Jeddah 15 Bugshan General Hospital - Jeddah 16 International Renal Care Center- Jeddah 17 Saudi German Hospital- Jeddah 10 Basharahil Hospital- Makkah

MOH Hemodialysis Centers in Madina Region N Hospital 1 Al Eass General Hospital 2 Al Mhad General Hospital 3 Badr General Hospital 4 King Fahad Hospital- Madina 5 Prince Abdul Mohsin Hospital. A1 Ulla 6 Al Hanakiya General Hospital 7 Khaiber General Hospital 8 Yanbu General Hospital

Govt. Non-MOH Hemodialysis Centers in Madina Region N Hospital 1 Royal Commission Medical Center- Yanbu

ANNUAL REPORT 2014 8

HD Hospitals Region Wise by Sector

Western Region Private Hemodialysis Centers in Madina Region N Hospital

1 Madina National Hospital 2 Saudi German Hospital- Madina

ANNUAL REPORT 2014 9

HD Hospitals Region Wise by Sector

Eastern Region MOH Hemodialysis Centers in Eastern Region N Hospital

1 Al Jubail General Hospital

2 Dammam Medical Complex 3 King Fahad Specialist Hospital- Dammam

4 Abgaig General Hospital

5 Al Gaissoma General Hospital 6 Al Nairiyiah General Hospital

7 King Fahad Hospital- Hofuf 8 King Khalid General Hospital- Hafar al Baten* 9 Qateef Central Hospital *Diaverum

Govt. Non-MOH Hemodialysis Centers in Eastern Region N Hospital 1 Royal Commission Hospital- Jubail (Ex. Al Fanater)

2 Dahran Health Center (ARAMCO)

3 King Abdul Aziz Medical City, Ahsa (NG)

4 King Fahad Military Medical Complex- Dhahran

5 King Fahad University Hospital- Al Khobar 6 King Khalid Medical City- Hafar Al Batin 7 Al Khafji Joint Operation Hospital

Private Hemodialysis Centers in Eastern Region N Hospital 1 Al Mouwasat Hospital- Dammam 2 Al Moosa General Hospital, Ahsa 3 Saad Specialist Hospital- Al Khobar 4 Al Ahsa Hospital 5 Al Mana Hospital- Dammam 6 Al Mouwasat Hospital- Qateef

ANNUAL REPORT 2014 10

HD Hospitals Region Wise by Sector

Northern Region MOH Hemodialysis Centers in Al Jouf Region N Hospital 1 Domat Al Jundal General Hospital 2 Prince A.R Sudeiry Hospital- Skaka 3 Tabarjal General Hospital

MOH Hemodialysis Centers in Hail Region N Hospital 1 Al Shammali General Hospital 2 Al Sulaymi General Hospital 3 Hail General Hospital 4 King Khalid Hospital- Hail 5 Baqaa General Hospital 6 Samira General Hospital

MOH Hemodialysis Centers in Northern Borders Region N Hospital 1 Al Owaigila General Hospital 2 Ar-ar Central Hospital

3 Al Qurrayat General Hospital 4 Rafah General Hospital 5 Turaif General Hospital

MOH Hemodialysis Centers in Tabuk Region N Hospital 1 Al Hawraa Hospital Amloj 2 King Khalid Hospital- Tabuk

3 Al Bada General Hospital

4 Al Wajeh General Hospital 5 Dhuba General Hospital 6 Haql General Hospital

7 Tayma General Hospital

Govt. Non-MOH Hemodialysis Centers in Tabuk Region N Hospital 1 King Salman Military Hospital Tabuk

ANNUAL REPORT 2014 11

HD Hospitals Region Wise by Sector

Southern MOH Hemodialysis Centers in Al Baha Region N Hospital

1 Gilwah General Hospital

2 King Fahad Hospital- Al Baha

3 Al Mandag General Hospital

4 Al Mikhwah General Hospital

5 Beljurasy General Hospital

6 Gilwah General Hospital

Private Hemodialysis Centers in Al Baha Region N Hospital

1 Ghodran Hospital- Beljurashi

MOH Hemodialysis Centers in Assir Region. N Hospital

1 Al Majardah General Hospital 2 Assir Kidney Center 3 Balasmar General Hospital 4 Mohayel General Hospital 5 Sabt Al Alayah General Hospital 6 Ahad Rufaidah General Hospital

7 Al Nammas General Hospital 8 Dharan Al Janoub Hospital 9 K.A.A.Daughter's Charity Center for Renal Diseases 10 Rijal Almaa General Hospital

11 Sarat Obaidah General Hospital

12 Tathleeth General Hospital

13 Besha General Hospital (Psych. H)*

14 Khamis Mushayt General Hospital* *Diaverum

ANNUAL REPORT 2014 12

HD Hospitals Region Wise by Sector

Southern Govt. Non-MOH Hemodialysis Centers in Assir Region N Hospital

1 KFMH- Khamis Mushayt

Private Hemodialysis Centers in Assir Region N Hospital 1 Saudi German Hospital- Abha 2 Abha Private Hospital

MOH Hemodialysis Centers in Gizan Region N Hospital

1 King Fahad Central Hospital- Gizan 2 Sabia General Hospital 3 Fursan General Hospital 4 Samtha General Hospital

MOH Hemodialysis Centers in Najran Region N Hospital

1 Habona General Hospital 2 King Khalid Hospital - Najran 3 Sharurah General Hospital

ANNUAL REPORT 2014 13

HD Hospitals Region Wise by Sector

Outsourcing Hemodialysis Centers

MOH Diaverum

Central Region Riyadh Prince Mohammad Bin Abdulaziz Hospital Hospital-Riyadh Qassim King Saud Hospital Unaiza

Western Region Makka/Jeddah/Taif Al Qunfudah General Hospital Prince Abdul Majid Dialysis Center

Eastern Region King Khalid General Hospital- Hafar al Baten

Southern Region Assir Besha General Hospital (Psych. H) Khamis Mushayt General Hospital

MOH Davita

Central Region Qassim Buraida Central Hospital

Western Region Makka/Jeddah/Taif King Abdul Aziz Hospital - Jeddah

Govt. Non-MOH Diaverum (Prince Naif Dialysis Center)

Central Region Riyadh Security Forces Hospital - Riyadh

ANNUAL REPORT 2014 14

Table 1: Total No. of Hemodialysis Centers in MOH* According to Region Total No. of No. of Follow No. of Consultant Nephrology No. of Outlet Total HD Region GP's Nurses HD up Tx. Pts Hospitals Nephrologists Specialists Connections Pts. 2014 Machines 2014 Riyadh 29 17 39 90 516 511 804 1474 471 Makkah/Jeddah 13 15 33 35 363 378 449 1593 362 Madina 8 6 9 10 170 206 285 758 137 Tabuk 7 1 6 14 71 143 178 260 155

Eastern 8 19 19 30 469 229 283 1066 332

Qassim 10 5 7 15 106 133 202 406 35 Al Baha 5 1 3 8 53 78 135 231 0 Al Jouf 3 0 6 8 55 63 108 202 0 Northern Borders 5 2 4 10 70 147 154 191 42 Hail 6 1 3 13 45 100 149 294 43 Jizan 4 2 7 8 124 124 177 659 96 Najran 3 2 3 4 46 79 98 185 0 Assir 12 0 13 11 161 227 319 795 53

Total 113 71 152 256 2249 2418 3341 8114 1726

*MOH Excluding Outsourcing Dialysis Program (Diaverum and Davita)

ANNUAL REPORT 2014 15

Table 1.1: Total No. of Hemodialysis Centers in MOH* According to Region Non- New Pts. HBsAg+ve HCV+ve Pts < 15 Diabetic Hypertensive HD Pts. Region Pts > 75 yrs Both Saudi Pts in 2014 Pts Pts Yrs Pts Pts Died 2014 Riyadh 106 240 61 254 40 117 221 394 556 145 Makkah/Jeddah 196 346 63 437 19 60 192 546 263 221 Madina 95 195 21 113 18 35 82 166 225 79 Tabuk 26 69 13 51 6 29 35 88 86 25 Eastern 92 251 23 127 16 65 143 281 444 115 Qassim 25 73 16 51 2 35 35 182 147 38 Al Baha 7 40 7 47 0 18 32 91 53 18 Al Jouf 8 50 0 23 6 19 66 43 55 22 Northern Borders 4 26 8 21 8 9 39 40 107 29 Hail 10 102 4 46 4 36 69 60 75 43 Jizan 117 130 49 146 8 29 60 279 65 99 Najran 32 56 9 18 8 6 45 52 33 16 Assir 30 158 26 122 1 103 79 204 229 65

Total 748 1736 300 1456 136 561 1098 2426 2338 915 *MOH Excluding Outsourcing Dialysis Program (Diaverum and Davita)

ANNUAL REPORT 2014 16

Table 2: Total No. of Hemodialysis Centers in MOH* DAVITA Outsourcing Dialysis Program According to Region Total No. of No. of Follow No. of Consultant Nephrology No. of Outlet Total HD Region GP's Nurses HD up Tx. Pts Hospitals Nephrologists Specialists Connections Pts. 2014 Machines 2014 Riyadh 0 0 0 0 0 0 0 0 0 Makkah/Jeddah/Taif 1 2 4 5 18 17 29 48 0 Eastern 0 0 0 0 0 0 0 0 0 Qassim 1 1 10 0 31 48 53 96 0 Assir 0 0 0 0 0 0 0 0 0

Total 2 3 14 5 49 65 82 144 0

Table 2.1: Total Data on Hemodialysis Patients in MOH* DAVITA Outsourcing Dialysis Program According to Region Non- New Pts. in HBsAg+ve HCV+ve Pts < 15 Pts > Hypertensive HD Pts. Hospital Name Saudi Diabetic Both 2014 Pts Pts Yrs 75 yrs Pts Died 2014 Pts Pts Riyadh 0 0 0 0 0 0 0 0 0 0 Makkah/Jeddah/Taif 0 6 0 13 0 0 11 17 8 6 Eastern 0 0 0 0 0 0 0 0 0 0 Qassim 0 96 2 9 2 5 4 31 41 2 Assir 0 0 0 0 0 0 0 0 0 0

Total 0 102 2 22 2 5 15 48 49 8

*MOH Outsourcing Dialysis Program Davita

ANNUAL REPORT 2014 17

Table 3: Total No. of Hemodialysis Centers in MOH* DIAVERUM Outsourcing Dialysis Program According to Region Total No. of No. of Follow No. of Consultant Nephrology No. of Outlet Total HD Region GP's Nurses HD up Tx. Pts Hospitals Nephrologists Specialists Connections Pts. 2014 Machines 2014 Riyadh 1 2 1 4 36 29 47 180 39 Makkah/Jeddah/Taif 2 4 9 36 60 138 133 350 0 Eastern 1 0 2 5 33 46 65 140 45 Qassim 1 0 1 0 19 20 32 151 1 Assir 2 2 1 2 34 68 89 247 0

Total 7 8 14 47 182 301 366 1068 85

Table 3.1: Total Data on Hemodialysis Patients in MOH DIAVERUM* Outsourcing Dialysis Program According to Region Non- New Pts. in HBsAg+ve HCV+ve Pts < 15 Pts > Hypertensive HD Pts. Hospital Name Saudi Diabetic Both 2014 Pts Pts Yrs 75 yrs Pts Died 2014 Pts Pts Riyadh 27 17 3 20 2 10 23 23 35 2 Makkah/Jeddah/Taif 5 232 17 83 1 42 78 126 39 27 Eastern 2 37 5 13 2 6 70 24 46 37 Qassim 1 12 4 12 2 10 50 48 19 18 Assir 4 27 3 22 2 18 14 46 76 14

Total 39 325 32 150 9 86 235 267 215 98

* MOH Outsourcing Dialysis Program Diaverum

ANNUAL REPORT 2014 18

Table 4: Total of Hemodialysis Centers in GOVT. NON-MOH** All Sectors According to Region Total No. of No. of Follow No. of Consultant Nephrology No. of Outlet Total HD Region GP's Nurses HD up Tx. Pts Hospitals Nephrologists Specialists Connections Pts. 2014 Machines 2014 Riyadh* 7 31 21 18 406 398 475 1137 3272 Makkah/Jeddah/Taif 6 19 24 4 244 337 385 817 415 Madina 1 1 1 0 17 24 24 61 13 Tabuk 1 3 1 0 68 38 55 210 183 Eastern 7 15 10 4 124 115 156 309 259 Assir 1 7 2 9 110 74 99 282 1853

Total 23 76 59 35 969 986 1194 2816 5995

Table 4.1: Total Data on Hemodialysis Patients in GOVT. NON-MOH** All Sectors According to Region

Non- New Pts. HBsAg+ve HCV+ve Pts < 15 Pts > Hypertensive HD Pts. Hospital Name Diabetic Both Saudi Pts in 2014 Pts Pts Yrs 75 yrs Pts Died 2014 Pts Riyadh* 29 375 43 133 15 143 160 243 358 73 Makkah/Jeddah/Taif 49 320 26 57 22 73 110 170 244 71 Madina 5 17 3 7 0 5 0 35 23 8 Tabuk 1 64 5 17 8 18 0 27 183 49 Eastern 17 65 7 17 0 41 8 78 154 44 Assir 1 137 8 19 6 32 36 88 102 32

Total 102 978 92 250 51 312 314 641 1064 277

**Gov’t Non-MOH including Outsourcing Dialysis Program Diaverum Riyadh (Prince Naif Dialysis Center in Security forces Hospital) & King Abdullah Hemodialysis Project)

ANNUAL REPORT 2014 19

Table 5: Total of Hemodialysis Centers in Private Sector According to Region Total No. of No. of Follow No. of Consultant Nephrology No. of Outlet Total HD Region GP's Nurses HD up Tx. Pts Hospitals Nephrologists Specialists Connections Pts. 2014 Machines 2014 Riyadh 14 10 16 11 131 192 206 607 33 Makkah/Jeddah/Taif 17 20 25 15 179 304 337 1241 77 Madina 2 2 1 1 6 13 14 30 0 Eastern 6 9 6 3 101 131 179 330 25 Al Baha 1 0 1 0 3 8 4 6 4 Assir 2 1 2 0 4 10 9 10 1

Total 42 42 51 30 424 658 749 2224 140

Table 5.1: Total Data on Hemodialysis Patients in Private Sector According to Region

Non- New Pts. HBsAg+ve HCV+ve Pts < 15 Pts > Hypertensive HD Pts. Hospital Name Diabetic Both Saudi Pts in 2014 Pts Pts Yrs 75 yrs Pts Died 2014 Pts Riyadh 364 164 12 77 6 46 72 203 193 48 Makkah/Jeddah/Taif 970 224 52 222 13 39 140 384 385 132 Madina 4 6 0 2 0 2 16 6 8 3 Eastern 33 145 3 33 0 65 7 60 241 52 Al Baha 2 2 0 6 0 1 1 1 3 0 Assir 4 5 0 2 0 0 0 4 4 0

Total 1377 546 67 342 19 153 236 658 834 235

ANNUAL REPORT 2014 20

Table 6: Total of Hemodialysis Centers in All Sectors According to Region Total No. of No. of Follow No. of Consultant Nephrology No. of Outlet Total HD Region GP's Nurses HD up Tx. Pts Hospitals Nephrologists Specialists Connections Pts. 2014 Machines 2014 Riyadh 51 60 77 123 1089 1130 1532 3398 3815 Makkah/Jeddah 39 60 95 95 864 1174 1333 4049 854 Madina 11 9 11 11 193 243 323 849 150 Tabuk 8 4 7 14 139 181 233 470 338 Eastern 22 43 37 42 727 521 683 1845 661 Qassim 12 6 18 15 156 201 287 653 36 Al Baha 6 1 4 8 56 86 139 237 4 Al Jouf 3 0 6 8 55 63 108 202 0 Northern Borders 5 2 4 10 70 147 154 191 42 Hail 6 1 3 13 45 100 149 294 43 Jizan 4 2 7 8 124 124 177 659 96 Najran 3 2 3 4 46 79 98 185 0 Assir 17 10 18 22 309 379 516 1334 1907

Total 187 200 290 373 3873 4428 5732 14366 7946

ANNUAL REPORT 2014 21

Table 6.1: Total Data on Hemodialysis Patients in All Sectors According to Region

Non- New Pts. HBsAg+ve HCV+ve Pts < 15 Pts > Hypertensive HD Pts. Hospital Name Diabetic Both Saudi Pts in 2014 Pts Pts Yrs 75 yrs Pts Died 2014 Pts Riyadh 526 796 119 484 63 316 476 863 1142 268 Makkah/Jeddah 1220 1128 158 812 55 214 531 1243 939 457 Madina 104 218 24 122 18 42 98 207 256 90 Tabuk 27 133 18 68 14 47 35 115 269 74 Eastern 144 498 38 190 18 177 228 443 885 248 Qassim 26 181 22 72 6 50 89 261 207 58 Al Baha 9 42 7 53 0 19 33 92 56 18 Al Jouf 8 50 0 23 6 19 66 43 55 22 Northern Borders 4 26 8 21 8 9 39 40 107 29 Hail 10 102 4 46 4 36 69 60 75 43 Jizan 117 130 49 146 8 29 60 279 65 99 Najran 32 56 9 18 8 6 45 52 33 16 Assir 39 327 37 165 9 153 129 342 411 111

Total 2266 3687 493 2220 217 1117 1898 4040 4500 1533

ANNUAL REPORT 2014 22

Table 7: Total of Hemodialysis Centers in MOH* All Sector According to Global Region Total No. of No. of Follow No. of Consultant Nephrology No. of Outlet Total HD Region GP's Nurses HD up Tx. Pts Hospitals Nephrologists Specialists Connections Pts. 2014 Machines 2014 Central 42 25 58 109 708 741 1138 2307 546 Western 24 27 55 86 611 739 896 2749 499 Eastern 9 19 21 35 502 275 348 1206 377 Northern 21 4 19 45 241 453 589 947 240 Southern 26 7 27 33 418 576 818 2117 149

Total 122 82 180 308 2480 2784 3789 9326 1811

Table 7.1: Total Data on Hemodialysis Patients in MOH* All Sector According to Global Region

Non- New Pts. HBsAg+ve HCV+ve Pts < 15 Pts > Hypertensive HD Pts. Died Hospital Name Diabetic Both Saudi Pts in 2014 Pts Pts Yrs 75 yrs Pts 2014 Pts Central 159 438 86 346 48 177 333 678 798 205

Western 296 779 101 646 38 137 363 855 535 333

Eastern 94 288 28 140 18 71 213 305 490 152

Northern 48 247 25 141 24 93 209 231 323 119

Southern 190 411 94 355 19 174 230 672 456 212

Total 787 2163 334 1628 147 652 1348 2741 2602 1021

* Including Diaverum and Davita Outsourcing dialysis Unit

ANNUAL REPORT 2014 23

Table 8: Total of Hemodialysis Centers in GOVT. NON-MOH** All Sector According to Global Region Total No. of No. of Consultant Nephrology No. of Outlet Total HD No. of Follow Region GP's Nurses HD Hospitals Nephrologists Specialists Connections Pts. 2014 up Tx. Pts 2014 Machines Central 7 31 21 18 406 398 475 1137 3272 Western 7 20 25 4 261 361 409 878 428 Eastern 7 15 10 4 124 115 156 309 259 Northern 1 3 1 0 68 38 55 210 183 Southern 1 7 2 9 110 74 99 282 1853

Total 23 76 59 35 969 986 1194 2816 5995

Table 8.1: Total Data on Hemodialysis Patients in GOVT. NON-MOH** All Sector According to Global Region

Non- New Pts. HBsAg+ve HCV+ve Pts < 15 Pts > Hypertensive HD Pts. Hospital Name Diabetic Both Saudi Pts in 2014 Pts Pts Yrs 75 yrs Pts Died 2014 Pts Central 29 375 43 133 15 143 160 243 358 73 Western 54 337 29 64 22 78 110 205 267 79 Eastern 17 65 7 17 0 41 8 78 154 44 Northern 1 64 5 17 8 18 0 27 183 49 Southern 1 137 8 19 6 32 36 88 102 32

Total 102 978 92 250 51 312 314 641 1064 277

**Gov’t Non-MOH including Outsourcing Dialysis Program Diaverum Riyadh (Prince Naif Dialysis Center in Security forces Hospital) & King Abdullah Hemodialysis Project)

ANNUAL REPORT 2014 24

Table 9: Total of Hemodialysis Centers in Private Sector According to Global Region Total No. of No. of Follow No. of Consultant Nephrology No. of Outlet Total HD Region GP's Nurses HD up Tx. Pts Hospitals Nephrologists Specialists Connections Pts. 2014 Machines 2014 Central 14 10 16 11 131 192 206 607 33 Western 19 22 26 16 185 317 351 1271 77 Eastern 6 9 6 3 101 131 179 330 25 Northern 0 0 0 0 0 0 0 0 0 Southern 3 1 3 0 7 18 13 16 5

Total 42 42 51 30 424 658 749 2224 140

Table 9.1: Total Data on Hemodialysis Patients in Private Sector According to Global Region

Non- New Pts. HBsAg+ve HCV+ve Pts < 15 Pts > Hypertensive HD Pts. Hospital Name Diabetic Both Saudi Pts in 2014 Pts Pts Yrs 75 yrs Pts Died 2014 Pts Central 364 164 12 77 6 46 72 203 193 48 Western 974 230 52 224 13 41 156 390 393 135 Eastern 33 145 3 33 0 65 7 60 241 52 Northern 0 0 0 0 0 0 0 0 0 0 Southern 6 7 0 8 0 1 1 5 7 0

Total 1377 546 67 342 19 153 236 658 834 235

ANNUAL REPORT 2014 25

Table 10: Total of Hemodialysis Centers in All Sectors According to Global Region Total No. of No. of Follow No. of Consultant Nephrology No. of Outlet Total HD Region GP's Nurses HD up Tx. Pts Hospitals Nephrologists Specialists Connections Pts. 2014 Machines 2014 Central 63 66 95 138 1245 1331 1819 4051 3851 Western 50 69 106 106 1057 1417 1656 4898 1004 Eastern 22 43 37 42 727 521 683 1845 661 Northern 22 7 20 45 309 491 644 1157 423 Southern 30 15 32 42 535 668 930 2415 2007

Total 187 200 290 373 3873 4428 5732 14366 7946

Table 10.1: Total Data on Hemodialysis Patients in All Sectors According to Global Region

Non- New Pts. HBsAg+ve HCV+ve Pts < 15 Pts > Hypertensive HD Pts. Died Hospital Name Diabetic Both Saudi Pts in 2014 Pts Pts Yrs 75 yrs Pts 2014 Pts Central 552 977 141 556 69 366 565 1124 1349 326 Western 1324 1346 182 934 73 256 629 1450 1195 547 Eastern 144 498 38 190 18 177 228 443 885 248 Northern 49 311 30 158 32 111 209 258 506 168 Southern 197 555 102 382 25 207 267 765 565 244

Total 2266 3687 493 2220 217 1117 1898 4040 4500 1533

ANNUAL REPORT 2014 26

Table 11: Total of Hemodialysis Centers in Saudi Arabia According to Sector No. of Consultant Nephrology No. of Outlet Total No. of HD Total HD No. of Follow up Hospital Sector GP's Nurses Hospitals Nephrologists Specialists Connections Machines Pts. 2014 Tx. Pts 2014 Ministry of Health Hospitals 113 71 152 256 2249 2418 3341 8114 1726

MOH: Diaverum 7 8 14 47 182 301 366 1068 85 MOH: Davita 2 3 14 5 49 65 82 144 0 GOVT. Non-MOH Hospitals 20 69 56 23 768 630 828 2271 5987 Gov’t. Non-MOH: King 2 5 1 8 146 301 301 348 8 Abdullah HD Project Gov’t. Non-MOH: Diaverum 1 2 2 4 55 55 65 197 0 Private Sector Hospitals 42 42 51 30 424 658 749 2224 140

Total 187 200 290 373 3873 4428 5732 14366 7946

Table 11.1: Total Data on Hemodialysis Patients in Saudi Arabia According to Sector Non-Saudi New Pts. HBsAg+ve HCV+ve Pts < 15 Pts > 75 Diabetic Hypertensive HD Pts. Died Hospital Name Both Pts in 2014 Pts Pts Yrs yrs Pts Pts 2014 Ministry of Health Hospitals 748 1736 300 1456 136 561 1098 2426 2338 915 MOH: Diaverum 39 325 32 150 9 86 235 267 215 98 MOH: Davita 0 102 2 22 2 5 15 48 49 8 98 624 73 217 48 260 220 532 980 262 GOVT. Non-MOH Hospitals Gov’t. Non-MOH: King Abdullah 0 314 7 12 3 28 1 44 84 1 HD Project 4 40 12 21 0 24 93 65 0 14 Gov’t. Non-MOH: Diaverum Private Sector Hospitals 1377 546 67 342 19 153 236 658 834 235 Total 2266 3687 493 2220 217 1117 1898 4040 4500 1533

ANNUAL REPORT 2014 27

200

187

184

182 182

177

176

175

173

180 171

160

149

147

144

136

140 130

124 124

120 110

106

103 103

97 94

100 91

60 51

40 22

2 1

2003 2014 1974 1976 1984 1986 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 1971 Dialysis Centers in Saudi Arabia 1971-2014

4000 3687

3500 3281 3187 3089 2944 3000 2847 2846 2643 2500 2389 2084 2042 2080 1918 1958 2000 1733 1718

1500

1000

500

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

New Hemodialysis Patients in Saudi Arabia 1995-2014

ANNUAL REPORT 2014 28

16000

14000

12000

10000

8000

6000

4000

2000

0 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 No. of Pts. 3357 3666 3737 4189 4665 5010 5706 6694 7004 7391 7020 7214 7837 8761 9419 10203 10928 11437 12116 12844 13160 14366

Dialysis Population Net Annual Increase 1993-2014

ANNUAL REPORT 2014 29

Private 42 (22%)

MOH Govt't Non- MOH Gov't. Non-MOH 23 (13%) King Abdullah Private Dialysis Project: 2 MOH Diaverum: 1 122 (65%) Diaverum: 7 Davita: 2 Total: 187

Hemodialysis Centers Affiliation 2014

Private 749 (13%)

Gov't Non-MOH MOH 1194 (21%) Gov't. Non-MOH Private

MOH 3789 (66%)

Total: 5732

Hemodialysis Machines 2014

Non-Saudi 2266 (16%)

Saudi Non-Saudi

Saudi Total: 14366 12100 (84%)

Hemodialysis Patients Nationality 2014

ANNUAL REPORT 2014 30

Female 6168 (57%) Male Female Male 8198 (57%)

Total: 14366

Sex Distribution amongst HD Patients 2014

4000 3400 3500 3289 3220 Total 14366 3000

2500 2208 2000

1500 1117 915 1000

500 187 30 0 < 10 10 - 15 16-25 26-45 46-55 56-65 66-75 >75

Age Distribution amongst HD Patients 2014; Age Group by Year

Below 75 years 217 (1%) Above 75 years 1117 (8%) 15-75 years Above 75 years Below 15 years 15-75 years 13032 (91%)

Total: 14366

Hemodialysis Patients; Age above 75 years & below 15 years 2014

ANNUAL REPORT 2014 31

AB 648 (4%)

B 2396 (17%) O A 7416 (52%) B AB O

A Total: 14366 3906 (27%)

Blood Groups amongst HD Patients 2014

Vascular Graft 845 (6%)

Others 1129 (8%) AVF AVF Jugular Cath. 9609 (67%) Others Vascular Graft Jugular Cath 2783 (19%)

Types of Vascular Accesses of HD Patients 2014

10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 MOH Govt. Non-MOH Private Sector Total HD Pts.: 14366 9326 2816 222400% Treated by EPO-r: 12269 8300 2056 1913 Percentage: 85.4% 89% 73% 86%

HD Patients Treated with Erythropoietin by Health Sector2014

ANNUAL REPORT 2014 32

Positive HBsAg Negative 493 (3%) Negative 13873 (97%) HBsAg Positive

HD Patients HBsAg Screen Status 2014

Positive Negative HCV Antibody Negative 2220 (15%) 12146 (85%) HCV Antibody Positive

HD Patients HCV Antibody Status 2014

6000

5000

4000 *% from HD Pts. 3000

2000 42% 1000 25% 17% 9% 7% 0 Central Western Eastern Southern Northern HCV+ve: 2220 556 934 190 382 158 T Pts. On HD: 14366 4051 4898 1845 2415 1157

HCV Positive HD Patients Region Wise 2014

ANNUAL REPORT 2014 33

Cause of Renal Failure No. % Diabetic Nephropathy 5991 41.7% Hypertensive Nephropathy 5100 35.5% Unknown Etiology 1016 7% Primary Glomerular Disease 689 5% Obstructive Uropathy 320 2% Hereditary Renal Disease 279 2% Congenital Malformation 215 1.5% Vasculitis 183 1.3% Primary Tubulo-Interstitial Disease 161 1% Pregnancy Related 110 1% Others 302 2% Total 14366 100% Causes of End-Stage Renal Disease in HD Patients 2014

Non-DM & HTN DM Only 3928 (28%) 1898 (13%)

DM & HTN 4500 (31%) HTN Only 4040 (28%) Total: 14366

Prevalence of Diabetes Mellitus & HTN in Dialysis Pts. 2014

On Waiting List for Work-up, 2873 (20%)

On Active Waiting List, 2873 (20%)

Waiting List for Renal Transplantation among Dialysis Pts. 2014

ANNUAL REPORT 2014 34

King Faisal MOH Military National Security University Private Other Specialist Hospitals Hospitals Guard Forces Hospitals Sector Hospitals Hospitals

HD Centers: 122 7 6 1 3 2 42 4 187

HD Patients: 9326 1184 798 197 202 281 2224 154 14366

Machines: 3789 395 431 65 104 126 749 73 5732

Outlets: 2784 303 378 55 114 71 658 65 4428

Pts/Outlets: 3.3 3.9 2.1 3.6 1.8 3.9 3.4 2.4 3.2 Number of HD Pts., Centers & Machines in MOH & Non-MOH Hospitals 2014

3000 2500 2000 1500 1000 500 0 Western Central Southern Eastern Northern Patients: 9326 2749 2307 2117 1206 947 Outlets: 2784 739 741 576 275 453 Machines: 3789 896 1138 818 348 589 Pts./Outlets: 3.3 3.7 3.1 3.6 4.4 2

HD Pts. & Machines in MOH Hospitals according to Region 2014

2500

2000

1500

1000

500

0 Private Military National KFS University Security Other Sector Hospital Guard Hospitals Hospitals Forces Hospitals Patients: 5040 2224 1184 798 281 202 197 154 Outlets: 1644 658 303 378 71 114 55 65 Machines: 1943 749 395 431 126 104 65 73 Pts./Outlets: 3.1 3.4 3.9 2.1 4 1.8 3 2.4

HD Pts. & Machines in MOH Hospital according to Region 2014

ANNUAL REPORT 2014 35

Peritoneal dialysis

In 2014, a total of 35 active peritoneal dialysis centers were recorded from MOH & Gov’t. Non- MOH. Among these PD centers, 20 centers belong to MOH while 15 to Gov’t Non-MOH sector. With a total of 1,416 patients, 70% of them were on Automated/Continuous Cyclic Peritoneal Dialysis or (CCPD/APD) machines, 27% were on Continuous Ambulating Peritoneal Dialysis (CAPD) and 3% were on Intermittent Peritoneal Dialysis (IPD).

By the end of 2014, a total of 1,416 patients on peritoneal dialysis were recorded by SCOT, of these 490 were new patients. Age Distribution of patients with ESRD showed that 90% were adults while only 10% were children.

Hepatitis B and C infection has shown that 2.4% of the ESRD patients are found to be HBsAg positive and 3.5% were HCV antibody positive.

ANNUAL REPORT 2014 36

Table 12: MOH Hospitals; Peritoneal Dialysis in the Kingdom of Saudi Arabia 2014 Total No. of No. of New Pts Type of Peritoneal Dialysis Hospital Name No. of Pediatrics Adults HBsAg+ve HCV+ve Non- Deaths 2014 Pts CAPD IPD CCPD/APD Saudi Pts 2041 King Saud Medical City 148 39 65 0 83 0 148 3 5 4 15 Children Hospital (KSMC) 10 3 0 0 10 10 0 0 0 4 0 King Salman Kidney Center, Riyadh 12 0 7 0 5 0 12 1 1 0 0 King Fahad Medical City, Riyadh 23 0 0 14 9 0 23 1 0 0 3 King Fahad Specialist Hospital, Buraidah 63 28 3 32 28 3 60 3 1 1 2 King Fahad Specialist Hospital, Dammam 29 10 0 0 29 9 20 0 1 0 4 King Fahd Hospital, Jeddah 37 12 1 0 36 3 34 1 1 0 6 King Abdul Aziz Hospital, Jeddah 26 10 18 0 8 0 26 0 1 0 2 Al Noor Specialist Hospital, Makkah 14 4 2 0 12 1 13 0 1 0 4 King Fahd Hospital, Madina 20 1 2 0 18 0 20 0 1 4 2 Dammam Medical Complex 33 18 0 0 33 0 33 1 0 0 3 King Fahd Hospital, Hofuf 36 10 0 0 36 0 36 1 5 1 1 Qateef Central Hospital 14 7 1 0 13 0 14 0 1 0 1 King Abdulaziz Specialist Hospital, Taif 27 7 1 0 26 0 27 0 2 0 2 King Khalid Hospital, Hail 15 8 0 0 15 0 15 0 3 2 0 Maternity and Children Hospital, Madina 21 9 7 0 14 21 0 1 0 3 0 K.AA. Daughters Charity Center for Renal 40 20 13 0 27 6 34 3 2 3 6 Diseases King Fahad Hospital, Gizan 21 14 2 0 19 4 17 1 0 0 5 King Fahad Hospital, Al Baha 11 11 9 0 2 0 11 1 0 0 4 King Khaled Hospital, Najran 3 3 3 0 0 0 3 0 0 0 0 Total: 20 603 214 134 46 423 57 546 17 25 22 60

ANNUAL REPORT 2014 37

Table 12.1 GOVT. NON- MOH Hospitals; Peritoneal Dialysis in the Kingdom of Saudi Arabia 2014 Total No. of No. of New Pts Type of Peritoneal Dialysis Hospital Name No. of Pediatrics Adults HBsAg+ve HCV+ve Non- Deaths 2014 Pts CAPD IPD CCPD/APD Saudi Pts 2014 King Faisal Specialist Hospital, Riyadh 77 34 17 0 60 32 45 1 3 3 0

King Abdulaziz Medical City, Riyadh (KFNGH) 55 4 13 0 42 20 35 0 0 1 1

Prince Sultan Military Medical City, Riyadh 55 21 18 0 37 0 55 0 5 1 6

King Khalid University Hospital, Riyadh 61 12 15 0 46 0 61 0 1 6 3

Security Forces Hospital, Riyadh 106 28 45 0 61 0 106 4 1 2 10

Khamis Mushyat Military Hospital 88 40 78 0 10 5 83 4 4 0 8

King Salman Military Hospital, Tabuk 22 7 2 0 20 6 16 0 1 0 2

Al Hada Military Hospital, Taif 59 27 7 0 52 6 53 2 2 0 6

King Fahd Armed Forces Hospital, Jeddah 44 12 24 0 20 0 44 1 1 0 2

King Fahd University Hospital, Al Khobar 141 66 8 0 133 0 141 3 3 12 11

King Faisal Specialist Hospital, Jeddah 23 6 10 0 13 0 23 0 1 0 2

King Abdulaziz University Hospital, Jeddah 28 8 5 0 23 10 18 0 0 11 1

Dhahran Medical Center (ARAMCO) * 24 5 1 0 23 6 18 0 0 0 5 King Abulaziz Med. City and National Guard, 8 2 1 0 7 2 6 1 1 0 2 Al Hassa King Abdulaziz Medical City, Jeddah (KFNGH) 22 4 4 0 18 2 20 1 1 0 3

Total: 15 813 276 248 0 565 89 724 17 24 36 62

ANNUAL REPORT 2014 38

Table 13: All Sector; Total Peritoneal Dialysis in the Kingdom of Saudi Arabia According to Sector- 2014 Total Type of Peritoneal Dialysis No. of No. of No. of New Pts Hospital Name No. of Pediatrics Adults HBsAg+ve HCV+ve Non- Deaths Hospitals 2014 Pts CAPD IPD CCPD/APD Saudi Pts 2014

MOH Hospitals 20 603 214 134 46 423 57 546 17 25 22 60

GOVT. NON-MOH Hospitals 15 813 276 248 0 565 89 724 17 24 36 62

Total : 35 35 1416 490 382 46 988 146 1270 34 49 58 122

ANNUAL REPORT 2014 39

1600 14021416 1400 1327 1240 1196 1200 1112 965 1000 861 772 800 645 595 600 506 442 379 400 302 335 196 196 200 132 133 0

Total Active PD in KSA 1995-2014

IPD 46 (3%)

CAPD APD/CCPD 382 (27%) 988 (70%)

Total: 1416

PD Pts.; Treatment Modality 2014

Pediatric 146 (10%) Adult 1270 (90%)

Total: 1416

PD Pts. Adults and Pediatrics 2014

ANNUAL REPORT 2014 40

Negative 34 (2%) Positive 1382 (98%)

Total: 1416

PD Pts. HBsAg Status 2014

Positive 49 (3%) Negative 1367 (97%)

Total: 1416

PD Pts. HCV Antibody Status 2014

400

350

300

250

200

150

100

0 Central: 610 Western: 321 Eastern: 285 Southern: 163 Northern: 37 MOH: 20 256 145 112 75 15 Govt. Non-MOH: 15 354 176 173 88 22

PD Distribution Region Wise 2014

ANNUAL REPORT 2014 41

PD 1416 (6%) HD 14366 (61%)

Renal Tx. Followed Up 7946 (33%) Total: 23,728 (791 pmp)

Renal Replacement Therapy 2014

20000 18951 18000 17168

16000 15979

1456214790 14000 14171 13356 12633 12000 12040 11168 10000 10280 9533 8492 8000 7833 7809 7383 7526 7029 6000 6008 5206 4861 4322 4000 3869

2000

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2016 2018 2020

Dialysis Population: Current & Projected 1995-2020; Average Net Annual Increase: 594 Pts. Average Percentage of Annual Increase: 7.7%

ANNUAL REPORT 2014 42

Dialysis Centers in KSA 2014 @Dialysis Centers #More than one (1) Dialysis Center

Post Renal Tx. HD PD

25000 1416 1010 1402 11961240 1327 20000 861 1112

780

645

595 15000

442 506

10500

14366

379 9450

13160

11437

8500

12844 10928

335 12116

302 196 7837

10000 196

7214

133

7020

7391

132

7004

6694

5706

5010

4665

5000 4189

3737

9600

10010

9002

8182

8098

8073

7946

7408

7269

7150

6902

6378

5656

4865

4396

4382

4046 4043 3713 0 3360

Renal Replacement Therapy in KSA 1995-2014

ANNUAL REPORT 2014 43

Region Population 2014 Dialysis Pts. 2014 Prevalence (pmp) Northern 1,741,586 1,194 686 Southern 4,709,220 2,578 547 Western 9,910,724 5,219 527 Central 9,758,662 4,661 478 Eastern 4,650,183 2,130 458 Total 30,770,375 15,782 513 Table14: Prevalence of Dialysis Pts. According to Region 2014

Region Population 2014 New Dialysis Pts. 2014 Incidence (pmp) Northern 1,741,586 326 187 Western 9,910,724 1,446 146 Southern 4,709,220 643 137 Eastern 4,650,183 616 132 Central 9,758,662 1146 117 Total 30,770,375 4,177 136 Table 15: Incidence of Dialysis Pts. According to Region 2014

ANNUAL REPORT 2014 44

Preface which highlights the current activities of deceased organ donation program as well The annual report 2014 of Saudi Center for as hospital sharing in all regions of the Organ Transplantation (SCOT) is based Kingdom and another chapter on largely on data in 2014 and cumulate data transplantation activities which include since the start of organ donation and kidneys, liver, heart, pancreas, lung, corneal transplantation program in the Kingdom of transplantation as well as bone donation. Saudi Arabia. Each section of organ transplantation

activities includes data on deceased and The data collected from SCOT records and living transplantation in currently active follow up the reports from respective transplant centers. Also new this year is transplant programs in the Kingdom. when possible, similar data and formats are

used for each section of organ activities; The medical department at SCOT conducted however, this is not always possible the required analysis, collated the statistics, because some data are not pertinent to all created figures and tables, drafted the text organs. and designed the documents. The data provided in the tables and figures and each Additionally, separate indices of tables and chapter has a brief introduction highlighting figures presented were included this year the salient aspects of data contained in for easy access of our data and glossary of relevant sections. abbreviation has been added.

Overview and highlights The data of this annual report will also be It contains chapters on Deceased Donors available on our website: www.scot.gov.sa after Brain Death and Organ Donation

ANNUAL REPORT 2014 45

Deceased Donors after Brain Death & Organ Donation

 The Kingdom of Saudi Arabia has an active deceased donation and transplantation program under the supervision of the Saudi Center for Organ Transplantation (SCOT)  Clear policies have been laid down to facilitate diagnosis of Death by Brain Function Criteria and the management of potential deceased donors  Religious scholars approved the concept of Death by Brain Function Criteria and Organ Donation

The critical pathway of deceased organ donation was of which, 110 (39%) were consented and 101 (92%) applied in all donors reported to Saudi Center for were recovered. Organ Transplantation (SCOT) with 570 possible, 350 potential, 279 eligible, 110 consent and 101 actual Evaluation and management of all possible DBD DBD donors. Averages of 19 pmp for possible DBD donors were continuously followed by SCOT donors were reported in 2014 and 21 pmp (mean according to the Directory of Regulation of Organ donors) in the last 5 years. Donation and Transplantation in the Kingdom of Saudi Arabia with the different ICU’s until recovery of In 2014, Characteristics of possible DBD donors organs for the purpose of transplantation or shows that majority were in age group between 21- cardiopulmonary arrest. 50 compared to the age group 11-40 over the years. Males constitute 70% of the donors with male to Transportation during the process of organ recovery female ratio of 3:1 compared to 4:1 over the years. were effectively used in majority of actual DBD Non-Traumatic cause due to CVA represents majority donors which includes air and land transport. of causes of death among possible DBD donors followed by the traumatic cause due to MVA in It is worth mentioning that there was an increase in contrary to data over the years; where traumatic is the consent rate per organ from DBD donors where in the major cause of death. 100% of consents were obtained for kidneys and liver, 97% for heart, 60% for corneas and 28% for Potential DBD donors were fully documented bones compared to the previous year. according to the Saudi National Protocol with 279 eligible DBD donors approached for organ donation;

Of the 570 possible deceased cases in the year 2014, 110 of them gave consent for organ donation. Retrieval was carried out in 92% of the consented cases

ANNUAL REPORT 2014 46

ANNUAL REPORT 2014 47

The Critical Pathways of Deceased Organ Region Possible Potential Eligible Consented Actual Riyadh 163 124 107 47 45 Donation Western 132 63 42 11 9 In 2014, the total possible DBD donors were 570, Qassim 79 46 35 7 7 350potential, 279 eligible, 110 consents and 101 and Hail actual donors (see figure I.2). Since 1986, the possible Eastern 77 41 34 13 11 Northern 25 10 2 1 1 DBD donors reached 10591, 6447 potential, 5454 Southern 25 2 2 0 0 eligible, 1817 consents and 1635 actual cases (see Outside 69 64 57 31 28 figure I.3). Kingdom Total 570 350 279 110 101 Table I.1: Critical pathway of deceased organ donation, region 570 wise in 2014

Possible DBD Donors 350 In 2014, there were 570 possible donors and since 279 1986, there were a total of 10591 possible donors reported to SCOT. Over the years, there was an increase in the number of possible DBD donors with 110 101 the peak in 2012 with 710 DBD donors and it was same in the last 2 years (see figure I.4). Possible Potential Eligible Consented Actual for Donation

Figure I.2: Critical pathway of deceased organ donation in 2014

710

631

615

570 570

533

526

503

474

427

410

385

374

372

367

364

360

355

348 348

337

10591 210

187

154

148

146

136

24 7

6447

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 5454 1986 Figure I.4: Annual trend of possible DBD donors over the years 1817 1635 1986-2014

Possible Potential Eligible Consented Actual Possible DBD donor characteristics for In 2014, analysis of the age distribution of the Donation possible DBD donors shows that the majority were Figure I.3: Critical pathway of deceased organ donation 1986- mainly in the age group between 21-50 yrs. 2014 composing 63%of the cases, with the highest number in age group between 21-30 yrs., having 23% of the Region Wise possible DBD donors (see figure I.5). Since 1986, the In 2014, the highest numbers of possible DBD donors majority of possible DBD donors were mainly from were from Riyadh region resulting in 124 potential, age group between 11-40 years composing 62% of 107 eligible, 47 consents and 45 actual DBD donors the cases (see figure I.6). while the Southern region was the lowest this year with 25 possible, 2 potential and eligible DBD donors Analysis of the gender among possible DBD donors with no consent acquired (see table I.1). shows that males represent 77% of the donors while females constitute the remaining 23% with a male to female ratio of 3:1. Since 1986, the males represent 80% of the possible DBD donors and females represent 20% with a male to female ratio of 4:1 (See figures I.7 & I.8).

Nationality distribution among possible DBD donors shows that Saudis were 260 (46%) and non-Saudis

representing 310 (54%) of the donors. Since 1986, Saudis represent 54% of the possible DBD donors and non-Saudis 46% (see figures I.9 and I.10).

ANNUAL REPORT 2014 48

Analysis of the causes of death among possible DBD donors in 2014, shows that traumatic causes were 132 43% and non-traumatic causes were 57%. Majority of 23% the traumatic causes were from Motor Vehicle Accident (MVA) 83% while non-traumatic causes were mainly due to Cerebro-Vascular Accident (CVA) Male 65% (See table I.2). Female

Over the years, there was no significant change in the trend of causes of death among possible DBD donors. Since 1986, traumatic causes were 57% and non- 438 traumatic causes were 40% and the remaining 3% 77% were categorized as others. Majority of the traumatic causes were from Motor Vehicle Accident (MVA) 82% Figure I.7: Sex distribution in possible DBD donors 2014 while non-traumatic causes were mainly due to Cerebro-Vascular Accident (CVA) 66% (see table I.3). 2161 20% 132 114 114

Male 76 Female 65

32 25 12 8430 80%

0 - 10 11 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 < 70 Figure I.8: Sex distribution in possible DBD donors1986-2014 Figure I.5: age distribution of possible DBD donors 2014

260 2675 46%

2081 1845 1394 non-Saudi 1253 Saudi 825

336 182 310 0-10 11-20 21-30 31-40 41-50 51-60 61-70 >70 54%

Figure I.6: age distribution of possible DBD donors 1986-2014 Figure I.9: Nationality distribution in possible DBD donors 2014

ANNUAL REPORT 2014 49

4844

46%

385

369

359

358

350

324

304

300

288

261

259

256

251

247

245

Saudi

219

218

211

208

198 197

non-Saudi

139

105

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 5747 1986 54% Figure I.9: Annual trend of potential DBD donors 1986-2014 Figure I.10: Nationality distribution in possible DBD donors 1986-2014

Cause of Death N % Traumatic 245 43% 220  Motor Vehicle Accident 204 39% (MVA)  Fall From Height (FFH) 31  Direct Head Trauma (DHT) 10 Documented Non-Traumatic 325 57%  Cerebro-Vascular Accident Not Documented 210 (CVA)  Anoxia 101  CNS tumor 14 350 Total 570 100% Table I.2: Cause of death among possible DBD donors in 2014 61%

Cause of Death N % Figure I.10: Documented and non-documented possible DBD Traumatic 6055 57% donors 2014  Motor Vehicle 4950 Accident (MVA)  Fall from height 669 (FFH)  Direct head trauma 326 (DHT) 4144  Gunshot 110 39% Non-traumatic 4190 40%  Cerebro-Vascular 2780 Accident (CVA) Documented  Anoxia 986 Not Documented  CNS tumor 424 Others 346 3% Total 10951 100% Table I.3: Cause of death among possible DBD donors in 1986- 6447 2014 61%

Potential DBD donors In 2014, there were 350 potential DBD donors and Figure I.11: Documented and non-documented possible DBD donors 1986-2014 since 1986, a total of 6447 potential DBD donors were

reported to SCOT. Over the years, there was an Eligible DBD Donors increase in the number of potential DBD donors with In 2014, there were 279 eligible DBD donors the peak in 2011 (see figure I.9). approached for organ donation. Since 1986, a total of

5454 eligible DBD donors were approached for organ The 350 potential DBD donors were fully documented donation by SCOT. Over the years, there an increase according to the Saudi National Protocol for Diagnosis in the number of approached eligible DBD donors of Death by Brain Function Criteria (see figure I.10 & with the peak in 2011 (see figure I.12). Approached I.11 cumulative). and Not approach families of DBD donors for organ

donation were also documented in 2014 and cumulatively from 1986. (see figure I.13 & I.14)

ANNUAL REPORT 2014 50

110

39%

309

297

289

282

279

271

243

238

235 235

233

231

230

214

203

195

194

186

177

167 167

133 Family Refusal

87 84

74 Consented

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 1986 Figure I.12: Annual trend of approached eligible DBD donors 169 1986-2014 61%

Figure I.15: Consented and non-consented approached eligible 71 DBD donors 2014 20% 1817 33% Approached not Approached

Family Refusal Consented 279 80%

Figure I.13: approached and not-approached eligible DBD donors 2014 3637 67%

993 Figure 1.16: Consented and non-consented approached eligible 15% DBD donors 1986-2014

Consent Inside Kingdom

Consent Outside Kingdom

Approached

not Approached

101

100

73 73

54 54

46 46

43 43

31 31 31

20 20

5454 13

12 12

10 10 10

3 0

85%

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Figure I.14: approached and not-approached eligible DBD 1986 donors 1986-2014 Figure I.17: Annual trend of consented eligible DBD donors 1986-2014 Of the 279 approached eligible DBD donors, 110 (39%) were consented for organ and tissue donation Actual DBD Donors and the remaining 169 (61%) donors, the family Of the 110 consented eligible DBD donors; 101 (92%) refused organ donation (see figure I.15 & 1.16 were recovered (actual DBD donor) and 9 (8%) were cumulative) and the trend of consented eligible DBD not recovered (figure I.19). Since 1986, a total of 1635 donors including consent from outside the Kingdom consented eligible DBD donors were recovered and of Saudi Arabia in 1986-2014 is shown in (figure I.17). 182 were not recovered (figure I.20). The annual trend of actual DBD donors is shown in (figure I.18).

ANNUAL REPORT 2014 51

Utilized DBD donor From the 101 actual DBD donors; 88 were utilized in the Kingdom, 5 were utilized by Transplant Center from Outside the Kingdom (cases from GCC countries) 105 102 98 101 and the remaining 4 were not utilized. (Details of the 82 80 83 71 68 73 not utilized actual DBD donors are listed in table I.4). 62 67 55 54 54 54 51 48 47 40 38 39 31 32 34 33 23 Reason N % 10 0 Unfit 2 50%

 Peritonitis 1

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014  Determined unsuitable donor 1 Figure 1.18: Annual trend of actual DBD donor 1986-2014 Donor sudden cardiac arrest 1 25% Technical 1 25%  Administrative issue 1 9 Total 4 100% 8% Table I.4: Reasons of not utilized actual DBD donors 2014

Organ specific utilization of actual DBD donor is as follows: Kidneys in 67 donors, liver in 69, heart in 31, Recovered pancreas in 2 and lung in 10 donors. Not Recovered Logistics Transportation was effectively used over the years during the process of organ recovery for the purpose 101 of organ transplantation. In 2014, transportation were used in 76 (69%) of the actual DBD donor; 92% Figure I.19: Recovered and non-recovered consented eligible wherein air transport was used in 39 (39%) of the DBD donor 2014 actual DBD donor and ambulance in 37 (37%) and the remaining 35%, no transportation was used (mainly, 182 the donor is in transplant center) 25 (25%) (see 10% figure I.21)

Medevac Ambulance No Transportation used 39 Recovered 38% Not Recovered 25 25%

1635 90% Figure I.20: Recovered and non-recovered consented eligible 37 DBD donor 1986-2014 37%

Figure I.21: Transportation used during organ recovery 2014

ANNUAL REPORT 2014 52

Hospital Sharing in Organ Donation Program

The total number of hospitals who reported possible Buraida Central Hospital also with both having 3 deceased donor (DD) cases during the year 2014 was consents each. Dammam Medical Complex had 2 103 hospitals. These were divided into either large consented cases. Lastly, Prince Salman Hospital- (>20 ICU beds), Medium (10-20 ICU beds) or small Riyadh, King Fahd Hospital-Hofuf, King Abdulaziz (<10 ICU beds). The top 3 hospital with the outmost specialist Hospital-Taif, Dr. Sulaiman Habib Hospital- consented cases are acknowledged below with their Riyadh and Saudi German Hospital-Riyadh each are corresponding ICU beds. having 1 consented case for organ donation.

Large hospitals (38) reported 230 cases (40.3% of the Small sized hospitals, with less than 10 ICU beds, total), of which 134 (58%) were fully documented shared 57 possible deceased cases (10% of the total and 34 consents were obtained for organ donation Possible DD) and 10 consents (9%) were obtained (32.69% of total consents). from them.

In this group, 16 consents were obtained from King Among this group, Al Mowasat Hospital-Dammam Saud Medical Complex, Riyadh (KSMC). KSMC is also was the most active with a total of 4 cases consented considered to be the largest source of consented cases for organ donation followed by Maternity and in the kingdom for the last nine years. King Abdul- Children Hospital-Dammam having 2 consented cases Aziz Medical City (National Guard Hospital), Riyadh then followed by Jubail General Hospital, Dr. Sulaiman came next with 9 consents followed by King Fahd Habib Hospital (Takasusi)-Riyadh, Al Jazeera Hospital, Jeddah, Ar-Ar Central Hospital, Obeid Hospital-Riyadh and King Abdul-Aziz Medical City Specialized Hospital Hofuf, King Saud Hospital, (National Guard Hospital) Al Hassa with 1 consented Unaiza, Maternity and Children Hospital Jeddah, Al case each. Hayat Hospital Riyadh, Dr. Ahmed Abanamy Hospital and Riyadh Care Hospital having 1 consented case Activities of the organ sharing program between the each. Kingdom and GCC countries showed that 31 consented cases were obtained under this program; Medium sized hospitals, with 10-20 ICU beds, distributed between Kuwait Hospitals (24 cases), contributed with 37.5% (214 cases) of the total Qatar Hospitals (2 cases), Bahrain Hospitals (4) and number of reported cases and 35 consents (32% of UAE Hospitals (1). total consents) were obtained for organ donation.

The most active hospitals in this group were Al Iman Hospital-Riyadh with 10 consents, National Hospital- Riyadh, Al Noor Specialist Hospital-Makkah and King Faisal Hospital-Makkah having 4 consents, then followed by King Fahd Specialist Hospital-Qassim and

ANNUAL REPORT 2014 53

In 2014, there were 103 ICUs reporting possible DBD donors to the organ donation program in the Kingdom of Saudi Arabia. Over the years, there was an increase in the number of ICUs contributing to this program see figure I.22.

103

83 83 83

73 73

68 68

58 58

36 36

33 33

1988 2011 2014 1987 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2012 2013 1986 Figure I.22: Annual trend of ICUs contributing in deceased donation program

Distribution of consents by region shows that 54 (49%) consents were obtained from the Central region (34 from MOH hospitals, 9 from Govt. Non-MOH hospitals and 11 from private hospitals). The Eastern region came next with 13 (12%) consents; followed by the Western region with 11 (10%) consents then Northern region with 1 (1%) consented cases (see table 1.5)

Possible Consent for Organ Region Actual DD DD Donation . Central 242 54 52 (Riyadh, Kharj, Qassim and Hail) . Western 132 11 9 (Jeddah, Makkah, Madinah & Taif) . Eastern (Dammam, Hofuf, Al Khobar, Dhahran, 77 13 11 Khafji, Qateef, Jubail & Hafar Al Baten) . Southern 25 0 0 (Assir, Al Baha, Gizan & Najran) . Northern 25 1 1 (Tabuk, Al Jouf, Northern Borders) . Outside KSA 69 31 28 (Kuwait, Qatar & Bahrain)

TOTAL 570 110 101

Table I.5: distribution of possible, consented and actual deceased donors according to region

The total number of 102 hospitals had reported 570 possible deceased donors (DD) during the year 2014 with 110 consents obtained for organ donation & 101 donors utilized for transplantation purposes

ANNUAL REPORT 2014 54

Donation after Brain Death (DBD) Donor Possible, Potential, Eligible, Consented and Actual from Different Hospitals in Saudi Arabia 2014

Table I.6: Hospitals with ICU's Having More than 20 Beds Possible Potential Eligible Consented Actual No. Hospital Name DD DD DD DD DD

1 King Saud Medical City (KSMC)-Riyadh 48 38 31 16 14

King Abdul-Aziz Medical City & National Guard 2 33 25 24 9 9 Hospital (KAMC & NGH)-Riyadh

3 King Fahd Hospital-Jeddah 13 5 4 1 1

King Abdul-Aziz University Hospital (KAUH)- 4 6 4 4 0 0 Jeddah

5 Ar Ar Central Hospital 6 5 2 1 1

6 King Saud Hospital (KSH)-Unaiza 6 2 2 1 1

7 Dr. Sulaiman Habib Hospital Ar Rayan-Riyadh 3 1 1 0 0

King Faisal Specialis Hospital and Research 8 1 0 0 0 0 Center (KFSH&RC)-Jeddah

9 Obeid Specialized Hospital-Riyadh 1 0 0 0 0

10 King Fahad Hospital (KFH)-Madinah 18 7 6 0 0

11 King Khalid Hospital (KKH)-Hail 22 5 1 0 0

Prince Sultan Military Medical City (PSMMC)- 12 4 4 3 0 0 Riyadh

13 King Abdullah Medical City-Makkah 5 4 1 0 0

King Fahad Armed Forces Hospital (KFAFH)- 14 4 2 1 0 0 Jeddah

15 Al Hada Military Hospital-Taif 3 1 1 0 0

16 King Fahad Medical City (KFMC)-Riyadh 3 1 1 0 0

17 Maternity and Children Hospital (MCH)-Jeddah 3 2 2 1 1

18 Assir Central Hospital 6 1 1 0 0

19 Dr. Abdulrahman Al Mishari Hospital-Riyadh 2 2 1 0 0

ANNUAL REPORT 2014 55

20 Obeid Specialized Hospital-Hofuf 4 2 2 1 1

King Abdul-Aziz Medical City & National Guard 21 1 0 0 0 0 Hospital (KAMC & NGH)- Jeddah

Maternity and Children Hospital (MCH)- 22 3 1 1 0 0 Madinah

23 Al Hayat Hospital-Riyadh 2 2 1 1 1

24 Riyadh Care Hospital-Riyadh 3 3 3 1 1

25 Al Mana Hospital-Al Khobar 2 2 2 1 0

26 Maternity and Children Hospital (MCH)-Makkah 1 1 0 0 0

27 Security Forces Hospital-Riyadh 2 2 2 0 0

28 King Khalid University Hospital (KKUH)-Riyadh 3 2 2 0 0

29 Prince Salman Miltary Hospital-Tabuk 3 0 0 0 0

30 Dr. Ahmed Abanamy Hospital-Riyadh 4 4 3 1 1

31 Hotat Bani Tamim Hospital-Riyadh 1 0 0 0 0

32 Al Hera General Hosptial-Makkah 3 2 2 0 0

33 Hail General Hospital 1 0 0 0 0

Prince Abdulrahman Sudeiry Hospital (PASH)-Al 34 5 3 0 0 0 Jouf

35 Al Qurayyat General Hospital 1 0 0 0 0

King Fahad Military Hospital (KFMH)-Khamis 36 2 0 0 0 0 Mushayt

37 Health Oasis Hospital-Riyadh 1 0 0 0 0

38 Prince Abdulaziz Bin Musaad Hospital-Ar Ar 1 1 0 0 0

230 34 TOTAL 134 104 31 (40.3%)* (31%) **

(*) Percentage from total possible donors, (**) Percentage from total consented donors.

ANNUAL REPORT 2014 56

Table 1.7: Hospitals with ICU’s Having 10 to 20 Beds

Possible Potential Eligible Consented Actual No. Hospital Name DD DD DD DD DD

1 Prince Salman Hospital-Riyadh 8 6 6 1 1

2 King Khalid Hospital-Al Kharj 3 1 1 0 0

3 King Fahad Specialist Hospital (KFSH)-Qassim 11 8 5 3 3

4 Al Rass General Hospital 18 15 14 0 0

5 Al Iman Hospital-Riyadh 17 15 14 10 10

6 Al Mana Hospital-Dammam 2 2 0 0 0

7 National Hospital-Riyadh 7 5 5 4 4

8 Al Noor Specialist Hospital-Makkah 23 15 7 4 4

9 King Fahad Hospital (KFH)-Hofuf 5 4 3 1 1

King fahad university Hospital (KFUH)-Al 10 10 1 1 0 0 Khobar

11 Buraida Central Hospital 18 15 12 3 3

12 Dammam Medical Complex 17 10 8 2 2

13 King AbdulAziz Hospital (KAH)-Jeddah 6 3 2 0 0

14 King Fahad Hospital(KFH)-Al Baha 11 0 0 0 0

15 King Khalid Hospital (KKH)-Tabuk 5 1 0 0 0

16 King Abdul Aziz Specialist Hospital (KASH)-Taif 14 5 2 1 1

17 King Fahad Hospital (KFH)-Makkah 12 9 8 4 2

18 Dr. Sulaiman Habib Hospital-Qassim 1 0 0 0 0

19 Abu Arish General Hospital 4 1 1 0 0

20 Wadi Dawasir Military Hospital-Riyadh 2 2 2 0 0

21 Dr. Sulaiman Habib Hospital Olaya-Riyadh 1 1 1 1 1

ANNUAL REPORT 2014 57

22 Security Forces Hospital-Dammam 1 1 1 0 0

23 Saudi German Hospital-Riyadh 3 3 1 1 1

24 Ohud General Hospital-Madinah 1 0 0 0 0

King Fahad Military Medical City (KFMMC)- 25 3 2 1 0 0 Dhahran

26 Al Mana Hospital-Al Hassa 1 0 0 0 0

Imam Abdulrahman National Guard Hospital- 27 2 2 2 0 0 Dammam

28 Imam Abdulrahman Al Faisal Hospital-Riyadh 1 1 1 0 0

29 Turaef General Hospital 5 1 0 0 0

30 PASH-Al Jouf (Prince Metab Bin Abdulaziz) 2 0 0 0 0

214 35 TOTAL 129 98 33 (37.5%)* (32%)

(*) Percentage from total possible donors, (**) Percentage from total consented donors

ANNUAL REPORT 2014 58

Table 1.8: Hospitals with ICU’s Having Less than 10 Beds

Possible Potential Eligible Actual No. Hospital Name Consented DD DD DD DD

1 Jubail General Hospital 6 4 4 1 1

2 Al Mowasat Hospital-Dammam 9 5 5 4 3

3 Al Thager Hospital-Jeddah 2 0 0 0 0

4 Qateef Central Hospital 6 0 0 0 0

5 King Faisal Hospital (KFH)-Taif 5 0 0 0 0

6 Kingdom Hospital-Riyadh 2 1 0 0 0

7 Khamis Mushayt General Hospital 1 0 0 0 0

8 Dr. Sulaiman Habib Hospital Takasusi-Riyadh 3 2 2 1 1 Maternity and Children Hospital (MCH)- 9 2 1 1 0 0 Buraida 10 Al Jeddaani Hospital-Jeddah 2 1 1 0 0

11 Al Yamama Hospital-Riyadh 3 1 1 0 0 Maternity and Children Hospital MCH- 12 3 2 2 2 2 Dammam 13 Dallah Hospital-Riyadh 2 1 0 0 0

14 Yanboo Royal Medical Center 1 0 0 0 0

15 Hafar Al Batin Central Hospital 1 0 0 0 0

16 King Fahad Hospital (KFH)-Tabuk 1 0 0 0 0

17 Rafha General Hospital 1 0 0 0 0

18 Sharourah General Hospital 1 0 0 0 0

19 Al Jazeera Hospital-Riyadh 1 1 1 1 1

20 Al Yousif Hospital-AL Khobar 1 0 0 0 0

King Abdul-Aziz Medical City & National Guard 21 4 4 3 1 1 Hospital (KAMC & NGH)-AL Hassa

57 10 TOTAL 23 20 9 (10%) (9%) (*) Percentage from total possible donor (**) Percentage from total consented donors.

ANNUAL REPORT 2014 59

Table 1.9: Hospitals outside the Kingdom of Saudi Arabia Consented No Hospital Name Possible DD Potential DD Eligible DD Actual DD DD

1 Kuwait Hospitals 55 53 47 24 22

2 Qatar Hospitals 2 2 2 2 2

3 Bahrain Hospitals 6 5 5 4 4

4 UAE Hospitals 5 4 3 1 0

5 Oman Hospital 1 0 0 0 0

TOTAL 69 64 57 31 28

Table 1.10 Total Number of DBD Donor for All Hospitals Potential Eligible Consented Actual Hospital Name Possible DD DD DD DD DD

Greater than 20 ICU Beds 230 134 104 34 31

10 - 20 ICU Beds 214 129 98 35 33

Less than 10 ICU Beds 57 23 20 10 9

Outside KSA 69 64 57 31 28

TOTAL 570 350 279 110 101

ANNUAL REPORT 2014 60

Organ Transplantation

Organ transplantation is the best existing method for in addition, 19 hearts were also procured as sources the treatment of end-stage organ failure and due to of valves. In total, 602 hearts were recovered as the increasing demand for viable organs in the sources of valves since 1993. Kingdom of Saudi Arabia; the deceased organ donation program was initiated. Later on, the The 1st Lung transplantation in the Kingdom was mentioned program was boosted with the inception performed in 1991 at King Fahd Hospital-Jeddah. In of the National Kidney Foundation (NKF) in 1984 and 2014, 19 lungs were recovered and transplanted from further during 1993, the organization was upgraded deceased donors. Up to date 144 lungs were and renamed to the presently known institution, the transplanted to 88 recipients, which either received Saudi Center for Organ Transplantation (SCOT). single or double lung transplantation.

In 1979, the 1st kidney transplantation was Pancreas transplantation was done in the kingdom in performed in the kingdom from living donor in Prince 2009 in Al Shaty Teaching Hospital in Jeddah. In 2014, Sultan Military Medical City (formerly known as 2 pancreases were transplanted inside the kingdom. RKH), and later in 1986 the 1st deceased kidney In total, 27 pancreases were transplanted since the transplantation was performed by the same program was started. transplant center. By 2014, a total of 627 kidneys were transplanted wherein, 496 kidneys were Tissue Donation, which includes corneas, bones and transplanted from living donors and 131 kidneys other musculoskeletal connective tissues were came from deceased organ donor. Since the start of started in the kingdom in 1983 and 2009 respectively. the program, a total of 6316 from living and 2694 In 2014, 13 corneas were recovered by KKESH, while from deceased kidneys were transplanted. 126 bones and 58 musculoskeletal were procured by KFSH & Research Center-Riyadh. Since the start of The liver transplantation program in the Kingdom each respective program, a total of 690 corneas were was started in 1990 and by the end of 2014, a total of recovered inside the kingdom, while 225 bones and 198 liver transplantations were performed, this 96 musculoskeletal connective tissues were includes 128 livers from living and 70 livers came recovered by respective center. from deceased donation. Since the liver transplantation program was initiated, there had The organ sharing program between the GCC been a total of 738 living and 790 deceased livers countries and the Kingdom of Saudi Arabia was 1st transplanted in the kingdom. implemented in 1996. In 2014, there were a total of 44 organs and tissues recovered and transplanted In 1986, 1st heart transplantation was performed in inside the kingdom. Since the cooperation was Prince Sultan Military Hospital-Riyadh (formerly initiated, there had been a total of 63 kidneys, 120 known as Riyadh Military Hospital) which marked the livers, 15 whole hearts, 22 lungs, 1 pancreas, 54 start of the heart transplantation program in the hearts as source of valves and 4 corneas shared to the Kingdom. By 2014, 31 hearts had been transplanted. Kingdom in addition to 1 kidney shared by SCOT to Up to present, a total of 280 hearts were transplanted United Arab Emirates (U.A.E.).

In 2014, a total of 627 kidneys, 198 livers, 19 lungs, 31 hearts and 2 pancreases were transplanted in addition to 126 bones, 58 musculoskeletal connective tissues and 11 corneas were recovered.

ANNUAL REPORT 2014 61

Kidney Transplantation

In the year 2014, 645 kidneys had been transplanted inside the kingdom of Saudi Arabia with 514 kidneys transplanted from living and 131 were transplanted from deceased donors. (Details of the living and deceased kidney transplantation are shown in Table II.1.1)

It is worth mentioning that a total of 9028 kidneys were transplanted inside the kingdom from 1990-2014; of these transplantation activities, 6054 (67%) were from living related, 2694 (30%) were from deceased donors and 280 (3%) from living unrelated kidney donor. Illustration of the cumulative living and deceased kidney transplantation is shown in (figure II.1.1)

1. DECEASED KIDNEY DONATION 2014 2. DECEASED KIDNEY TRANSPLANTATION 2014 110 deceased donors were consented for the purpose of organ donation and 100% of them were also 220 deceased kidneys were consented for the consented for kidney donation; of which 67 donors purpose of kidney transplantation; with 131 kidneys were utilized for kidney by transplant centers inside transplanted inside the kingdom (6 kidneys were the Kingdom, 24 donors were utilized by kidney transplanted as en-bloc to 3 recipients), 46 were transplant centers outside the kingdom (cases from transplanted by transplant centers outside the GCC countries), 17 donors were not recovered and kingdom and 8 kidneys were discarded. The total the remaining 2 donors, kidneys were discarded deceased kidney transplantation this year were (recovered but not transplanted). (The details of performed in 9 out of the 10 currently active kidney utilized kidney donor characteristics are listed in table transplant centers all over the Kingdom (see table II.1.2) and the details of the deceased kidney donation II.1.5). Illustration of the cumulative deceased kidney are listed in (Tables II.1.3 & II.1.4 cumulative) transplantation is shown in (figureII.1.2).

Characteristic N % N Transplant Center Transplanted Age 1 King Fahd Specialist Hospital-Dammam 37 King Faisal Specialist Hospital & 0-10 4 6% 2 29 11-20 2 3% Research Center-Riyadh King Faisal Specialist Hospital & 21-30 11 16% 3 22 31-40 23 35% Research Center-Jeddah Prince Sultan Military Medical City- 41-50 16 23% 4 21 Riyadh 51-60 9 14% King Abdul-Aziz Medical City & National 61-70 2 3% 5 17 Guard-Riyadh Blood Group 6 Al Hada Military Hospital-Taif 2 A 21 30% 7 King Fahd Hospital-Jeddah 1 B 16 25% King Faisal Military Hospital-Khamis 8 1 AB 4 6% Mushayt O 26 39% 9 King Salman Military Hospital-Tabuk 1 Gender King Fahd Armed Forces Hospital- 10 0 Male 58 87% Jeddah Female 9 13% Total 131* Donor Type Table II.1.5: Deceased kidney transplantation SCD 47 70% Performance of deceased kidney transplantation in currently active ECD 20 30% national kidney transplant centers in 2014 Cause of Death *6 kidneys transplanted as en-bloc to 3 recipients Anoxia 12 17% CVA 24 36% Head trauma 30 45% Non-recovered deceased kidneys CNS tumor 1 1% 220 deceased kidneys were consented for kidney Circumstance of Death MVA 17 25% donation; out of which, 35 (16%) were not recovered Non-MVA 50 75% (see table II.1.6). The major causes of non-recovered Table II.1.2: Deceased kidney donor characteristics kidneys are shown in (table II.1.7). Characteristics of utilized deceased kidney donors 2014

Kidney Donor Risk Index (KDRI) KDRI for locally recovered deceased kidneys was ranging between 0.73 and 2.25 with mean KDRI of 1.25; of which 22% of the cases has the KDRI <1, 54% are between 1-1.5 and 24% had KDRI of 1.5 above.

ANNUAL REPORT 2014 62

Reasons of Non Recovery N % Adult and pediatric deceased kidney Sudden cardiac arrest 18 51% Infection 6 17% transplantation  Peritonitis 2 131 deceased kidneys were transplanted inside the  Fungal 2 kingdom, with 108 (82%) kidneys transplanted to  2 TB adults and 23 (18%) kidneys were transplanted to No available suitable recipient 4 11%  Hepatitis B+ & C+ 4 pediatric recipient (see table II.1.10). Diseased Kidney 4 11%  CKD 2 N Transplant Center Adult Pediatric Total King Fahd Specialist Hospital-  ESRD 2 1 29* 8 37 Dammam Technical 2 6% King Faisal Specialist Hospital  Administrative issue 2 2 22 7 29 & Research Center-Riyadh Congenital Anomalies 1 3% King Faisal Specialist Hospital 3 21 1 22  No left kidney found 1 & Research Center-Jeddah Total 35 100% Prince Sultan Military 4 18 3 21 Table II.1.6: Reasons of non-recovered deceased kidneys Medical City-Riyadh Reasons of non-recovery of kidneys among eligible donors consented King Abdul-Aziz Medical City 5 14 3 17 for kidney donation in 2014 & National Guard-Riyadh 6 Al Hada Military Hospital-Taif 2 0 2 7 King Fahd Hospital-Jeddah 0 1 1 Discarded deceased kidneys King Faisal Military Hospital- 8 1 0 1 220 deceased kidneys were consented for kidney Khamis Mushayt King Salman Military 9 1 0 1 donation; of which 8 (4%) kidneys were discarded Hospital-Tabuk King Fahd Armed Forces (see table II.1.8). Causes of discarded deceased kidneys 10 0 0 0 Hospital-Jeddah from 1986-2014 are listed in (table II.1.9). Total 108 23 131* Table II.1.10: Adult and pediatric deceased kidney transplantation Reason of Discard N %

Glumerulosclerosis 3 38% Tuberculosis 2 25% Deceased donor–recipient matching Pyelonephritis 1 12% Matching sex was done in 46% of cases and matching Black discoloration 1 12% blood group for kidney transplantation between Traumatic kidney injury 1 12% Total 8 100% deceased donors and recipients were done in 92% of Table II.1.8: Reasons of discarded deceased kidneys the cases. Age distribution between deceased kidney Discarded kidneys among actual deceased kidney donors 2014 donor and recipient is shown in (table II.1.12)

Cold ischemia time (CIT) Donor Recipient Age (yrs.) Recipient/ Age 16- 30- The CIT for locally transplanted deceased kidneys <5 5-15 51-65 >65 Kidneys (yrs.) 29 50 were ranging from 2 to 31 hrs. 30 minutes with mean <5 3/5* 1 4/6 CIT of 12 hrs. In 52 % of cases, the deceased kidney 5-15 3 1 4 transplantation was practiced with CIT < 12 hrs, 41% 16-29 5 5 11 21 30-50 8 22 35 10 4 79 of which ranged from >12-24 hrs, while 7% ranged 51-65 7 11/12* 2 20/21 from >24-36 hrs. >65 0 Total 19/21 27 55 21/22 6 128/131 Table II.1.12: Age distribution between deceased kidney donor SCD & ECD kidney transplantation and recipients 2014 131 total deceased kidneys were transplanted; with *enbloc deceased kidney transplantation were performed to 2 93 (71%) kidneys were transplanted from standard pediatric and 1 adult recipient by KFSH-Dammam criteria donors (SCD) and the remaining 38 (29%) kidneys transplanted from expanded criteria donors (ECD). The criteria for ECD kidneys transplanted are listed in (table II.1.11).

Characteristics Utilized Kidneys Age ≥ 60 years 5 Age 50-59 years and having 2 of 21 the following:  CVA  Hypertension  SCr. ≥ 133 µmol/L (1.5 mg/dl) CVA, Hypertension and SCr. result 12 doubled during admission and before retrieval Total 38 Table II.1.11: Transplanted deceased ECD kidneys Transplanted deceased ECD kidneys in 2014

ANNUAL REPORT 2014 63

Living 3. LIVING KIDNEY TRANSPLANTATION 2014 Transplant center Deceased Total LR LUR King Faisal Specialist A total of 514 living kidney transplants had been Hospital & Research 142 5 29 176 Center-Riyadh performed; with 466 (91%) kidney transplantation King Faisal Specialist 89 22 22 133 from living related donors and 48 (9%) kidney Hospital-Jeddah King Fahd Specialist transplantation from living unrelated donor. The total 84 3 37 124 Hospital-Dammam living kidney transplantation this year was performed Prince Sultan Military 64 8 21 93 in 10 currently active kidney transplant centers (see Medical City-Riyadh King Abdul-Aziz table II.1.13). Illustration of the cumulative living Medical City & National 32 2 17 51 kidney transplantation is shown in (figure II.1.3). Guard-Riyadh King Fahd Hospital- 13 5 1 19 Jeddah Living Living Al Hada Military N Hospital Name Total 13 2 2 17 Related Unrelated Hospital-Taif King Fahd Armed King Faisal Specialist 12 0 0 12 1 Hospital & Research 142 5 147 Forces Hospital-Jeddah Center-Riyadh King Faisal Military King Faisal Specialist Hospital-Khamis 11 0 1 12 2 89 22 111 Hospital-Jeddah Mushayt King Fahd Specialist Prince Salman Military 3 84 3 87 5 0 1 6 Hospital-Dammam Hospital-Tabuk Prince Sultan Military Saad Specialist 4 64 8 72 1 1 0 2 Medical City-Riyadh Hospital-Al Khobar

King Abdul-Aziz 466 48 131 645 Medical City & Total 5 32 2 34 National Guard- Table II.1.1: Living and deceased kidney transplantation Riyadh Transplant centers performing living and deceased kidney King Fahd Hospital- 6 13 5 18 transplantation in 2014 Jeddah Al Hada Military 7 13 2 15 Hospital-Taif Kidneys from deceased donors N % King Fahd Armed Transplanted in KSA 131 59% 8 Forces Hospital- 12 0 12 Transplanted by other transplant 46 21% Jeddah centers in GCC countries King Faisal Military Not recovered kidneys 35 16% 9 Hospital-Khamis 11 0 11 Discarded kidneys 8 4% Mushayt Total 220 100% Prince Salman Military 10 5 0 5 II.1.3: Deceased kidney donation 2014 Hospital-Tabuk Saad Specialist 11 1 1 2 Hospital-Al Khobar Kidneys from deceased donors N % Total 466 48 514 Transplanted in KSA 2694 94% Table II.1.13: Living kidney transplantation 2014 Discarded 163 6% Performance of living kidney transplantation in currently active Total 2857 100% national kidney transplant centers in 2014 II.1.4: Deceased kidney donation 1986-2014

Non-recovered kidneys N % Donor sudden cardiac arrest 18 51% Medical reason 15 43% Technical 2 6% Total 35 100% Table II.1.7: Major Causes of non-recovered deceased kidneys 2014 The causes of non-recovered deceased kidneys among eligible donors consented for kidney donation in 2014

ANNUAL REPORT 2014 64

600

514

506

180 166

156

154

462

151

500

160

431

131 131

140

122 122

400 118

349

111

120

95 95

272

88 88

260

100 84

300 251

228 228 228

221

220

208

195

188

59 59

57 57

174

200 160 147

145 60

136

128

122

77 40

63 63

100

36 36

21 20

20 4

2 11

0 0

1984 1985 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 1979 Figure II.1.3: Cumulative living kidney transplantation Figure II.1.2. : Cumulative deceased kidney transplantation Details of living kidney transplantation in the Kingdom of Saudi Details of the deceased kidney transplantation in the Kingdom of Arabia during 1979-2014; Saudi Arabia 1984-2014; Total living kidney transplantation: 6316 Total deceased kidney transplantation: 2694

Cause N % Congenital & vascular anomalies 34 21% CKD 24 15% Traumatic renal injury 22 13% Necrosis 18 11% No available suitable recipient 13 8% Malignancy & neoplastic kidney 10 6% Technical 9 6% Vascular thromobosis 9 6% TB 7 4% Sepsis 5 3% Sent abroad 3 2% Fibrosis/sclerosis 3 2% Glumerulosclerosis 3 2% Multiple renal stones 1 0.5% Pyelonephritis 1 0.5% Black discoloration 1 0.5% Total 163 100% Table II.1.9: Causes of discarded deceased kidneys Discarded kidneys among actual deceased donors during 1986-2014

700

Total Deceased: 2694

600

Total Living Unrelated: 280

131 118

Total Living Related: 6054

500

122

400 46

156

300 111

122

89 71 166

151

466

88 432

200

406

385

131

154

313

260

252

251

59 57

228 228 228

100

221

220

208

195

188

174

160

147

145

136

128

122

77 77

21 11 14 20

63 63

36 36

0 30

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 1979 Figure II.1.1: Cumulative living and deceased kidney transplantation Details of living and deceased kidney transplantation in the Kingdom of Saudi Arabia during 1979-2014; Total kidneys transplantation: 9010

ANNUAL REPORT 2014 65

Liver Transplantation

In the year 2014, 198 livers had been transplanted inside the kingdom of Saudi Arabia; with 128 livers transplanted from living and 70 transplanted from deceased donor. Details of the living and deceased liver transplantation 2014 are shown in (table II.2.1).

It is worth mentioning that a total of 1596 livers were transplanted inside the kingdom from 1979 to 2014; of these transplant activities, 790 (49%) were transplanted from deceased donors, 738 (46%) were from living related donors and 68 (4%) were from living unrelated donor. Illustration of cumulative living and deceased liver transplantation is shown in (figure II.2.1).

1. DECEASED LIVER DONATION 2014 It is worth mentioning that out of the 69 recovered deceased livers, 1 was split and transplanted to 2 110 deceased donors were consented for the purpose recipients by King Faisal Specialist Hospital & Research of organ donation. 110 (100%) were consented for Center-Riyadh. liver donation in 2014 (see table II.2.2); out of which, Deceased 69 donors were utilized, 35 donors were not N Hospital Name Donors recovered and the remaining 6 donors, livers were King Faisal Specialist Hospital & Research 1 27 discarded (recovered but not transplanted). The Center-Riyadh King Abdul-Aziz Medical City and National details of utilized liver donor characteristics are listed 2 27 Guard-Riyadh in (table II.2.3). Details of the cumulative deceased 3 King Fahd Specialist Hospital-Dammam 16 liver donation are listed in (table II.2.4). Total 70 Table II.2.5: Deceased liver transplantation 2014 Performance of deceased liver transplantation in currently active Characteristic N % national liver transplant centers in 2014 Age 0-10 2 3% 11-20 3 4% Non-recovered deceased livers 21-30 13 19% 110 deceased livers were consented for liver 31-40 23 33% donation; out of which, 35 (32%) were not recovered 41-50 13 19% 51-60 14 20% (see table II.2.6). The major causes of non-recovered 61-70 1 1% deceased livers are mainly due to donor sudden Blood Group cardiac arrest, determined unsuitable liver donor and A 19 35% B 24 27% hemodynamic instability. Major causes of non- AB 2 3% recovered deceased livers in 2014 are listed in (see O 24 35% table II.2.7). Illustration of the cumulative major cause Gender Male 58 84% non-recovered deceased liver transplantation from Female 11 16% 1994 is shown in (table II.2.8). Cause of Death Anoxia 12 17% CVA 29 42% Reasons of Non Recovery N % Head trauma 27 39% Sudden cardiac arrest 9 25% CNS tumor 1 1% Determined unsuitable liver donor 7 20% Circumstance of Death  High liver enzymes 6 MVA 15 22%  Low donor weight 1 Non-MVA 54 78% Hemodynamic instability 7 20% Table II.2.3: Deceased liver donor characteristics Biopsy findings 4 11% Characteristics of utilized deceased liver donors in 2014 No available suitable recipient 2 6%  No HCV+ compatible 2 recipient 1. DECEASED LIVER TRANSPLANTATION 2014 Infection 2 6% Technical 2 6%  No medevac available 1 110 deceased livers that were consented for liver  Administrative issue 1 donation, there were 70 livers transplanted inside the Diseased Liver 1 3% kingdom with 35 not recovered and 6 discarded. The  Cirrhosis 1 Macroscopic findings 1 3% deceased liver transplantations this year were  Fatty 1 performed in 3 currently active liver transplant Total 35 100% centers in the kingdom (See table II.2.5). Table II.2.6: Reasons of non-recovered deceased livers Reasons of non-recovery of livers among eligible donors consented for liver donation in 2014

ANNUAL REPORT 2014 66

Discarded deceased livers 1. LIVING LIVER TRANSPLANTATION 2014 110 deceased livers were consented for liver donation; out of which, 6 (5%) were discarded (see A total of 128 living liver transplants were performed; table II.2.9). Causes of discarded deceased livers from 124 (97%) were from living related donors and 4 1994-2014 are listed in (table II.2.9). (3%) livers were from living unrelated liver donor. The total living liver transplantations this year were Reason of Discard N % performed in 4 currently active national liver Hepatocyte necrosis & steatosis 4 66% transplant centers (see table II.2.13). High liver enzymes & biopsy 1 17% report Infection (TB) 1 17% Living Living N Hospital Name Total 6 100% Related Unrelated Total Table II.2.9: Reasons of discarded deceased livers King Faisal Specialist Discarded livers among actual deceased liver donors in 2014 1 Hospital & Research 93 2 95 Center-Riyadh King Abdul-Aziz Medical Adult and Pediatric deceased liver 2 City and National Guard- 14 0 14 transplantation Riyadh King Fahd Specialist 3 13 0 13 A total of 70 deceased livers were transplanted inside Hospital-Dammam Prince Sultan Military the Kingdom with 61 (87%) livers transplanted to 4 4 2 6 adult recipients and 9 (13%) livers transplanted to Medical City-Riyadh Total 124 4 128 pediatric recipient (see table II.2.11). Table II.2.13: living liver transplantation Performance of living liver transplantation in currently active national liver transplant centers in 2014 N Liver Transplant Center Adult Pediatric T King Faisal Specialist 1 Hospital & Research 23 4 27 Living Transplant center Deceased Total Center-Riyadh LR LUR King Abdul-Aziz Medical King Faisal Specialist 93 2 27 122 2 City and National Guard- 23 4 27 Hospital Riyadh Riyadh King Fahd Specialist King Fahd Specialist 13 0 16 29 3 15 1 16 Hospital Dammam Hospital-Dammam King Abdulaziz Medical 14 0 27 41 Total 61 9 70 City Riyadh Table II.2.11: Adult and pediatric deceased liver transplantation Prince Sultan Military 4 2 0 6 Pediatric and adult deceased liver transplanted in currently active Medical City Riyadh national liver transplant centers in 2014 Total 124 4 70 198 Table II.2.1: living and deceased liver transplantation Cold ischemia time (CIT) Transplant centers performing living and deceased liver transplantation in 2014 CIT for locally transplanted deceased livers was ranging from 1hr. 7 minutes to 13 hrs. 33 mins., with Livers from deceased donors N % mean CIT at 6 hrs. 46 mins. In 34 (49%), the deceased Transplanted 70 63% livers were practiced with CIT ≤ 6 hrs., 35 (50%) at Not recovered 35 32% ≥6-12 hrs. and the remaining 1 (1%) was done with Discarded 6 5% Total 110 100% >12 hrs. Table II.2.2: Deceased liver donation 2014

Deceased donor-recipient matching Livers from deceased donors N % Transplanted 790 54% Matching sex was done in 53% of the cases and Not recovered 455 31% matching blood group for liver transplantation Discarded 207 14% between deceased donors and recipients was done in Total 1452 100% Table II.2.4: Livers from deceased donors 1994-2014 89% of the cases. Age distribution between deceased kidney donor and recipient is shown in (table II.2.12). Not recovered deceased livers N % Medical reason 24 Donor sudden cardiac arrest 9 Recipient Age (yrs.) Donor Technical 2 5- 16- 30- 51- Total Age (yrs.) <5 >65 Total 35 100% 15 29 50 65 Table II.2.7: Major causes of non-recovered deceased livers <5 2* 2 Major causes of non-recovered deceased livers among eligible donors 5-15 2 2 consented for liver donation in 2014 16-29 1 3 1 7 12 30-50 1 6 11 20 1 39 51-65 1 5 8 1 15 >65 0 Total 2 2 10 19 35 2 70 Table II.2.12: Age distribution between deceased liver donor and recipients 2014; *performed as split liver transplantation

ANNUAL REPORT 2014 67

Cause N % Not recovered deceased livers N % Fatty Changes 90 43% Medical reason 354 Granulomatous Donor sudden cardiac arrest 94 40 19% Changes/Fibrosis/Atherosclerosis Technical 7 Ischemia/Long CIT 21 10% Total 455 100% Macro/Microstasis, Steatosis 20 10% Table II.2.8: Major causes of non-recovered deceased livers Sepsis 11 5% Major causes of non-recovered deceased livers among eligible donors Hepatitis (B,C) Changes 6 3% consented for liver donation 1994-2014 Neoplastic 6 3% Cardiac Arrest (Donor/Recipient) 5 2% Infectious Disease (TB, Bilharziasis, Others) 5 2% Congenital/Vascular Abnormalities 1 .4% Necrosis 1 .4% Traumatic Liver Injury 1 .4% Total 207 100% Table II.2.10: Causes of discarded deceased livers 1994-2014 Discarded livers among actual deceased donors consented for liver donation during 1994-2014

250

4 200 Total Deceased: 790 Total Living Related: 738 Total Living Unrelated: 68 3 150 4 43 124

14 100 92 106 72 38 58 26 37 39 50 41 32 1 7 11 19 59 62 70 44 45 16 19 49 54 51 49 50 49 1 2 2 28 26 20 18 19 29 28

0 10 10 15

2005 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014 1990 Figure II.2.1: Cumulative living and deceased liver transplantation in KSA Details if the living and deceased liver transplantation in the Kingdom of Saudi Arabia 1994-2014; Total deceased and living liver transplantation 1990-2014: 1596

ANNUAL REPORT 2014 68

Heart Transplantation

In the year 2014, 31 whole hearts had been transplanted and 19 hearts were recovered as source of valves inside the kingdom of Saudi Arabia. It is worth mentioning that a total of 280 hearts had been transplanted from 1986-2014 in addition, 602 hearts were recovered as sources of valves since 1993. Illustration of the cumulative deceased heart transplantation and recovered hearts as source of valves in Saudi Arabia is shown in (figure II.3.1).

1. DECEASED HEART DONATION 2014 Non-recovered hearts 107 deceased hearts were consented for heart 110 deceased donors were consented for the purpose donation; out of which 57 (53%) were not recovered of organ donation with 107 (97%) were consented (see table II.3.6). The major causes of non-recovered for heart donation (see table II.3.1); of which, 31 deceased hearts are mainly due to determined donors were recovered, 19 were recovered hearts as unsuitable heart donor, no available suitable recipient source of valves and 57 donors were not recovered. and diseased heart. The details of the utilized deceased heart donor characteristics are listed in (table II.3.1.2). Illustration Reasons of Non Recovery N % of the cumulative deceased heart donation from 1986 Determined unsuitable heart donor 16 28%  Old age 11 is shown in (table II.3.3).  High dose inotropic agents 2  History of post cardiac 2 arrest Characteristic N %  Multi-organ failure 1 Age No available suitable recipient 13 23% 11-20 1 3%  No ABO identical recipient 6 21-30 9 29%  Donor-recipient mismatch 31-40 15 48% o Weight 41-50 5 16% 4 disproportion 51-60 1 3%  No HCV+ compatible Blood Group 3 recipient A 8 26% Diseased Heart 11 19% B 8 26%  Low ejection fraction during 8 AB echocardiography O 15 48%  History of post CABG 2 Gender  Severed hypertrophy 1 Male 30 97% Hemodynamic instability 6 10.5% Female 1 3% Technical 6 10.5% Cause of Death  Cardiac catheterization 5 Anoxia 5 16% cannot be performed CVA 4 13%  Recipient unavailable 1 Head trauma 22 71% Donor sudden cardiac arrest 3 5% Circumstance of Death Infection 2 4% MVA 14 45%  Fungal 1 Non-MVA 17 55%  Peritonitis/puruluent 1 Table II.3.2: Deceased heart donor characteristics discharge Characteristics of utilized deceased heart donors in 2014 Total 57 100% Table II.3.6: reasons of non-recovered deceased hearts 2. DECEASED HEART TRANSPLANTATION Reasons of non-recovered deceased hearts among eligible donors 2014 consented for heart donation in 2014

Adult and pediatric heart transplantation 107 (97%) deceased hearts were consented for the 31 hearts were transplanted inside the kingdom with purpose of heart donation; with 31 (29%) hearts 27 (87%) hearts utilized for adult recipients and 4 transplanted by two heart transplant centers inside (13%) hearts for pediatric recipients (see table II.3.7). the kingdom (see table II.3.4). In addition, 19 Heart for valves were also recovered (see table II.3.5). N Liver Transplant Center Adult Pediatric T King Faisal Specialist Transplanted Deceased 1 Hospital & Research 22 4 26 Transplant Center Hearts Center-Riyadh King Faisal Specialist Hospital & Prince Sultan Cardiac 26 2 5 0 5 Research Center-Riyadh Center-Riyadh Prince Sultan Cardiac Center- Total 27 4 31 5 Riyadh Table II.3.7: Adult and pediatric deceased heart transplantation Total 31 Adult and pediatric deceased heart transplantation in currently Table II.3.4: Deceased hearts transplantation active national heart transplant centers in 2014 Performance of deceased heart transplantation in currently active national heart transplant centers in 2014

ANNUAL REPORT 2014 69

Deceased donor-recipient matching Hearts from deceased donors N % Consented 107 97% Matching sex was done in 71% of the cases and  Transplanted 31 matching blood group for heart transplantation  Recovered as source of valves 19 between deceased donors and recipients was done in  Not recovered 57 90% of the cases. Age distribution between deceased  Discarded 0 Not consented 3 3% kidney donor and recipient is shown in (table II.3.8). Total 110 100% Table II.3.1: Deceased heart donation 2014

Recipient Age (yrs.) Donor 5- 16- 30- 51- Total Hearts from deceased donors N % Age (yrs.) <5 >65 15 29 50 65 Consented 1391 86% 16-29 4 4 2 10  transplanted 280 30-50 1 6 9 4 20  Recovered as source of valves 602 51-65 1 1  Not recovered 509 Total 1 10 13 7 31  Discarded 0 Table II.3.8: Age distribution between deceased heart donor and Not consented 219 14% recipients 2014 Total 1610 100% Table II.3.3: Deceased heart donation 1986-2014

Aortic Pulmonary Total valve valve Used 5 13 18 To be used 0 0 0

Discarded 14 6 20

Total 19 19 38

Table II.3.5: Heart for valve recovery and utilization

Recovered heart as source of valves from eligible deceased hearts in

2014

Total Whole Heart: 280 52 Total Hearts as Source of Valves: 602

39 38 36 35 33 32 31 31 29 29 26 27 23 23 24 22 22 21 19 19 1920 19 19 19 17 15 12 12 13 12 9 9 8 7 8 5 6 5 5 6 5 3 4 3 3 4

1 1 2

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 1986 Figure II.3.1: Cumulative deceased heart transplantation and recovered hearts as source of valves in Saudi Arabia 1986-2014

ANNUAL REPORT 2014 70

Lung Transplantation

In the year 2014, 19 lungs have been transplanted from deceased donation inside the kingdom of Saudi Arabia. It is worth mentioning that a total of 144 lungs have been transplanted from 1991-2014. Illustration of the cumulative deceased lung transplantation is shown in (figure II.4.1).

1. DECEASED LUNG DONATION 2014 Non-recovered deceased lungs 206 deceased lungs were consented for lung 110 deceased donors were consented for deceased transplantation; out of which 184 (89%) were not organ donation. 103 (94%) were consented for lung recovered (see table II.4.5). The major causes of non- donation (see table II.4.1); of which, 10 donors were recovered deceased lungs is shown in (figure II.4.6) utilized for lung transplantation, 92 donors were not recovered and the remaining 1 donor, the lungs were Reasons of Non Recovery N % discarded (recovered but not transplanted). The Poor lung function 24 26%  Low PO2 during challenge test 21 details of the utilized lung donor characteristics are  Blood clots seen during 1 listed in table II.4.2. bronchoscopy  Poor ABG result 1  Poor bronchoscopy result 1 Characteristic N % No available suitable lung recipient 22 24% Age Deceased Organ 10 11% 21-30 1 10%  Abnormal cxr 2 31-40 3 30%  Atelectasis 2 41-50 2 20%  Lung infiltration 4 51-60 4 40%  Pleural effusion 2 Blood Group Technical 10 11% A 4 40%  Challenge test cannot be 1 B 2 20% performed AB  Needed more time for 3 O 4 40% evaluation Gender  No blood sample available for 2 Male 8 80% cross-match Female 2 20%  Recipient not fit for 2 Cause of Death transplantation Anoxia 3 30%  Recipient unavailable 1 CVA 5 50%  No surgeon 1 Head trauma 2 20% Hemodynamic Instability 7 8% Circumstance of Death Infection 6 7% MVA 1 10%  Lung consolidation 5 Non-MVA 9 90%  HCV+ 1 Table II.4.2: Deceased Lung Donor Characteristics Traumatic Lung Injury 5 5% Characteristics utilized deceased lung donors  Lung contusion 3  Lung hemorrhage 1 2. DECEASED LUNG TRANSPLANTATION  Traumatic lung injury 1 Determined unsuitable lung donor 4 4% 2014  Old age 2  Long stay in ICU 1  History of prolonged cardiac 1 206 deceased lungs that were consented for lung arrest donation; there were 10 lungs transplanted inside the Donor sudden cardiac arrest 3 3% Kingdom wherein, 18 lungs were transplanted as Others 1 1%  History of severe smoking 1 double lungs to 9 recipients and a single lung Total 92 100% transplanted to 1 recipient, 184 lungs were not Table II.4.5: Reasons of non-recovered deceased lungs recovered and 3 were discarded. The deceased lung Reasons of non-recovered of lungs among eligible donors consented for lung donation in 2014 transplantations this year was performed by King Faisal Specialist Hospital & Research Center, Riyadh Discarded Lungs the currently active lung transplant center in the 206 deceased lungs were consented for lung Kingdom (see table II.4.3). donation; out of which, 3 (1%) were discarded (see table II.4.7). Deceased Lung Lung Transplant Center Lung Transplants Transplanted King Faisal Specialist Hospital & 19 10 Research Center-Riyadh Table II.4.3: Deceased Lung Transplantation Performance of deceased lung transplantation in currently active national lung transplant center in the year 2014

ANNUAL REPORT 2014 71

Reason of discard N % No of High ventilator settings with Transplant Center Period Transplant 2 67% bilateral lung contusions Operation Recipient for single lung King Faisal Specialist Hospital & 1 33% 1996-2014 72 transplantation RC-Riyadh King Faisal Specialist Hospital & Total 3 100% 2001-2011 12 Table II.4.7: Reasons of discarded deceased lungs RC-Jeddah Discarded lungs among actual deceased lung donors in 2014 King Fahd Hospital-Jeddah 1991-1994 4 Total 88 Table II.4.4: deceased lung Transplantation Activity 1991-2014 Adult and pediatric lung transplantation Total lungs transplanted: 144 19 deceased lungs were transplanted inside the Total transplant recipient: 88 kingdom and all were transplanted to 10 (100%) adult recipients (see table II.4.8). Lungs from deceased donors N % Transplanted 10 10% Not recovered 92 89% Adult Pediatric Discarded 1 1% Lung Transplant Center Single Double Single Double Total 103 100% King Faisal Specialist Table II.4.1: Lungs from deceased donation 2014 Hospital & Research 1 9 Center-Riyadh Not recovered N % Table II.4.8: Adult and Pediatric Lung Transplantation Medical reason 79 86% Adult and pediatric deceased lung transplanted in currently active Technical 10 11% national lung transplant center in 2014 Donor sudden cardiac arrest 3 3 Total 92 100% Table II.4.6: Major causes of non-recovered lungs 2014 Deceased donor-recipient matching The reasons of non-recovery of lungs among eligible donors Matching sex was done in 60% of the cases and consented for liver donation 2014

matching blood group for lung transplantation

between deceased donors and recipients was done in 80% of the cases. Age distribution between deceased kidney donor and recipient is shown in (table II.4.9).

Donor Recipient Age (yrs.) Age 5- 16- 30- 51- Total <5 >65 (yrs.) 15 29 50 65 16-29 1 1 30-50 2 2 1 5 51-65 1 2 1 4 Total 4 4 2 10 Table II.4.9: Age distribution between deceased lung donor and recipients 2014

125 Total Lungs Transplanted: 144

31 24 25 19 19 19

6 5 4 4 4 4 5 3

1 1 1

Figure II.4.1: Cumulative deceased lung transplantation 1991-2014

ANNUAL REPORT 2014 72

Pancreas Transplantation

In the year 2014, 2 pancreases had been transplanted inside the kingdom of Saudi Arabia with a total of 27 pancreases were transplanted inside the kingdom from 1990-2014. It is worth mentioning that the first pancreas transplantation in the Kingdom was performed in 1990 then followed by kidney-pancreas transplantation in 1991. Another combined operation was also done in 1992 at Al Shati Hospital in collaboration with King Abdul-Aziz Hospital-Jeddah. Illustration of the cumulative deceased pancreas transplantation is shown in (figure II.5.1).

1. DECEASED PANCREAS DONATION 2014 Non-recovered deceased pancreas 84 deceased pancreases were consented for pancreas 110 deceased donors were consented for the purpose donation; out of which 81 were not recovered (see of organ donation and 84 (76%) were consented for table II.5.4). The major causes of non-recovered pancreas donation for KSA; out of which, 2 donors deceased pancreas are shown in (table II.5.5). were utilized for pancreas transplantation, 81 donors were not recovered and the remaining 1 donor, the Reasons of Non Recovery N % Determined unsuitable pancreas pancreas was discarded (recovered not transplanted) 56 69% donor (see table II.5.1). The details of utilized pancreas  High pancreas enzyme 18 donor characteristics are listed in (table II.5.2)  Old age 16  DM 13  Long stay in ICU 8 Characteristic N %  Young age 1 Age No available suitable recipient 8 10% 0-10 1 50% Hemodynamic instability 5 6% 11-20 1 50% Technical 5 6% Blood Group Macroscopic findings 5 6% A Donor sudden cardiac arrest 1 1% B 1 50% Traumatic organ injury 1 1% AB Total 81 100% O 1 50% Table II.5.4: Reasons for non-recovered deceased pancreases Sex Reasons of non-recovered deceased pancreas among eligible donors Male 2 100% consented for pancreas donation but not recovered in 2014 Female Cause of Death Head trauma 2 100% Discarded deceased pancreas Circumstance of Death 84 pancreases were consented for pancreas donation; MVA 2 100% Table II.5.2: Deceased pancreas donor characteristics of which, 1 (50%) was discarded (see table II.5.6). Characteristics of utilized deceased pancreas donors in 2014 Reason of Discard N % 2. DECEASED PANCREAS TRANSPLANTATION Fatty pancreas 1 100 Table II.5.6: Reason of discarded pancreas 2014 Discarded pancreas among actual deceased donors consented for pancreas donation in 2014 84 deceased pancreases were consented for pancreas donation; with 2 pancreases transplanted inside the Adult and pediatric pancreas transplantation Kingdom as Pancreas Transplant Alone (PTA), and 1 2 pancreases were transplanted inside the kingdom pancreas discarded. The 2 pancreas were both to adult recipients as PTA (see table II.5.7). transplanted in 1 out of the 2 currently active pancreas transplant centers in the Kingdom (see table Pancreas Transplant N Adult Pediatric T II.5.3). Center King Faisal Specialist 1 Hospital & Research Center- 2 0 2 Transplanted Riyadh N Hospital Name Deceased Table II.5.7: adult and pediatric deceased pancreas Pancreases transplantation King Faisal Specialist Hospital & Adult and pediatric deceased pancreas transplantation in currently 1 2 Research Center-Riyadh active pancreas transplant center in 2014 Table II.5.3: deceased pancreas transplantation Performance of deceased pancreas transplantation in currently active national pancreas transplant center in 2014

ANNUAL REPORT 2014 73

Pancreas from deceased donors N % Not recovered N % Transplanted 2 2.4% Medical reason 75 93% Not recovered 81 96.4% Technical 5 6 Discarded 1 1.2% Donor sudden cardiac arrest 1 1 Total 84 100% Total 81 100% Table II.5.1: Pancreas from deceased donors 2014 Table II.5.5: Major causes of non-recovered deceased pancreas 2014 The reasons of non-recovery of pancreas among eligible donors consented for pancreas donation in 2014

7 Total Pancreas: 27 6 6

5 4 4

3 2 2 2 2 2 2 2 1 1 1 1 1 1

0 1990 1991 1992 2004 2005 2006 2007 2008 2009 2010 2011 2013 2014

Figure II.5.1: Cumulative deceased pancreas transplantation Details of the deceased pancreas transplantation in the Kingdom of Saudi Arabia 1990-2014; total deceased kidney transplantation: 27

ANNUAL REPORT 2014 74

Corneal Recovery

Corneal tissue donation program and transplantation was established in the kingdom since 1983. Corneas were recovered along with multi-organ retrieval from actual DBD donors. In the year 2014, 13 corneas were recovered inside the Kingdom of Saudi Arabia, A total sum of 692 corneas had been recovered inside the kingdom from 1983- 2014. Illustration of cumulative corneal recovery is shown in figure II.6.1. It is worth mentioning that King Khalid Eye Specialist Hospital-Riyadh, being the most active corneal transplant center having 566 patients in their waiting list and performing 879 corneal transplantation which were harvested abroad and transplanted, in addition to 701 corneas sent to other eye care facilities.

Recovered 1. DECEASED CORNEAL DONATION 2014 N Cornea Transplant Center Corneas King Khalid Eye Specialist Hospital- 110 deceased donors were consented for the purpose 1 11 Riyadh of organ donation and 44 (40%) of them were 2 King Abdul-Aziz Specialist Hospital-Taif 2 consented for corneal donation; 7 donors were Total 13 recovered and 37 were not recovered. The details of Table II.6.2: Deceased corneal recovery Performance of deceased corneal recovery in currently active the recovered corneal donor characteristics are listed national corneal transplant center in 2014 in (table II.6.1). Non-recovered deceased corneas Characteristic N % 88 deceased corneas were consented for corneal Age 21-30 1 17% donation and of which, 75 were not recovered (see 41-50 5 83% table II.6.3). Blood Group A 1 17% Reasons of Non Recovery N % B 3 50% Technical 32 43% AB Infection 30 40% O 2 33% Hemodynamic instability 6 7% Gender Determined unsuitable cornea donor 5 7% Male 5 83% Donor sudden cardiac arrest 2 3% Female 1 17% Total 75 100% Cause of Death Table II.6.3: Reasons for non recovered deceased corneas CVA 4 67% Reasons of non-recovered deceased corneas among eligible donors Head trauma 2 33% consented for corneal in 2014 Circumstance of Death MVA 1 17% Discarded corneas Non-MVA 5 83% 88 deceased corneas were consented for corneal Table II.6.1: Deceased Cornea Donor Characteristics Characteristics of utilized deceased donors from whom corneas were donation; out of which 2 (2%) were discarded (see recovered and transplanted table II.6.4).

2. DECEASED CORNEAL RECOVERY 2014 Reason of Discard N % No syphilis screen 2 100 88 deceased corneas were consented for the purpose Table II.6.4: Reason of discarded deceased corneas of corneal recovery; with 13 corneas recovered and Discarded corneas among actual deceased donors in 2014

75 were not recovered. Deceased corneal recovery was performed by 2 currently active corneal transplant centers (see table II.6.2).

3150 Total Corneas Recovered Locally: 692 Total Corneas Recovered Abroad: 25508

1578 1577 1344 1366 1133 1167 1209 931 946 941 1005 945 962 840 843 800 879 693 731 642 741 350 355 380 9 14 13 23 62 36 49 48 53 34 26 38 16 21 19 31 44 17 32 23 24 15 16 16 13

Figure II.6.1: cumulative corneal recovery Details of the deceased corneal recovery and transplantation in the Kingdom of Saudi Arabia 1983-2014

ANNUAL REPORT 2014 75

Bone Banking

Bone donation program from deceased donors was started in the Kingdom by King Faisal Specialist Hospital & Research Center in 2009. Up to date, bone recovery goes along with multi organ recovery from actual DBD donors from central region. In the year 2014, 126 bones and 58 musculoskeletal tissues were recovered inside the Kingdom of Saudi Arabia. It is worth mentioning that 226 bones had been recovered in addition to 90 musculoskeletal connective tissues were recovered for the purpose of bone allograft. Illustration of the cumulative recovered deceased bones and musculoskeletal tissues is shown in (figure II.7.1).

DECEASED BONE DONATION 2014 Of the 31 the bone tissue donors, 126 bones and 58 musculoskeletal tissues were recovered, a total of 38 110 deceased donors were consented for tissue femurs, 37 tibias, 37 fibulas and 14 pelvises including donation, of which 31 (28%) were consented for bone 58 musculoskeletal connective tissues (see II.7.2). and musculoskeletal tissue donation wherein, 23 (74%) donors were recovered and the remaining 8 Bone Bank Femur Tibia Fibula Pelvis MST King Faisal (26%) were not recovered. The details of the utilized Specialist Hospital 38 37 37 14 58 deceased bone and musculoskeletal tissue donor & Research Center- characteristics are listed in table II.7.1. Riyadh Table II.7.2: Deceased bone and MSCT recovery Performance of deceased bone and MST recovery in currently active Characteristic N % national bone bank in 2014 Age 21-30 2 9% 31-40 6 26% Non-recovered bones 41-50 9 39% 31 deceased donors were consented for bone 51-60 5 22% donation and of which, 7 (6%) were not recovered 61-70 1 4% Blood Group see (table II.7.3). A 6 26% B 6 26% Reasons of Non Recovery N % AB 1 4% Donor outside Riyadh 5 71% O 10 5% Donor poor general condition 1 14% Gender Administrative issue 1 14% Male 21 91% Total 7 100% Female 2 9% Table II.7.3: Reasons of non-recovered bones Cause of Death Reasons of non-recovery of bones among eligible deceased donors Anoxia 2 9% consented for bone donation in 2014 CVA 14 61%

Head trauma 7 30%

Circumstance of Death

MVA 14 45%

Non-MVA 17 55% Table II.7.1: Deceased bone and musculoskeletal connective tissue donor characteristics Characteristics of utilized deceased donors from whom bones and musculoskeletal connective tissues were recovered and recovered

126 Total Bones Recovered: 226 Total Musculoskeletal Connective Tissue Recovered: 90

29 21 20 13 17 17 3 4 8

2009 2010 2011 2012 2013 2014

Figure II.7.1: cumulative recovered deceased bones and musculoskeletal tissues 2009-2014

ANNUAL REPORT 2014 76

Organ Sharing between the Kingdom of Saudi Arabia and GCC Countries 2014

In 2014, 45 organs and tissues were recovered from DBD donors in GCC countries and shared to the Kingdom. Of the shared organs; 8 kidneys, 21 livers, 5 whole hearts, 4 lungs and 7 hearts as source of valves were recovered. Over the years, there was continuous successful cooperation in organ sharing program between the GCC countries and it is worth mentioning that this year, 45 organs and tissues were shared from Kuwait, Qatar and Bahrain which marked the peak of organ sharing since 1996. In addition to this year’s organ sharing program, 1 kidney was shared to U.A.E. by the Kingdom (see table II.8.1).

Recovered/Transplanted Organs Total Year Recovered/Tx. Kidney Liver Heart HFV Lung Organs 1996-2000 6/6 19/14 4 /4 11 2/2 42/37 2001 13/12 3/3 - 1 - 17/16 2002 2/2 2/2 - 2 - 6 2004 6/6 6/5 1 /1 4 - 17/16 2005 7/7 13/10 1 /1 12 4/2 37/32 2006 6/3 12/8 - 7 - 25/18 2007 2/2 14/13 1 /1 2 - 19/18 2008 6/5 12/11 - - - 18/16 2009 2/2 5/5 - 1 - 8/8 2010 2/2 11/10 - - - 13/12 2011 4/3 5/3 1/1 - - 10/7 2012 6/3 13/10 - 7 10/10 36/30 2013 2/2 5/6** 2/2 4/4 13/14

2014 8/8 21/20 5/5 7/7 4/4 45/44 Total 72/63 141/120 15/15 54 24/22 306/274 Table II.8.1: Recovery and transplantation activities from organ sharing program between the kingdom and other countries* 1996-2014, *Kuwait, Qatar, Bahrain and Spain, **Tx. as split liver transplantation

Transplanted Organs Year Country Total Organs Kidney Liver Heart HFV Lung 1996-2002 Kuwait 3 19 4 14 2 42 2000-2001 Spain 17 - - - - 17 Kuwait 10 39 2 18 2 2004-2009 Qatar 15 12 1 8 - 108 Bahrain - 1 - - - Kuwait - 5 - - - 2010 Qatar 2 4 - - - 12 Bahrain - 1 - - - Kuwait 1 2 1 - - 2011 7 Qatar 2 1 - - - Kuwait 1 9 - 7 10 2012 30 Qatar 2 1 - - - Kuwait 2 6 1 - 2 2013 14 Qatar - - 1 - 2 Kuwait 1 16 5 4 4 2014 Qatar 4 1 - - - 44 Bahrain 3 3 - 3 - Total 63 120 15 54 22 274 Table II.8.2: Transplant activities from organ sharing program between the kingdom and other countries 1996-2014

ANNUAL REPORT 2014 77

Whole Heart for Kidney Liver Lungs Pancreas Cornea Bones Heart Valves No. of Organs 131 70 31 19 2 19 11 126 Cost Inside KSA 6.5 24.5 15.5 9.5 1.2 5.7 0.44 2.52 Cost Outside KSA 65.5 140 62 38 2.4 9.5 0.132 7.56 Figure II.8.1: Cost of organ and tissue utilized inside and outside the Kingdom in 2014 (Million SR) The figure shows cost of transplantation for different organs (kidney, liver heart, etc.) and the amount of savings when comparing inside and outside the Kingdom in organ transplantation

Total cost outside KSA 325092000

Total cost inside KSA 65514000

0 100000000 200000000 300000000 400000000

Figure II.8.2: comparison of estimated total cost of organs and tissues transplanted inside and outside the Kingdom in 2014 Estimated savings: 259.578 Million SR

3000 2694 2500

2000

1500 790 1000 602 690 500 280 225 27 144 90 0 Kidney Liver Whole Pancreas Lung HFV Cornea Bones MSCT Heart

Figure II.8.3: Total number of deceased organs and tissues utilized 1986-2013

214

256

253

246

218

214

211

210

203

189

185

183

139

128

119

117

113

111

110

101

1986 1987 2005 2006 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2007 2008 2009 2010 2011 2012 2013 2014 1988 Figure II.8.4: Total deceased organs and tissues transplanted in KSA 1986-2014 Total Organs (kidney, liver, heart, pancreas, lung): 3926 Total Tissues (corneas, heart for valves, bones, musculoskeletal tissues): 1609

ANNUAL REPORT 2014 78

Appendix I Responsibilities of the Saudi Center for Organ Transplantation (SCOT)

1. Setting up a national registry for end-stage organ failure patients, organ transplant recipients and organ donors with their follow-up and outcome, and setting up the necessary procedures.

2. Receiving and following-up of brain death cases in intensive care units, coordinating the removal of organs after getting the necessary approvals and distributing the organs to the organ transplant centers in the various health institutions in the Kingdom.

3. Coordinating with the concerned authorities to send medical teams to the various areas in the Kingdom and abroad, to remove the organs from the person mentioned in paragraph 2 of this clause and transplant it to a patient.

4. Cooperating and coordinating with the health authorities in the field of organ transplantation, both inside the Kingdom and abroad.

5. Preparing and updating the necessary procedures for organ transplantation from living donors in accordance with Sharia law restrictions.

6. Preparing and updating the policies and procedures (measures, descriptions, conditions and restrictions) related to organ transplantation in the Kingdom.

7. Monitoring and following-up on the application of organ transplantation programs, carrying out regular appraisals of the establishments and following-up with the specialized bodies.

8. Preparing administrative and financial roles for the personnel of the center, the researchers and those collaborating with it.

9. Holding symposia and conferences and educational and training programs, in the field of organ failure, organ donation and transplantation, on regional and international levels and holding orientation programs.

10. Offering awareness and educational health programs, in the field of organ failure and organ donation and transplantation in the community.

11. Publishing a scientific journal specializing in organ transplantation on the subjects of organ failure, organ donation and transplantation.

12. Taking part in scientific research related to organ transplantation and organ failure, in the Kingdom and abroad.

13. Cooperating with charities to support organ failure patients.

ANNUAL REPORT 2014 79

Appendix II Regulations for Organ Transplantation in the Kingdom of Saudi Arabia

Regulations are essential to the process of organ donation and transplantation and therefore, the Higher National Committee for the Development of Organ Donation and Transplantation in the Kingdom of Saudi Arabia (KSA), which was formed according to the Ministerial resolution 14853/84 dated 30/2/1431, reviewed the regulations and passed them as follows:

Item 1: The following terms are defined as follows: Council: The Council for the Health Services Center: The Saudi Center for Organ Transplantation (SCOT) Directory: The Directory for Organ Donation and Transplantation in the KSA.

Item 2: Only authorized specialized physicians can perform organ transplantation from the living or deceased human donors to a human recipient with intention for cure and rescue according to the regulations included in this document.

Item 3: Any rightful person can donate or place a directive for donation of one of his body organs to rescue or treat a patient with end-stage organ failure. A statement should be signed by the donor as a will for donation. Nevertheless, only those who attain 18 years of age can donate to their relatives.

Item 4: Fully known medical investigations as advised by the specialist in the field should be performed before approving the organ donation from living donors. Full discussion of the risks and possible outcomes should be conducted with the donor before donation.

Item 5: Donors have the right to withdraw their consent for donation any time before the operation without penalties. No donor can claim his organ after transplantation is completed.

Item 6: It is prohibited for living donors to donate vital organs, donation of which could result in the death of the donor or complete disabling of vital functions.

Item 7: Organ donation can be from the persons only after full documentation of death by a committee of specialized physicians and in the absence of a directive by the donor objecting to donation during his life.

Item 8: Organ donations, as in item 7, can be performed if brain stem death is documented by the available means of technology.

Item 9: Commercial transplantation is prohibited in any manner.

Item 10: Transplantation is performed only in centers authorized by the Ministry of Health in the GCC Countries.

Item 11: Penalties will be levied in case of any violation of the above regulations according to system of the medical practice, after intensive investigation by the SCOT and the concerned authorities.

ANNUAL REPORT 2014 80

Appendix III Memorandum by the Minister of Health on Deceased Organ Donation

Ref: 328025/11 Date: 17/12/1432H 13/11/2011G

Important Memo

His Excellency the Director of the National Guard Health Affairs

His Excellency the Executive Administrator of the General Organization King Faisal Specialist Hospital and Research Center

Deputy Minister of Higher Education

His Excellency Deputy Minister for Executive Affairs

His Excellency Director General of Medical Services of the Armed Forces

Director General of Security Forces Hospital Program

Due to the importance of supporting the national program for organ donation and transplantation and the large increase in the number of patients on waiting lists for transplantation and the resulting health and social burden on the patients and financial burden on different health sectors , I appeal to the staff in all hospitals and especially those in the intensive care units, emergency departments, neurology and neurosurgical departments, and all relevant departments to cooperate with the Saudi Center for Organ Transplantation of the administration of each hospital to fulfill the following:

1. Early Notification of cases of brain death to Saudi Center for Organ Transplantation and considering that as the core tasks of intensive care physicians and other relevant departments. 2. Support for organ donation in the hospital and put the appropriate plan with the Saudi Center for Organ Transplantation for optimizing cases of organ donation after death and overcome the obstacles faced by. 3. Facilitate continuous communication of medical and administrator coordinators inside the hospitals with intensive care units and emergency departments and relevant departments with respect to the organ donation and transplantation program.

DR. ABDULLAH BIN ABDELAZIZ AL RABEEAH Minister of Health Chairman of the Health Services Council

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Appendix IV Official Statement of the National Committee for the Diagnosis of Death by Neurological Criteria and Ventilator System

The members of National Committee for diagnosis of death by Neurological Criteria held a meeting in Saudi Center for Organ Transplantation (SCOT) on Sunday 31/01/2010 (23/11/1431H) to discuss what has been published recently in the media about the reluctance of some medical doctors on the “fatwa” on removing the ventilator machine from brain dead case where some consider it as killing a person. Accordingly the following steps were done by the committee:  Review of these articles and international global scientific publications emerging on the subject.  Review of the medical ethics of diagnosis of death by neurological criteria.  Review the legal opinion “Fatwa” issued within the Kingdom of Saudi Arabia (Senior Ulama Commission) or abroad, especially the resolution of the Council of Islamic Jurisprudence on Resuscitation Apparatus. Hence, we have decided unanimously the following: 1. The diagnosis of death by the time was, and continues to be a medical decision made by the experienced professionals. 2. The concept of brain death based on evidence has not undergone any recent disputing developments both in the definition or diagnosis using the Saudi protocol. Moreover, the protocol used within the Kingdom of Saudi Arabia is one of the most demanding protocols in the world. 3. According to the diagnosis of brain death by neurological criteria using the strict scientific protocol, the deceased person reaches the point of no return and no chance that he will regain his life. 4. It is permissible to remove the respirator from the persons diagnosed dead by the neurological criteria according to the scientific protocol applied in all the health institutions in the Kingdom and supervised by the committees of ethics and medical expertise.

The National Committee For The Diagnosis Of Death By Neurological Criteria

Dr. Mohammad Zuheir Alkawi Dr. Abdullah Turki Chairman, Consultant Pediatric Intensivist, Senior Consultant Neurologist Director, Pediatric Critical Care Unit King Faisal Specialist Hospital & Research Center, King Faisal Specialist Hospital & Research Center, Riyadh Riyadh

Dr. Mohammed Al-Bar Dr. Mohammad Ibrahim Almajeed Consultant, Islamic Medicine Consultant Anesthesiologist, King Abdul Aziz University - Jeddah King Khalid University Hospital – Riyadh

Dr. Nabil Biary Dr. Awad Addasi Consultant, Neurologist Consultant Intensivist, Riyadh Military Hospital Riyadh Military Hospital

This statement is approved by the Saudi Society of Critical Care (SCCS):

Dr. Yasser Mandourah Dr. Amin M. Yousef

Consultant Intensivist, Consultant Intensivist, Head, Saudi Society of Critical Care Deputy Head, Saudi Society of Critical Care Head, Intensive Care Unit Head, Intensive Care Unit Riyadh Military Hospital King Saud Medical Complex , Riyadh

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Appendix V Purport of the Senior Ulama Commission Decision No. 99 Dated 06-11-1402 H

The board unanimously resolved the permissibility to remove an organ, or a part thereof from a Moslem or Thimmi living person and graft it onto him, should the need arise, should there be no risk in the removal and should the transplantation seem likely successful.

The board also resolved, by majority the following:

The permissibility to remove an organ or part thereof from a dead person for the benefit of a Moslem, should the need arise, should the removal cause no harm and should the transplantation seem likely successful. The permissibility for the living person to donate one of his organs or part thereof for the benefit of a Moslem in need thereof.

Senior Ulama Commission.

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Appendix VI Resolution of the Council of Islamic Jurisprudence on Resuscitation Apparatus Decision No. (5) D 3/07/86

The council of Islamic Jurisprudence in its third meeting held in Amman, capital of Jordan from 8 to 13 Safar 1407 H corresponding to 11 to 16 October 1986 and after discussing all relevant aspects of resuscitation apparatus and after hearing the detailed explanation from specialist doctors, decide the following:

A person is pronounced legally dead and consequently, all dispositions of the Islamic law in case of death apply if one of the two following conditions has been established:

There is total cessation of cardiac and respiratory functions, and doctors have ruled that such cessation is irreversible.

There is total cessation of all cerebral functions and experienced specialized doctors have ruled that such cessation is irreversible and that brain has started to undergo autolysis.

In this case, it is permissible to take the person off resuscitation apparatus, even if the function of some organs e.g., heart are still artificially maintained.

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A Consented eligible donor: Glossary: a. In whom an operative incision was Brain Death made with the intent of organ recovery Irreversible cessation of cerebral and brain for the purpose of transplantation. stem; characterized by the absence of electrical activity in the brain, blood flow to the brain, and b. From whom at least one organ was brain function as determined by clinical recovered for the purpose of assessment of responses. A brain dead person is transplantation. dead, although his or her cardiopulmonary functioning may be artificially maintained for Utilized DBD donor some time. An actual donor from whom at least one organ was transplanted. Critical Pathway of Deceased Organ Donation Organ Donation: is the donation of biological Provides a systematic approach to the organ tissue or an organ of the human body to a donation process, considering both donations recipient in need of transplantation. after cardiac death than donation after brain death. The pathway provides a tool for assessing Living Organ Donation the potential of deceased donation and for the Organ donation from living donor to living prospective identification and referral of recipient possible deceased donors. Deceased Organ Donation Donor Organ donation from deceased donor who is Someone from whom at least one organ or pronounced brain dead or circulatory death tissue is recovered for the purpose of who is apparently medically suitable for organ transplantation. A deceased donor is a patient donation who has been declared brain death or cardiac death criteria. Organ Recovery / Procurement The obtaining of organs for transplantation, Deceased Donor or DD which included methods of obtaining through An individual from whom at least one solid programs, systems or organization. It includes organ is recovered or the purpose of also the transporting of donor organs, after transplantation after suffering brain death or surgical removal to the hospital for processing cardiac death. and transplant.

Living Donor Organ Failure Is one who donates an organ or segment of an Is altered organ function in an acutely ill patient organ for the intent of transplantation. requiring medical intervention to achieve homeostasis. Possible Deceased Organ Donor A patient with a devastating brain injury or Organ Transplant lesion or a patient with a circulatory failure and An operation moving an organ from one apparently medically suitable for organ organism (donor) to another one (recipient) donation

Allograft Potential DBD donor An organ or tissue that is transplanted from one A person whose clinical condition is suspected person to another of the same species: i.e. to fulfill brain death criteria. human-to-human.

Eligible DBD donor Biopsy A medically suitable person who has been A tissue sample from the body, removed and declared dead based on neurologic criteria as examined under a microscope to diagnose fro stipulated by the law of the relevant jurisdiction. disease, determine organ rejection, or assess donated organ or tissues.

Chronic Developing slowly and lasting for a long time, possible the rest of person’s life. e.g. chronic kidney disease Actual DBD donor

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Split Liver Transplantation Kidney Donor Risk Index or KDRI The division of a donor liver into parts in order Is an estimate of the relative risk of post- to transplant the tissue into a child or small transplant kidney graft failure (in an average, recipient adult recipient) from a particular deceased donor compared to the median (50th percentile) En bloc Kidney Transplantation donor. the transplant of both kidneys into a single receiver and using the donor aorta and vena Expanded-criteria donors or ECD cava for vascular anastomosis. Refer to older kidney donors (≥60 yr) or donors who are aged 50 to 59 yr and have Cold Ischemia Time or CIT or in surgery two of the following three features: The time between the chilling of a tissue, organ, Hypertension, terminal serum creatinine >1.5 or body part after its blood supply has been mg/dl, or death from cerebrovascular accident. reduced or cut off and the time it is warmed by

having its blood supply restored. This can occur Standard Criteria Donor or SCD while the organ is still in the body or after it is Is a donor who is under 50 years of age and removed from the body if the organ is to be used suffered brain death from any number of causes. for transplantation. This would include donors under the age of 50 who suffer from traumatic injuries or other medical problems such as a stroke.

Abbreviations: SCOT: Saudi Center for Organ Transplantation NFK: National Kidney Foundation DBD: Donation After Brain Death DD: Deceased Donor PMP: Per Million Population CVA: Cerebrovascular accident MVA: Motor Vehicle Accident ICU: Intensive Care Unit FFH: Fall from Height DHT: Direct Head Trauma CNS: Central Nervous System GCC: Gulf Cooperation Council MOH: Ministry of Health Gov’t: Government HFV: Heart for Valves HCV: hepatits C Virus TB: Tuberculosis LR: Living Related LUR: Living Unrelated MSCT: Musculoskeletal Connective Tissue SCD: Standard Criteria Donor ECD: Expanded-criteria donors KDRI: Kidney Donor Risk Index CIT: Cold Ischemia Time

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II.2.11: Adult and pediatric deceased liver Index: transplantation II.2.12: Age distribution between deceased liver Tables: donor and recipients 2014 II.2.13: living liver transplantation

I. Deceased Donors after Brain Death & II.3: Heart Transplantation Organ Donation II.3.1: Deceased heart donation 2014 II.3.2: Deceased heart donor characteristics I.1: Critical pathway of deceased organ donation, II.3.3: Deceased heart donation 1986-2014 region wise in 2014 II.3.4: Deceased hearts transplantation I.2: Cause of death among possible DBD donors in II.3.5: Heart for valve recovery and utilization 2014 II.3.6: reasons of non-recovered deceased hearts I.3: Cause of death among possible DBD donors in II.3.7: Adult and pediatric deceased heart 1986-2014 transplantation I.4: Reasons of not utilized actual DBD donors II.3.8: Age distribution between deceased heart 2014 donor and recipients 2014 I.5: distribution of possible, consented and actual deceased donors according to region II.4: Lung Transplantation I.6: Hospitals with ICU's Having More than 20 II.4.1: Lungs from deceased donation 2014 Beds II.4.2: Deceased Lung Donor Characteristics I.7: Hospitals with ICU’s Having 10 to 20 Beds II.4.3: Deceased Lung Transplantation 2014 1.8: Hospitals with ICU’s Having Less than 10 Beds II.4.4: deceased lung Transplantation Activity I.9: Hospitals outside the Kingdom of Saudi Arabia 1991-2014 I.10 Total Number of Brain Death II.4.5: Reasons of non-recovered deceased lungs II.4.6: Major causes of non-recovered lungs 2014 II. Organ Transplantation II.4.7: Reasons of discarded deceased lungs II.4.8: Adult and Pediatric Lung Transplantation II.4.9: Age distribution between deceased lung II.1: Kidney Transplantation donor and recipients 2014 II.1.1: Living and deceased kidney transplantation II.1.2: Deceased kidney donor characteristics II.1.3: Deceased kidney donation 2014 II.5: Pancreas Transplantation II.1.4: Deceased kidney donation 1986-2014 II.5.1: Pancreas from deceased donors 2014 II.1.5: Deceased kidney transplantation II.5.2: Deceased pancreas donor characteristics II.1.6: Reasons of non-recovered deceased II.5.3: deceased pancreas transplantation kidneys II.5.4: Reasons for non-recovered deceased II.1.7: Major Causes of non-recovered deceased pancreases kidneys 2014 II.5.5: Major causes of non-recovered deceased II.1.8: Reasons of discarded deceased kidneys pancreas 2014 II.5.6: Reason of discarded pancreas II.1.9: Causes of discarded deceased kidneys II.5.7: adult and pediatric deceased pancreas 1986-2014 transplantation II.1.10: Adult and pediatric deceased kidney transplantation II.6: Corneal Transplantation II.1.11: Transplanted deceased ECD kidneys II.6.1: Deceased Cornea Donor Characteristics II.1.12: Age distribution between deceased kidney II.6.2: Deceased corneal recovery donor and recipients 2014 II.6.3: Reasons for non-recovered deceased II.1.13: Living kidney transplantation 2014 corneas Table II.6.4: Reason of discarded deceased II.2: Liver Transplantation corneas II.2.1: living and deceased liver transplantation II.2.2: Deceased liver donation 2014 II.7: Bone Transplantation II.2.3: Deceased liver donor characteristics II.7.1: Deceased bone and musculoskeletal II.2.4: Livers from deceased donors 1994-2014 connective tissue donor characteristics II.2.5: Deceased liver transplantation 2014 II.7.2: Deceased bone and MSCT recovery II.2.6: Reasons of non-recovered deceased livers II.7.3: Reasons of non-recovered bones II.2.7: Major causes of non-recovered deceased livers (2014) II.2.8: Major causes of non-recovered deceased livers (1994-2014) II.2.9: Reasons of discarded deceased livers 2014 II.2.10: Causes of discarded deceased livers 1994- 2014

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II.8: Organ Sharing between the II. Organ Transplantation Kingdom of Saudi Arabia and GCC Countries 2014 II.1: Kidney Transplantation II.8.1: Recovery and transplantation activities II.1.1: Cumulative living and deceased kidney from organ sharing program between the II.1.2: Cumulative deceased kidney kingdom and other countries* 1996-2014, transplantation *Kuwait, Qatar, Bahrain and Spain II.1.3: cumulative living kidney transplantation II.8.2: Transplant activities from organ sharing program between the kingdom and other II.2: Liver Transplantation countries 1996-2014 II.2.1: Cumulative living and deceased liver transplantation in KSA

Figures: II.3: Heart Transplantation

II.3.1: Cumulative deceased heart transplantation I. Deceased Donors after Brain Death & and recovered hearts as source of valves in Saudi Organ Donation Arabia 1986-2014

I.1: Critical Pathway of Organ Donation II.4: Lung Transplantation I.2: Critical pathway of deceased organ donation II.4.1: Cumulative deceased lung transplantation in 2014 1991-2014 I.3: Critical pathway of deceased organ donation 1986-2014 II.5: Pancreas Transplantation I.4: Annual trend of possible DBD donors over the II.5.1: Cumulative deceased pancreas years 1986-2014 transplantation I.5: age distribution of possible DBD donors 2014 I.6: age distribution of possible DBD donors 1986- 2014 II.6: Corneal Transplantation I.7: Sex distribution in possible DBD donors 2014 II.6.1: cumulative corneal recovery I.8: Sex distribution in possible DBD donors 1986- 2014 II.7: Bone Transplantation I.9: Annual trend of potential DBD donors 1986- II.7.1: cumulative recovered deceased bones and 2014 I.10: Documented and non-documented possible II.8: Organ Sharing between the DBD donors 2014 Kingdom of Saudi Arabia and GCC I.11: Documented and non-documented possible DBD donors 1986-2014 Countries 2014 I.12: Annual trend of approached eligible DBD II.8.1: Cost of organ and tissue utilized inside and donors 1986-2014 outside the Kingdom in 2014 (Million SR) I.13: approached and not-approached eligible II.8.2: comparison of estimated total cost of DBD donors 2014 organs and tissues transplanted inside and I.14: approached and not-approached eligible outside the Kingdom in 2014 DBD donors 1986-2014 II.8.3: Total number of deceased organs and I.15: Consented and non-consented approached tissues utilized 1986-2013 eligible DBD donors 2014 II.8.4: Total deceased organs and tissues 1.16: Consented and non-consented approached transplanted in KSA 1986-2014 eligible DBD donors 1986-2014 I.17: Annual trend of consented eligible DBD donors 1986-2014 1.18: Annual trend of actual DBD donor 1986- 2014 I.19: Recovered and non-recovered consented eligible DBD donor 2014 I.20: Recovered and non-recovered consented eligible DBD donor 1986-2014 I.21: Transportation used during organ recovery 2014 I.22: Annual trend of ICUs contributing in deceased donation program

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