Organ Transplantation in Jamaica

Jamaica is a 10 991 km2 island and the largest English-speaking Caribbean country. The island is home to 2.95 million people whose life expectancy at birth is 75.2 y.1 The 2017 estimate of GDP was $26.06 billion (USD), ranking Jamaica at 140 out of 228 countries in the world.2 Although Jamaica has had a steady improvement in life expectancy, poorly controlled hypertension and diabetes mellitus, with a current prevalence of 31.5% and 10.2%, respectively, have plagued the country with increasing rates between 2001 and 2017.3,4 Arterial hypertension and diabetes are also the major causes of chronic kidney disease and end-stage renal disease (ESRD) in Jamaica and the Caribbean.5,6 Jamaica is considered a middle-income country, with a per capita income between $1026–12 475 USD (2011),7 faced with economic challenges and a constrained healthcare service. There are 22 hemodialysis centers and a total of 160 hemodialysis chairs for approximately 890 patients. Additionally, 28 patients receive peritoneal dialysis. The cost of a single hemodialysis session ranges between $70 and 100, with <50% of ESRD-eligible patients receiving dialysis regularly as they are unable to afford the treatment. Approximately 32% of patients receive dialysis in public facilities, whereas patients on a waiting list are accommodated in private centers. Approximately 70%, 20%, and 10% of patients receive dialysis twice, once, and 3 times per week, respectively NUMBER OF TRANSPLANT PROGRAMS Kidney Organ transplantation was first introduced in the Caribbean in September 1970, when the first deceased donor kidney transplant took place at Kingston Public Hospital (KPH)8 located in Jamaica’s capital and largest city, Kingston (Figure 1). The procedure was performed by Professor Lawson Douglas who had returned from Ottawa, Canada, after residency training in Urology and Transplantation in December 1969 to practice at KPH. The second and third transplants, both from deceased donors to patients with ESRD due to glomerulonephritis, occurred in 1971. From 1970 to 1993, there was a minimum of 2 transplants per year, and all were from deceased donors. Transplantation continued as a joint effort between KPH and the University Hospital of the West Indies (UHWI). Between 1994 and 1995, a living donor program was developed at UHWI as immunologic risk studies became attainable and were performed at the UHWI. Kidney transplants in Jamaica waned after 2001, and we would not see a resurgence until 2013 when the Cornwall Regional Hospital (CRH) performed their first living-donor transplant with the support of Transplant Links United Kingdom. Nine living-donor transplants were done between 2013 and 2017 at CRH and 6 at UHWI between 2019 and 2020.FIGURE 1.: Map of Jamaica showing Nephrology clinics participating in the transplant program: (1) University Hospital of the West Indies,+ (2) Kingston Public Hospital,+ (3) Cornwall Regional Hospital,+ (4) St. Ann’s Bay Hospital,* (5) Mandeville Regional Hospital,* and (6) Spanish Town Hospital.* +Hospital that has performed kidney transplant. *Nephrology clinics for transplanted patients, potential donors, and potential organ retrieval centers.Liver Liver transplants started in the pediatric population with the assistance of a team from Delaware who assisted with 4 cases of Jamaican children being transplanted overseas between 2016 and 2017. Through logistical, educational, medicosurgical, and Ministerial support, a local program was spearheaded and formalized by Dr Colin Abel, a Pediatric Surgeon and Urologist. In 2018, a 1+-y-old boy with biliary atresia received a liver segment from his mother at the Bustamante Hospital for Children in Kingston. A second liver transplant was performed in the same year for the same indication. All live-donor liver transplant cases have been for biliary atresia and typically use segments 2 and 3. Currently, there are 5 postliver transplant children being followed at the liver transplant clinic. There is no adult liver transplant program, nor has an adult liver transplant been done. DATA SYSTEMS AND OVERALL TRANSPLANT VOLUME An electronic data registry was designed by the Caribbean Institute of Nephrology with E-Health Portfolio in 2009. A national registry of patients with kidney disease was developed for Jamaica and the Caribbean, but its utilization is poor. In continuing the development of a National Organ Transplant Program, the UWHI has embarked on making multilateral partnerships with various clinical and nonclinical, local and overseas entities in pursuit of standardizing and protocolizing a fully functioning transplant program. In 2019, the deceased organ donation and transplantation program was started in partnership with the Donation and Transplant Institute Foundation and with sponsorship by the European Union. To date, no living donor kidney transplants have been performed. The Ministry of Health and Wellness; Culture, Health, Art, Sports and Education Fund; and National Health Fund have all been instrumental in supporting transplantation. St. Ann’s Bay Hospital, Mandeville Regional Hospital and Spanish Town Hospital have been identified as potential centers to support deceased organ retrieval and living donor programs. BARRIERS TO LIVING AND DECEASED DONATION Qualitative data are lacking on the public perception of transplantation and organ donation. Patient involvement in clinical research and trial design are crucial to improving their individual bio-psychosocial outcomes and can help decrease barriers to transplantation.9 Large family size and close community bonds favor living donation, but Jamaica’s traditionally high migration rate to North America, Europe, and other Caribbean islands diminish donor organ availability. Another contributing barrier is the cultural belief of bodily integrity at death. A pilot study was conducted on the knowledge and attitude of healthcare professionals to organ donation showing a support for organ donation and transplantation. SIGNIFICANT ACHIEVEMENTS AND CHALLENGES To date, approximately 55 living and 121 deceased donor kidney transplants have been performed in Jamaica. The 5-y graft survival before 1990 was 60%. Within the last 2 y, the 1-y graft survival and patient survival at UHWI has been 100%, and 5-y graft survival and patient survival at CRH has been 88.8%. The reported causes of recipient deaths were cardiovascular, pulmonary, and malignancy related. Living donor nephrectomies have been performed through open laparotomies and more recently through a hand-assisted laparoscopic approach. Two donors have had complications: 1 wound infection requiring staple removal and another with intra-abdominal hemorrhage requiring relaparotomy and suturing of a muscle bleeder. Although expertise is available, the resources for a sustainable program are still in their infancy. There is a need for local capacity building in the transplant workforce and upgrading facilities for immunology, pathology, and tissue typing. Constant recruitment from overseas agencies has been challenging to the growth of transplant services. The development of a central database for organ donation is needed not only in Jamaica but also as a regional effort to involve the entire Caribbean with the goal of developing a kidney-sharing scheme. The Caribbean Donation and Transplantation Society was conceptualized in February 2021 to foster sharing of knowledge and support for organ and tissue transplantation within Caribbean countries. The established Caribbean Renal Registry has the capacity to collect data on chronic kidney disease stage 5 patients, which can serve as a repository for patients in preparation for transplantation. Innovative revenue streams will need to be sought as the government is under very tight fiscal restraints worsened by the COVID-19 pandemic. GOVERNMENT AND REGULATORY SYSTEMS INVOLVEMENT AND OVERSIGHT The Human Tissue Act of 1972 (amended in 1976) facilitates deceased organ donation, but more government and regulatory measures are being developed, including public education regarding the benefits of organ donation, training of transplant professionals, the establishment of a central donor registry, and consideration of an opt-out national donor policy. These initiatives will require the collaborative effort of the Ministry of Health & Wellness, government agencies, and bioethicists to formulate public policies and gain the public confidence to move forward. CONCLUSIONS The transplant program in Jamaica has had some early success but needs robust expansion of local workforce, medico-legal operating framework and infrastructure. The efforts may be best facilitated through regional collaboration toward the development of a Caribbean Transplant Institute serving the needs of the wider community. ACKNOWLEDGMENTS The authors acknowledge the support by Professor Lawson Douglas (Urologist, Transplant Surgeon, KPH), Professor Everard Barton (Nephrologist, UHWI), Dr Colin Abel (Pediatric Surgeon & Urologist, BCH), and Dr Curtis Yeates (Nephrologist, CRH). We are particularly grateful for the support of Transplant Links United Kingdom, Donation and Transplant Institute, and other international partners who have supported local transplant efforts.

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