Saudi Journal of Kidney Diseases and Transplantation

: 2021  |  Volume : 32  |  Issue : 1  |  Page : 49--59

Barriers to Kidney Transplantation among Adults on Maintenance Dialysis in Western Region Saudi Arabia: A Cross-Sectional Study

Sami Alobaidi1, Naji Dwid2, Nada Salem3, Fahtima Mehdawi2, Abdullah Kashgary3, Hanadi Alhozali3, Rana Nablawi4, Enad Alsolami1, Faissal Shaheen2, Ahmed Akl5,  
1 Department of Internal Medicine, University of Jeddah, Jeddah, Saudi Arabia
2 Department of Internal Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
3 Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
4 Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
5 Department of Internal Medicine, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia; Urology and Nephrology Center, Mansoura University, Mansoura, Egypt; Department of Internal Medicine, Fakeeh College of Medical Sciences, Jeddah, Saudi Arabia

Correspondence Address:
Sami Alobaidi
Department of Internal Medicine, University of Jeddah, Jeddah
Saudi Arabia


Kidney transplantation (KT) is the treatment of choice for patients with end-stage renal disease. However, in Saudi Arabia, KT accounts for only 4.5% of the total existing renal replacement therapies in 2016. This cross-sectional study was conducted from September 2017 to January 2018. The aim was to assess the main barriers to the low KT rate in the Saudi community. Data were obtained by direct interviewing using a specifically pre-coded and pre-tested online questionnaire. A total of 321 adult hemodialysis and peritoneal dialysis (PD) (hemodialysis and PD, respectively) patients eligible for KT were selected from several dialysis units in Jeddah, accounting for 11% of the total dialysis population in Jeddah. The mean age was 49.9 ± 14.9 years, and 62.1% were male. Twenty-six percent were employed, and 88.2% were Saudis. Of those interviewed, 90.7% had been counseled for KT mostly by the nephrologist (86.5%) and 178 (55.5%) were referred for pre-transplant evaluation and 92 (28.6 %) were on the active transplant list. The most common barriers were lack of donor availability for 107 patients (40.5%), 58 patients (22%) worried about long-term complications, and 24 (9.1%) worried about surgical complications. Only 17 patients (6.4 %) reported financial constraints as the main reason for not having a KT, especially in non-Saudi patients. Additional initiatives to promote and improve the education and knowledge about kidney donation and the current outcome of KT is needed to improve the transplant rate in the country.

How to cite this article:
Alobaidi S, Dwid N, Salem N, Mehdawi F, Kashgary A, Alhozali H, Nablawi R, Alsolami E, Shaheen F, Akl A. Barriers to Kidney Transplantation among Adults on Maintenance Dialysis in Western Region Saudi Arabia: A Cross-Sectional Study.Saudi J Kidney Dis Transpl 2021;32:49-59

How to cite this URL:
Alobaidi S, Dwid N, Salem N, Mehdawi F, Kashgary A, Alhozali H, Nablawi R, Alsolami E, Shaheen F, Akl A. Barriers to Kidney Transplantation among Adults on Maintenance Dialysis in Western Region Saudi Arabia: A Cross-Sectional Study. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2023 Feb 4 ];32:49-59
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Full Text


Chronic kidney disease (CKD) is a very common disease worldwide, the global prevalence of CKD is around 13.4%.[1] The estimated number for patients with end stage renal disease (ESRD) is 0.1% globally. In Saudi Arabia, the number of patient with ESRD in 2017 was around 604/million population, total death was 1726 (9%), while the incidence of treated ESRD is estimated at 163 cases/per million population.[1],[2] Kidney transplantation (KT) has significant benefits toward reducing mortality, provides a better quality of life, and reduces cardiovascular diseases compared to regular dialysis.[3],[4] Multiple factors influence a patient’s decision toward undergoing KT, including socioeconomic class, religion, and education in addition to the availability of donors.[5]

Information on KT barriers in Saudi Arabia and the Middle East is scarce. Our aim in this study was to define the possible barriers toward kidney transplant among ESRD patients in our region, including non-Saudi patients regardless of the type of insurance or lack of it.

 Patients and Methods

This cross-sectional self-designed questionnaire study was conducted between September 2017 and January 2018 and involved 321 hemodialysis (HD) and peritoneal dialysis (PD) (on APD) outpatients. To test the validity of the questionnaires, a pilot study was conducted first. The patients were recruited from four hospitals, including three governmental and one private one in Jeddah, Saudi Arabia. The inclusion criteria for the patients consisted of several parameters: (1) over 18 age; (2) able to communicate in Arabic or English; and (3) undergoing regular HD three times/week or undergoing PD.

Informed consent was obtained from patients who agreed to participate in the study. The study was approved by the ethical committees from each of the four hospitals. Trained medical doctors who were not involved in patient care, explained the purpose of the study to the patients and read each question verbally. All questionnaires were completed anonymously.


Each patient completed a 3-part questionnaire. The first part concerned sociodemographic data (age, sex, marital status, education level, employment status, nationality, and type of medical insurance). The second part focused on HD-related data (cause of kidney failure, comorbidities, duration, number of sessions per week, and type of vascular access). This section included questions rated on a 5-point Likert scale which is a psychometric scale involved in questionnaire-based research[6]. It measures the degree of satisfaction with the current therapy ranging from totally satisfied to totally unsatisfied in the symmetric agree-disagree scale. The third part of the questionnaire focused on knowledge and experience with KT (transplantation history, knowledge about kidney transplant, source of this knowledge, willingness to undergo transplantation, barriers against transplantation that the patients face, and source of the donated kidney). We did not include religion in the questionnaire, only less than 12% were non-Saudis and most of them were originally from Muslim dominant countries. In order to measure how many of the participants took actual steps into undergoing KT, we included questions asking whether they were referred for pretransplant evaluation and whether they were already on the waiting list.

 Statistical Analysis

Statistical analysis was performed using Statistical Package for Social Sciences version 16.0 (SPSS Inc., Chicago, IL, USA). Results were expressed in the form of tables. Significance of testing between proportions was conducted in which it was applicable using the Chi-squared test and a P <0.05 was considered statistically significant. Multivariate analysis utilizing logistic regression analysis was performed to identify independent factors that could have significant barrier to transplantation.


The study included 321 patients of whom 97.2% were undergoing HD in one of the study centers. The two included centers have only 3% of their patient on PD, however overall the kingdom the percentage of PD, is only 6% from the total number on replacement therapy.[7] The sociodemographic characteristics of the participants are presented in [Table 1]. Participants included Saudis (88.2%) with 62% were male. Patients’ mean age was 49.9 ± 14.9 years. Ninety-six patients (29.9%) were below the age of 40, and 97 patients (30.2%) were above the age of 60. Only 19.9% had no education, and the rest had either average education (58.9%) or higher levels of education (21.2%). The majority were either unemployed (41.1%) or retired (29.3%), and 220 patients were married (68.5%) as shown in [Table 1].{Table 1}

Of the participants, 291 (90.7%) were aware that kidney transplant is the treatment of choice for kidney failure. However, only 40 (12.5%) knew this fact before starting dialysis. Nephrologists were responsible for educating two-third (69.2%) of the patients regarding kidney transplants, and the rest received education from other resources such as other patients, family members, media, internet or educational materials. Two-hundred forty (74.8%) were considering kidney transplants, but only 18 (5.6%) preferred to have it abroad while the rest said no to transplant abroad (15.3%) or were not sure (79.1%). More than half of the patients (55.5%) were referred for pre-transplant evaluation at the time of the study. Two-hundred forty-eight (77.3%) were aware that kidney transplant offers a better quality of life compared to dialysis. When we asked if kidney transplant is permissible in the SHARIA of Islam, 262 (81.6 %) answered yes [Table 2].{Table 2}

Two-hundred fifty-five participants (79.4%) were willing to accept a kidney from a deceased donor compared to 211 (65.7%) who said yes to accepting a kidney from living related donor and 245 (76.3%) from a living unrelated donor. Only 92 (28.6 %) were on the active transplant list. The most common barrier was lack of donor availability in 107 patients (33.3%) followed by misconceptions regarding long-term complications for donors in 58 patients (18.1%) and of surgical complications in 24 (7.5%). Only 17 patients (5.3%) reported financial constraints as the main reason for not having a living kidney transplant with a higher ratio in non-Saudi patients. Out of 321, 30 participants (9.3%) asked someone to donate a kidney, and 22 out of these 30 (73.3%) received a positive response from potential donors. When asked if anyone had offered to donate a kidney to them, 173 (53.9%) said yes. However, 69 out of the 173 (40%) declined to accept the offer [Table 3].{Table 3}

Chi-squared univariate analysis shows that KT was significantly accepted among married patients compared to single individuals (P = 0.028), and a higher or lower level of education has a significant burden effect on transplantation (P <0.005). The lack of satisfaction for patients undergoing dialysis had a favorable effect on transplantation acceptance (P = 0.043). No significant differences between males and females regarding the acceptance of transplantation (P = 0.235) were noted [Table 4].{Table 4}

Logistic regression multivariant analysis shows not being married was a significant independent transplantation barrier by our ESRD patients, and single patients had a 3.32 times less acceptance of transplantation compared to married patients [P = 0.016; Exp(B) 3.32, confidence interval (CI) 95% 1.25–8.86]. Higher and lower education levels presented a double significant barrier to transplantation compared to average education level [P = 0.003; Exp(B) 2.0; CI 95% 1.28–3.37]. Lack of satisfaction with dialysis presented a 1.7 times greater trend toward transplantation [P =0.012; Exp(B) 1.74; CI 95% 1.13–2.69] while employment status had an insignificant impact on transplantation in our cohort (P = 0.313) [Table 5].{Table 5}


KT is the treatment of choice for ESRD and provides better patient survival and quality of life. It is more cost-effective when compared to dialysis.[1],[2],[8] The one year survival rate for patients and grafts in those who received living-related kidney transplant in Saudi Arabia was 98.4% and 96.9%, respectively.[9] Since the initiation of the kidney transplant program in Saudi Arabia in 1979 up to 2017, 11,509 kidney transplants were performed. In 2017 alone, 921 kidney transplants were performed inside the kingdom while the number of patients receiving dialysis was 19,659 with only 15.5% on the active kidney transplant list.[3]

In our study, 77.3% were aware that kidney transplant is a treatment of choice for kidney failure, which was similar to other studies.[5] However, only 12.5% were aware of that fact before starting dialysis, which indicates a significant lack of early education on management options for the patient with CKD.

The most common barrier for KT in this study was the lack of donor availability (33.3%). Only 9.3% had approached someone to donate a kidney. Transplant candidates are reluctant to pursue live donations.[10],[11] On the other hand, 73.3% of those who asked someone to donate received a positive response. The knowledge of the way in which to ask someone to donate was demonstrated by the transplant candidates to be the most prevalent barrier to living kidney donation.[12]

Many studies proved that living kidney donors have survival similar to that of non-donors and that their risk of ESRD is not increased.[13],[14],[15] Misconception regarding long-term complications for donors in was reported in 18.1% of the participants and fear of surgical complications in 7.5%. Similar findings were observed in local and regional studies.[5],[16],[17]

While Saudi Center for Organ Transplantation (SCOT) has made considerable efforts to increase public awareness of deceased organ and tissue donations, data show the rate of family approval of organ donation in brain dead donors is still low (33%)[18] compared to other countries in the region.[19] In 2017, 921 kidney transplants were performed, and only 145 of the kidneys were from deceased donors (15.6%). Out of the 145 deceased kidneys, 121 (83%) were transplanted from standard criteria donors, and the remaining 24 (17%) were from expanded criteria donors.[3] In our study, around 80% of participants were willing to accept kidneys from deceased donors.

Financial constraints as the main reason for not having a living kidney transplant was reported in only 17 patients (5.3%). The rate was higher in non-Saudi patients as Saudi patients have a free access to all government transplant centers. This finding is different from other studies in which kidney transplant has no governmental funds.[17],[20],[21]

In Saudi Arabia, such as in many other countries, laws prohibit selling organs, and transplant is only allowed between relatives. In case of unrelated donors, permission needs to be granted first from SCOT. Despite the fact that commercial transplantation has become more restricted and is associated with poor outcomes, transplant tourism still comprises up to 10% of all transplants worldwide.[22] In a local study by Albugami et al, 86 patients who had undergone a transplant abroad between September 2008 and December 2015 had poor outcomes compared to local transplant recipients.[23] In our study, only 15.3% rejected the idea of transplant abroad, 5.6% approved it, and 79.1% were not sure.

Access to transplantations remains low among dialysis patients as referral to a transplant center does not occur or is delayed.[24] While referral to a transplant center is the first critical step toward transplantation, it is only the beginning of a long, complicated process. The disparities in access are not primarily driven by patients’ inability to “get into the system” via the initial referral but may largely result from difficulty navigating the complexities of the kidney transplant evaluation and waitlist process.[25] In our study, only 55.5% of the patients had been referred for pre transplant evaluation.

In this study, 81.6% believed that kidney transplant is permissible in Islamic law, only 1.2% believed it is not allowed, and the rest (17.2%) were uncertain. This finding was mainly due to an increase in public awareness of organ donation in Saudi Arabia in recent years. However, only 79.4% are willing to accept kidney from a deceased donor.

Worldwide studies have been conducted, an Australian study focused on the access for transplantation in minorities.[26] American study focused on the limitations of finding suitable kidney donors among the black population.[27] IMPAKT study tried to outline stepwise approach to identify the barriers for transplantation among minorities.[28] Another study investigated the gender effect, females were less successful to have transplantation compared to males.[29]

In conclusion, more initiatives to promote and improve education and knowledge about kidney donation and the current outcome of KT are needed to improve low transplant rate in the region. This can be achieved by (1) establishing an educational program for patients with CKD sage 4 and 5 to discuss renal replacement options early, (2) increase awareness of living kidney transplant benefits, (3) increase awareness among physicians covering dialysis units to discuss transplantation with every dialysis patient, (4) increase public awareness of the benefits of living KTs and outcome, (5) follow up of the donors and secure their health, and (6) introduction of new model to overcome high sensitize patient by donors exchange, and desensitization.

Conflict of interest: None declared.


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