We read with interest the comprehensive Review by R. Vanholder et al. (Reducing the costs of chronic kidney disease while delivering quality health care: a call to action. Nat. Rev. Nephrol. 13, 393-409;

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Background and Aims Kidney transplantation is the renal replacement therapy of choice for patients with end-stage kidney disease. Egypt is a developing country with social, religious and demographic characteristics having enormous impact on the development and progress of its own national transplant program. Method A web-based review of relevant bibliography: articles and textbooks, reporting the progress in the transplant practice in Egypt and its legislations was conducted. Results Kidney transplantation started in Egypt about 43 years ago when the first transplant was performed at Mansoura Urology and Nephrology Center (UNC) in March 1976. The practice of kidney transplantation in Egypt has then evolved over the years. While about ten thousand transplants were performed from 1976 to 2011, the annual mean number of kidney transplantation between 2011 and 2016 increased to 1100 cases/year. The number of transplant centers has also grown from 12 in 1997 to 35 currently licensed centers. However, Egypt is still lacking a national transplant registry data. The legal framework developed over the last decade towards establishing a national transplant program. Until 2010, organ transplantation was only regulated by the professional code of ethics and conduct of the Egyptian Medical Syndicate. Representatives of the Istanbul Declaration met with the Egyptian Minister of Health and Egyptian Society of Nephrology leaders in Cairo in October 2008; since then, Egypt has been working to terminate illegal practices associated with organ transplantation, organ trafficking and transplant tourism. The first legislation for a national organ transplant program “The executive list for law number 5 of the year 2010 regarding regulating human organ transplants” was then issued after approval by the parliament. The law established “The Higher Committee for Organ Transplants” which includes 7 - 11 experts and is responsible for regulating and supervising all organ and tissue transplant procedures in the country. The new law criminalizes organ trafficking and set strict penalties for physicians, hospitals and medical facilities performing illegal organ transplant procedures. In 2017, the legislation has been further modified to make the penalties even harsher “Law number 142 of the year 2017 modification of some articles in law number 5 of the year 2010 regarding regulating human organ transplants”. Transplantation practice is still limited to live transplants. The cadaveric transplant program has not yet been put into action despite the new 2010 legislation has set the legal framework, yet lacking a clear definition of the legal death. Cadaveric transplantation was performed twice in Egypt in 1992 at Cairo (kasr El Aini hospital) from 2 criminals after execution in Alexandria. This was faced with social anger and rejection which led to legal restrictions for non-living organ procurement at that time. Barriers to establishment of a national transplant program in Egypt include cultural and religious rejection of deceased donation, organ shortage, and long waiting time in national transplant centers. Conclusion Despite the recent ameliorations in the current Egyptian transplant practice, the overall progress has been slow. This can be attributed to a complex interaction between social, religious and financial factors. Further advances are vital to reduce the burden implied by the state-funded dialysis therapy and to demolish organ trafficking and transplant tourism. As such, state efforts would continue to further improve the living donor and to implement the deceased donor transplantation programs.

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