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"Solid Organ Transplantation i Childre- A South African Perspective" by Dr Thozama Siyotula, Consultant Paediatric Surgeon, Cape Town, South Africa

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Summary

This on-demand teaching session is led by Dr. Tua, a pioneering pediatric surgeon specializing in solid organ transplants at the prestigious Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Current professionals in the field and those seeking further knowledge on the subject are welcome to join the session. Dr. Tua dives into the complex domain of pediatric transplant surgery, offering a unique South African perspective. She delves into the historical foundation of organ transplantation and discusses its positive impact on improving the quality of life for children suffering from multiple organ failures. The session also includes a comprehensive overview of South Africa's organ transplantation scene, insights into operational transplantation centers, and the legal frameworks governing transplantation practices. In addition, Dr. Tua discusses the challenges facing the country's transplant infrastructure and shares her insights into improving the system for greater patient access to these life-saving procedures. The session is a fantastic opportunity to engage with adult or pediatric medical professionals interested in transplant surgery.

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Description

This is an invited talk on "Solid Organ Transplantation in Childre- A South African Perspective" by Dr. Thozama Siyotula, Consultant Paediatric Surgeon, Red Cross War Memorial Children's Hospital, Cape Town, South Africa, as a part of the Zoom academic meeting of the Department of Paediatric Surgery in East London, South Africa.

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Learning objectives

  1. Understand the historical progression and current status of solid organ transplantation in children in South Africa.
  2. Learn about the significant contributions of Dr. Tua in the field of pediatric solid organ transplantation.
  3. Understand the importance, challenges and benefits of organ transplantation with a focus on South Africa's healthcare system.
  4. Learn about the referral pathways and scoring system for determining transplant eligibility in South Africa.
  5. Understand the process of organ allocation and the factors considered in prioritizing patients on the waiting list for transplantation.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Yes, I think it's just five o'clock. I'm sure we can start. Um So, ok, can you see my first line now? Uh Yes, I keep. Ok. Good. Hello, good afternoon. Good evening, good morning. Wherever you are joining from, um, you're welcome to the Zoom Academic meeting of the Department of pediatric Surgery in East London, South Africa. And we are really lucky to have Doctor Tomato to present about solid organ transplantation in Children. A South African perspective. Uh Doctor Tua maybe young in her age, but not in her achievements. She is a specialist pediatric surgeon at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa, which is like a prestigious institute. Um She says she is an aspiring clinic, correlation scientist with special interest in neonatal surgical outcomes, hepatobiliary thoracic surgery. And the topic of interest today is transplant surgery in Children. And uh to my knowledge, she probably could be the only woman of African heritage who is involved in pediatric solid organ transplants. Uh She can tell us whether there are any outside Africa. So Dr Tua has been involved in various executive committees of South African. I believe Thoracic society International Pediatric Transplant Association. She is on the executive committee of the Organ and Multiorgan Transplant in South Africa. And she is a recipient of many accolades and awards like the Future Leaders career development award. The ma and 200 Young South Africans Award is a educational global grant and is a mentorship program in 2024. She is an academic affiliated to the University of Cape Town. She's a program convener for the fifth year undergraduate students. She supervises research for the registrars who undertake their masters. And she is an alumna of executive leadership course in Global Surgery at the graduate school of Business at University of Cape Town. And she says, whatever little spare time she has, she enjoys serving at the local church, mentoring young people, spending time with family and friends over good food and traveling to experience the world. So, uh Theresa, thank you for uh for sharing your knowledge and skills and um expertise and uh you can share and start your talk. Thank you. Thank you very much. All right, I think we sorted with our slide. I will just minimize here. Um So good afternoon, everybody. Thank you for the opportunity to be able to present at this meeting. And I hope I'll do this topic. A lot of justice. I think pediatric transplant or transplant in general is something that really does um interest. Um me. All right, let's get started. So I think prophet introduced me nicely. Thank you very much. Um Just to go on, I've got nothing to declare for this meeting. Besides the fact that I love transplantation, I think it's important with anything to always start back and look at history and where we come from and speci specifically pertaining to South Africa and the history of transplantation. The first liver transplant was performed by Thomas DZO in 1963 on a two year old child affected by B Atresia in December, the third of 1967 Christian Barner transplanted a heart from a 20 five-year-old fatally injured in a car accident at the time to uh Mr Lewis wass who was a 53 year old male South Africans and dying from chronic heart disease. Um Unfortunately, he died 18 days later after his surgery due to lung infection and pneumonia, which claimed his life. What is also not frequently mentioned is that from the same donor, there were two kidneys that were procured and these were transplanted into pediatric patient. Now, over the years or the next few years, there's been an improvement in drugs such as cycloSPORINE, which are immunosuppressive drugs that have dramatically reduced organ rejection by suppressing the human immune system and increasing survival rates from transplantation. So, what is this transplantation transplanting organs allows us to treat end organ failure on specifically um for us with solid organs such as liver and kidneys, this is able to improve the quality of life for recipients that receive these organs. Organ transplantation procedure was first performed in adults in the 19 fifties and in Children. In the 19 sixties, there has been advances with regards to surgical techniques, immunosuppressive therapies, as well as treatment of diseases that have previously limited organ recovery for transplantation. This has subsequently later marked increase in successful transplantation of organs over time. And it is evident as we create awareness. Now, I want us to look at this and look at the global view or the contextual view of what we look like as South Africa with regards to transplantation. So we can we see here the different or the various provinces that are performing transplantation and the various organs that are transplanted in the various center. Noting that Johannesburg and Cape Town making up quite a great proportion of patients that have been transplanted involving both private and public sector. Also to note that these places, Johannesburg and um Cape Town are the ones that transplant our pediatric patients. So in Johannesburg, we have Charlotte male, which is a government hospital, Wits Don Gordon as well as in Netcare. Johannesburg, which are in private sector in the Western Cape. We go hospital Red Cross Children's Hospital Tygerberg, which um they just do kidneys um Netcare bar out as well as UT um private. Also to note in Cape Town that the Children listed for um transplantation and both private and public and private do get um transplanted in the public sector. As we're able to actually offer the specialist service with regards to both the um gastroenterologist or the hepatologist, the nephrologist, as well as a transplant surgeons, South Africa has one of the largest incidents of kidney failure in Africa. 5000 patients with endstage renal failure and more than 2500 of these patients are awaiting transplantation. Now, transplant has become more costeffective and better quality of life than being on dialysis. So it is definitely better for patients to be transplanted as opposed to be on dialysis. Liver transplantation has become more common over the last 10 years. Noting that the Wits Donald Gordon had expanded their program and they are the only ones in the country that are currently practicing living related transplantation. Red Cross had previously done so and um I was looking to move into that program in the Western Cape, the liver transplant program um for deceased um donors, these can be D BD which brain dead or cardiac um donors at Roske Hospital um private as well as Red Cross or memorial Children's Hospital. Heart transplants are performed in Johannesburg and Cape Town and lung transplant to molar proportion also performed in Johannesburg or Cape Town in the Cardiothoracic Unit. The National Health Act of 2003 legislates the framework with which human blood blood products, tissue games, both living and deceased may be used. It gives a broad overview and um directive pertaining to procurement and utilization of human organs, an important step forward in comparison to the human acts, tissue or human tissue Act of 1983. Despite this legal framework, transmission and implementation of the ground um on the ground has really become difficult and isn't quite congruent. So there are many steps and miles to actually go ahead with transplantation that still need to be reached. Guidelines from the National Hospital are still not uh are still underdeveloped. And as the incidence of endstage liver disease continues to grow in Sub Saharan Africa, the need for transplantation is growing. This situation is best represented by growing national organ wait list. In the context of a decreasing proportion of organ transplantation or organs to transplanting, we will see later while many factors have contributed to the slow growth of transplantation as a national agenda, it is beneficial to have careful control monitored expansive transplant system to ensure timeous referral for ordinated transplant allocation and expanded access to transplantation for Children with severe acute and chronic organ failure. Although we speak of Children, this also involves adults in expanding that system of transplantation. Now we need to start somewhere. So we look at the referral pathways as well as the scoring system. So how do we decide who gets to the deceased donor waiting list for transplantation? Now, looking in the state sector, the adults, if you qualify for dialysis, if you qualify for dialysis, it is likely that you will be a candidate or definitely you'll be a candidate for transplantation because of the resource constraints that affected um in that affect the the state sector as opposed to in the private sector where you may be offered dialysis but not the transplantation or some other things may preclude transplantation in Children who are here at Red Cross is very different. Patients are offered dialysis even though and or trans candidates. There's a scoring system that they're actually allocated and this scoring system looks at social economic, the parents, the home situation, how close you are to a healthcare facility, enlisting a patient um for um transplantation, they also look at the mental status of the parents as well. It is rare that patients are declined, dialysis and it has to be some social factor that will cause more harm to the family or patient that the patient doesn't get dialysis. Continue on this. There are shared wait list between the state and private sector in the western cape, usually preempted transplant. That means no dialysis is performed or no dialysis is offered to the patient. They go straight into transplantation and these are times we're able to offer to patients with a G fr of less than 20 endstage kidney failure and gome filtration rates of less than 10. These patients will be eligible straight for transplantation and may or may not have uh um uh dialysis depending on the speed availability of the organ. At that time, extra points are allocated to the pediatric um potential recipients that's putting them up on the waitlist. Potential candidates need to actually be assessed first. Besides the scoring system, are they fit for the procedure? The general condition, their cardiac condition, are they able to tolerate surgery? They postoperative immune suppression as well as the patient's blood grouping and trying to match to the donor on this again. So what happens then? So the patient when presented gets presented to the physicians, the surgeons, the transplant coordinator, nursing staff, social workers, as well as psychologists that sit in a meeting and discuss in detail about this patient and whether they should be listed or not. Also reviewing the scoring system at that time. Note in the private sector, there are patients on chronic dialysis program that are not eligible for transplant. And this is because there is availability of resources and financing as opposed to the state sector, especially in the adults where there's limited dialysis. So patients who are offered dialysis are usually transplant candidates. Now what happens? So kidney transplantation works on a point system. At that time, we look at the time on the waiting list, the age previous transplantation sensitization as well as other medical conditions that especially if they have, they're running out of lines, they will need to be transplanted earlier and then an organ becomes available. So in that case, suitable recipient for the blood group will be crossmatched against the donor. So those patients on the waiting list organs will be allocated according to the position on the wait list. After cross matching and pediatric to pediatric till the age of 18 is what is actually practiced um in the Western Cape and most of the country as well as internationally liver and heart transplantation. The waiting list is much shorter for these patients and allocated according to the patient's current clinical condition, as well as urgency of transplantation. There were declining. Number of deceased donors is a big problem in transplantation in South Africa. Despite an increased wait list for solid organs, the number of transplants annually remained stable and they even lowered compared to previous years. When you look at the current stats in many centers, living donation has become the mainstay of kidney transplantation. So the parents or um uh another altruistic donor would donate to the the patient. So what did we do? We wanted to look at the state of pediatric deceased donation in South Africa of a 14 year period. In a study that we published in the S MJ. Earlier this year, our aim was to identify and further define the factors preventing referred pediatric donors from becoming actual solid organ donors. So we evaluated this over an eight, a 14 year period, looking at cause of death eligibility um for solid organ donation as well as consent rates over this time period. So our findings on the initial assessment, 67 of the 93 potential donors. This standing at 72% were assisted eligible for donation of at least one solid organ of which were approached by consent um for consent by the transplant coordinators, five of the families on it could not be located at that time and the remaining 62 eligible donors. 44 families declined consent for solid organ transportation. This resulted in a consent rate of 29%. This is only 18. Several families refused based on religious reasons and one consented do not progress to procurement because there were no suitable donors. 17 proceeded to theater with the intention but only two donors were taken off as assessed nons suitable at the time of transplantation. So we remained with 15 donors. A total of 46 organs were procured where we had 14 livers, 30 kidneys as well as two hearts that were transplanted successfully. So here of the 100 of 1581 patients, which is 5.9% were actually referred to the transplant coordinate. This is such a low number. If you think of the amount of patients that are sitting on the wait list for organs of these 6 9% had been involved in road traffic accidents as you can see which with uh motor vehicle collisions and pedestrian vehicle collisions, making up a great percentage of the patients that were um referred to the transplant coordinators. Here, we're able to see the trends over time of the number of patients um uh or the potential donors over um time. So we do know that there's a decrease um in the um number of road traffic accidents and these due to certain criterias or laws that have actually been put in place. But when we're able to look at um noting decreasing debt over time, while the number of potential referrals actually remain steady. And that's how we're transplanting less or have less organs available here. We can see the trends over the years, not making any improvements in our donor referrals and consent conversion rates. So there's still quite a low. With regards to when you look at referred eligible to consented, we notice that the number is declining and there's lots that can actually be done in this field. This is considered creating awareness um uh both for medical professionals as well as the general public. Noting that August is organ um donor awareness month. So when we're looking at marginal donors, because we do need donors for transplantation, so many new programs have been introduced to to improve organ donor numbers, the use of marginal donors. So this would not be ideal. But when you say March sort of ok to but not really ideal are being used to explore worldwide. And as a result, the threshold for using patients with preexisting medical conditions as organ donors is actually getting low. This thought of small organs to be able to lose to use in South Africa a huge HIV, positive population and for this reason HIV, positive to HIV Positive Transform program has been started at Coke in twen in 2008 with HIV, positive patients with endstage renal failure. To date, they've transit to more than 22 patients um that have received transplantation with good outcomes for these patients. Now, when we look at the way forward in terms of donation, we're also able to offer these patients DCD which is donation after cardiac death. So one way of increasing organ donation dramatically is to use patients after circulatory death in donation after cardiac death program. So patients are not brain dead but they have some other medical condition and they would consent or get consent for cardiac death if they are su die from a suitable medical conditions. This is practiced in most European countries as well as in the U in the USA and DCD. Donor rates not equal the traditional bra brain dead um donor rates. So we're matching this in the case of dismal prognosis and a decision to withdraw treatment uh to the patient or the potential DCD donor, the family. Uh the the treating physician uh will speak to the to coordinators and they speak to the parent and consent will then be obtained for these patients. The family has asked for permission to use the organs and once it has been given after death certification in the patient, um with cardiac death certification, this patient is then taken to theater and the plan is to procure the organs as fast as possible. The plan is you wanna maintain warm ischemic time or between 10 to 13 minutes is acceptable, but a cold ischemic time is kept to a minimum. What they also use internationally, which is something that we don't have available is ma is machine perfusion to improve the outcomes of the organs at the time of transplantation. So this machine perfusion is based on a renaissance of dynamic preservation techniques. So is the way that we could prevent, we could preserve these organs to allow better outcome. This is also allows us to extend the donor um organ pool and have much better um organs. Um because when you look at these extended um criteria donors, um we're looking at livers that carry an increased risk of early allograft dysfunction, primary non dysfunction as well as biliary complications. So I veiling the limitations that this is actually what happens when or can happen when the patient, when the organs go into cold storage. Now, if we have machinery perfusion, there's less time for cold storage, the the the the organs are able to actually be assessed um at that time and also mitigation of some of the complications. And actually looking is this organ actually viable at the time that we actually want to transfuse it. So this way we achieve higher utilizations of the available um organs and obviously better outcome for our patient. Now, this interesting enough is using Xenograft. So that means using other members of um different species. So using the organs members. So in this way, we're able to actually expand and increase and that has become something interesting over time. And obviously the advantages are there because we have such a limited supply and the procedure is elective just like with living related, everything is actually controlled for. Now, pigs are physiologically similar to humans and organ size is comparable. It can be raised in con in a controlled environment. Obviously, these are genetically modified um pigs. And the main limitation with xenotransplant is rejection including hyperacute and chronic vascular rejection as well as transmission of z um zosis. So we can see that there's an article in, in March of 2014, this year where they actually did a US surgeons perform the first pig to pig human transplant, but obviously in the genetically modified field. So this is an interesting part of transplants that we can look, um we're able to actually look into. So when we look at what are we doing here at Red Cross or War Memorial Children's Hospital. So on review, we did a study reviewing um Red Cross War Memorial um Children's Hospital and we're looking at liver transplant over uh a twenty-year period. And what are outcomes in this? So we noted that the 71 of the total 100 and 41 periodic liver transplants were performed um during the, the 20 years that they actually looked at eight out of the 11 had combined liver and kidney transplant, which is offered here as well as in Johannesburg. The mean age of transplantation was 4.6 years and most of them were transplanted for extra hepatic biliary. Um Atresia, most of the donors were deceased donors. So these were D BD donors and the one and five year survival were 83 and 22, um 72% respectively. A total of six, which is 8.4 patients demise within the first month and looks at um the complication of hepatic artery thrombosis, um posttransplant complication that included lymphoproliferative uh disease, thrombosis as well as bowel duct pathology. We then did the same sort of review. Um And here we looked at um the kidney transplantation, the same over a twenty-year um period as well at Red Cross Memorial Children's Hospital. And what we noted um here was that there were 100 since to date, we've done more. There were 100 and 69 of the total. Um 2, 84 pediatric transplants were performed during the same study period. Um This ranged between one year, 11 months to um 20 years and seven months. Um What we noted here is that the end due to endstage kidney disease is no longer called endstage renal disease. Um due to nephrotic syndrome, post urethral valves, kidney dysplasia, um was one of the common causes of um endstage kidney disease. Um There were 53.8% donation after brain death with made, made up most of the percentage with 38.4 from living related, which is mostly what we're seeing now. 1.7 from nonliving related but non-related um donors which obviously have to get special permission. So our one and five-year patients survival stood between 94 and 85.8% respectively. And our one and five-year graft survival was at 84.4 and 62.6% respectively for these patients. So, where are we today? Oh, wait, sorry. OK. We have noted today that we currently have 247 that we've done at Red Cross and 295 kidneys that have been done at the institution and the number is still growing. We potentially do between on a good year five livers transplantation and kidneys. About 13 transplantation which are a mixed between living related and deceased donation. Now, let's look up at Johannesburg. So here we look also the S MJ this year, the pediatric liver transplant experience in Johannesburg, South Africa and this offered a broad overview. So here they looked at an update of the unit 17 years experience and this done is a retrospective review at the Wits Donald Gordon Center between First of January 2005, as well as 31st of December 2021 with a minimum of a one year follow up. A total of 270 patients were transplanted. Noting that 66.7 were aged less than five years, 50% received a living donor graft for these patients. And the most common indication for liver transplantation was bilia atresia followed by acute and chronic. So we can see how the increase in the living donation was able to offer patients more transplantation, especially on the background of limited organs being available. The weightless mortality um decreased from 27 to 5.9% between 2017 and 2021. So this living related program has really done well in terms of what they've established in Johannesburg. So in the Living in the liver program, they have living donors split donors, a bo incompatible liver transplantation and at work rate, more, more organs availability, more transplantations that they've been able to perform. Looking at the annual report of 2022. Um and, and here they're able to look at the 57 liver transplants were performed um 58% in adults, 42% in pediatrics, 65% waitlisted candidates um for transplantation, 52% of the waitlisted were less than a year before um undergoing liver transplantation. And sometimes that is, it can go between 5 to 10 years to receive a a transplantation. Uh decrease in adult pretransplant mortality. We can transplant earlier better patient outcomes in terms of morbidity and mortality as well. Um So the the the decrease in transplant from 9% now at 9% from 25% which is a dramatic drop. Most adult recipients received a deceased donor and recipient. Uh survivors of one and three years survival was between 75 and 74% which noted improvement and improved outcome. So, with regards to the pediatric ology, so obviously, it's mostly cholestatic liver disease and acute and chronic as I mentioned um in the previous study, and there's a decrease in pediatric pres mortality, which now is uh 27% in 2017 and 6% in 2021. The longer that Children wait on the wait list, the poorer outcomes that these Children will have. So most pediatric recipients receiving a living donor graft about seven to 9% and one and three year survival was noted between 85 and 68% which can actually not improvement um over time. So this just looked at a study that was done and looking at the review of South African transplants. This was between 1991 and 2011 and noting that a total of 7280 transplants were performed across the public and private sector. Um at that time, which which a majority of these were actually kidney transplantation. What we also note is a liver related program, most of these patients in between Gauteng and the Western Cape um with, with 46 and uh 42 respectively. And Kwazulu Natal was performing 20 until their program um got stopped due to um traffic or organ trafficking. Um at that time. So it's important now that centers actually sign the Istanbul um letter that says they do not support organ transplantation. So bringing this home, where do you go? What does the future look like? So it's important that we have private and public health care can work together to offer transplantation and resource constraint, especially in a developing world or a developing country like ours or continent. More. So government oversight and funding is essential to ensure adequate regulation and equitable access to transplantation. We need a national system to actually manage your transplantation. As opposed to this provincial or institutional system, we need to focus on patient outcomes, but more so we need to focus on activities. So how do we do and what do we do to actually increase transplant activity and ensure equitability across the entire country with regards to transplantation, a comprehensive pediatric liver and kidney transplant service that is transparent and is national based collaborative. Um hard work on this and this goes to centers that do and don't perform transplantation as we're able to create awareness and get more organs, the more organs we have the transplants, more transplants we're able to do which then equate to less Children having morbidity um in opposed to patients on dialysis for transplantation because it's, it has been shown evidence that there is better outcomes for patients who are on less period of time on dialysis or those who don't are aren't on dialysis as well improved techniques and care. So, I mean, Xenograft is something that's up and coming. But I think more for us is looking at ma uh machinery perfusion, um developing uh organs or genesis of um organs as well and surgical techniques as well, both for procuring organs as well as for um transplantation and better preservation solutionss or better preservation methods as well. And most importantly, I think for me is creating a national framework um of uh with regards to transplantation where there are many stakeholders both from um provincial national various institutions and organizations with regards to um the transplant program. So in conclusion, we need to eliminate the wait list for transplantation by saving more lives with more organs. So we need to create awareness with regards to this, both for the healthcare professional and as well as the general public as healthcare professionals. We need to know which patients to be able to refer. What are the, what are the specific referral uh triggers for us to be able to refer? It's counseling patients, it's being opened to donation of the co death, donation of the brain death. How to actually have the conversations with the pa with the parents, how to engage with the coordinators, knowing who the coordinators are Um It's also increased capacity with regards to our surgeons that are able to form transplantation and improving on our technique. We need to expand the donor criteria, close evaluation of donation after circulating uh determination of death is something that we're trying to actually increase awareness and actually improve on. Um and educate in this and this is a program that's running in the Western Cape that they're trying to expand on opportunity and advancement and organ preservation are just some innovations in developing to increase the number of organs available for transplantation, sharing experiences, both national and international. I think they're most important of also being involved in different societies, organization. So we're able to information, share, experience, share, um be able to bring people across to assist us and to improve our program, expand our programs as well and figure out what is it that they're doing that we could actually improve on evaluate donation performance in hospitals? I think this is important and this is evaluating in terms of um especially which was highlighted in our study. So as a center, looking at the number of deaths, how many patients could potentially have been referred to a coordinator? What is the reasoning that these patients weren't actually referred to a coordinator for po for possible donation? If we're able to have that an open transparent system and a reporting system, that way we're creating awareness and we can increase the amount of donors that we have implementation of clinical triggers for referral of potential organ donors and um discipline of vigorous data reporting and measurements of processes and outcomes. As clinicians, we both know researchers the most uh the importance of having clinical data. When we have data, then we're able to actually engage government, we're able to engage policyholders. We're able to sit tables where we're a, we're able to have this conversation about transplantation, its needs and how we actually create um expansion on this. So, research around this is important and continue seeking answers and solutions. I'm hoping that we'll reduce our waitlist um for our patients, reduce morbidity and mortality uh for our patients and increase the number of donors while difficult problems remain with regards to transplantation. We have a tremendous, we have made tremendous progress, progress with transplantation over the years. Um As South Africa. Thank you. OK, Theresa. Thank you very much. That was really an excellent overview of transplantation in our country. Uh Before I ask um some experts and colleagues present for the appointments and questions. My only question to you is uh outside South Africa. Um How many countries do you think undertake solid organ transplants in Africa? Are you aware does it happen in Nigeria, Egypt? So, Egypt, Egypt is one of the countries that is performing um organ transplantation. So I'm aware of the, the, the program that they actually performing, but it's very few countries that are actually performing uh organ transplantation in Africa. And I think if we look at it, it's sort of um transplantation is expensive and transplantation is a coordinated team. Now, there are lots, I mean, if you look at in terms of global surgery, I would think and what we're trying to improve around surgery, um transplantation needs a system that actually uh works and support um and both from a medical side, a surgical side, both from governance and policy um holders for these patients. So when that system comes together, then it's able to actually offer these. So I think yes, there are patients that do need the transplantations and obviously, this is something that is raised um um or what do they call it tourism or travel transplantation where people are actually traveling to various um uh countries in the world. Um India being amongst them to, to actually get transplanted there. Now, the problem is they come back to their country and there isn't anyone that is able to manage the patient with post transplantation. So it's, it's not, you know, it's not just about putting the organ in. Um It's not about just having the organ. Um but it's important to also think the management the immunosuppression drugs. Um If there's rejection, the biopsies around that, the, the the complications like who manages that if they have now been transplanted in another country and the expense of actually traveling to and from different countries. So we would then say, ok, are these patients actually coming down or they wanna come to, to South Africa, I think for us as um South Africa, um if you're not South African, um then one first there needs to be approval at a government level that you can have your transplant here. And the other thing there needs to be um or or approval ministerial consent of some sort and you need to have your own funding. Um and most of the time you need to have your own donor. So these will be patients that will um undergo the living related um program for both liver and kidney transplant where the donor would be a family member or a parent that will offer this. And then we need to create that link up with the team and the home base. Where can they actually follow up? Do they have access to immunosuppression drugs? And that's why we have um a scoring because this actually protects the failure around transplantation because you'll say, ok, um the, the child is a is in terms of a candidate, stand alone is a good candidate. They, they, they are deserving of the transplant we have. But you need to think the system around the child like do they have um where, where do they stay? Do they have running water? Do they have sanitation? Do they have a hospital that is close to them that if they come replicate, they're able to actually go to um how are they accessing that do they have a parent that is earning an income that is able to support because you end up transplanting. But stressing the system in terms of the family, not providing support. And then when you have bad transplant outcomes now, is that reflective of the uh transplantation itself or the failure of the system to be able to provide transplant? And this is something that we have to look into, especially for us in the Western Cape where we do transport, transport transplant, the Children from um the Eastern Cape and, and even a adult patients from the Eastern Cape. So what is nice is that if there's a donor from the Eastern Cape, we do try to search for a recipient that is on the Eastern Cape um transplant list. Now, with regards to some of our pediatric donors, we're going to an extensive research of is, is in terms of the candidate, is it ideal? Do they have the support? Can we reach out to clinicians? And, and say um uh the nephrologist, the, the J A two hepatologist, can you assist us to manage this patient? And, and I mean, the Eastern Cape and Western Cape is not far, but if I'm managing you from Uganda, uh that that's for how you're gonna get there. If you have an infection, like, you know, some patients have um were doing well, then they had like um you know, diarrhea in a transplant patient does not diarrhea, a uti in a transplant patient is not a uti because they're so immunosuppressed to prevent them from rejecting the organ that by the time they're mounting a response, the disease or, or, or condition is actually far uh far on. And that has resulted in mortality. So that was a long winded answer. It's the whole system. It's not only a skin surgeon doing the actual operation. Um Yes, one more logistical question. So have you started a living related donor transplantation in Cape Town now for Children, especially liver? No, not, not for liver as yet. Ok. Um I think we're also uh we, we sort of structuring to put the system in place. Also realizing the same thing. It's a system, the system needs to be in place. So it's increasing certain skills, certain capacity. Um Also looking at, you know, the, the the parents because Red Cross is a separate um institution, not separate is at, at a distance. They're not in one complex um from, yes. So one is getting transferred um procured in a, in another center and having a surgeon capacity to procure and also to then um transplant. And how would that work? So that is in the pipeline or in the processes and hopefully it's something that we can get started on because that will then offer us or increase our um our donation um or organ pool um for these patients, it would really uh be great um For for a pedia, a pediatric group of patients. Yeah. Yeah. Ok. No, thank you very much. Um I see Omar Kamar is here. Um Omar is, is uh a pediatric surgeon who trained in South Africa at, at Red Cross. Then he has done a fellowship in Birmingham and I believe he's back in Cape Town. If not, we're waiting for him, we'll, he's probably there. So please comment, you know the um South African system, you know, the UK system. So please comment. Yes. Uh bro, thank you so much. Thank you for, for um your great um overview. Yes. No, definitely. The, the um we've been involved with a couple of comment, a couple of meetings from, from South Africa, really proud and um uh so um optimistic about moving forward regarding the program, but what we need to focus on, yes, just to make it solid in regards to DCB and D BD, um you know, uh program and then move forward to the living related. Um II would say what I've seen, which we all knew, but what I realized that how much funding is needed to be honest, you know, to, to, to, to drive the program and to keep it going. You know, like in terms as, as someone has mentioned, you know, the investigation pretransplant, the communication with the family, the social support, you know, it's, it's very important in addition to that once you start transplant, especially liver transplant, you know, the number of, um, like investigations that you need to do on a daily basis, you know, like to pick up any rejection and to see what's going on, you know, and, and all of that it really needs, um, um, huge, like, well proper or huge funding. So, I don't know, does the medical insurance support, you know, transplants? Does it support? Is it supported? Like, yes. So here, well, here where you'll be coming soon. Um We, we, we do both um the in terms of pediatrics, solid organs, the livers and kidneys um for pediatrics, they're all done at Red Cross. So there isn't any that actually done in the private sector in the Western Cape and the patients that have medical aid because obviously they'll be referred from hepatologist and nephrologist in the um the private sector do get charged um medical aid rates for these patients. Um Also noting that it's something that we're working to sort of try to increase the charging sort of at par with uh what they get charged in, in, in private, but they, they definitely are on medical aid rates. And I think it's important to say what you're saying. Omar that it, it is expensive and I think even the immunosuppression drugs um that these patients are on it. It, it's quite an an expensive exercise. And I, and, and when looking at like those austerity measures or during COVID not transplanting, trying to figure out is it, you know, like are we, is it like a privileged thing we're transplanting? Shouldn't we hold, hold back the funds and put it to somewhere else? And, and I tend to say no, because these patients actually affect the quality of life if they're not transplanted. Um As you mentioned that being on um on, on dialysis, it it offers a different quality of life, but these patients have better outcomes if they're actually transplanted um early or even preemptively um trans transplanted. So I think it's definitely trying to, to, to increase that um awareness and being knowledgeable that this is an expensive but it's a, it's a needed. It, it, I mean, if you look at the patients when they come into the hospital, um and they have end-stage um organ failure both from kidneys and uh livers. Um and what they look like once they've actually recovered and they're running around in the ward. It's, I mean, it, it, it makes it worthwhile and then we just need to justify it to the government, why this is actually worthwhile. And also the research like when we publish and look at our outcomes, then we can say this is what we're actually doing to improve um children's lives. Thank you so much. Thanks. And the other thing that um I would like to highlight and, and when I went there, you know, in the, to the UK, you know, I thought, OK, I'm going to program, you know, and and, and, and, and I now expecting that, you know, there, there will be no complications and things. No, it's, there is transplant itself. It's, it's, it's, um, it's a procedure that's full with morbidity, you know, like I think need to have kind of agreement on that and to accept that, you know, it's like it's an essential part of it. So, uh, but the difference is how you deal with that or how comfortable, you know, it's like um the, the way they deal with, they accept complication, you know, I've seen transplants being done by the best surgeons. Nevertheless, you know, they do have complications. They took the child for reloc once, twice, three times, you know, they accept that, oh, there is, they take him back, there is um um collection, you know, it needs to be, you know, washed out or burly drained or, you know, the way they look at it and, and they don't consider that as a failure. So I think the concept of having a high level of morbidity in trans blood needs to be, you know, um like will and, you know, like it is not exactly to, to, to, to, to really look and, and accept that, you know, among the staff, among the family, among the community, you know, of the surgeons, you know, it's not a failure or luck start pointing finger to someone. And I have to say I felt that this is the most important because, you know, the surgeon works with a bit less stress knowing that, you know, this is, everyone knew that they knew like the anesthetist team, the radiologist, the staff, the nursing staff, the scrub. That yes, it might be an excellent procedure. However, you might need to go back, like, within six hours or 12 hours. Everyone takes this as an like, you know, like acceptable thing and, and, and they take it over. Yes, some Children, they spend three months in the hospital, you know, but when you, and, and at some point as I says, OK, does it worth really taking them back for Relook? And, and it, and it works, you know, at the end with collaboration, it worked very well. That's one thing, the other thing and II have to say, I think I might be overemphasizing but the role of interventional radiology, I just can't emphasize this enough how much like confidence this adds to the team, you know, knowing that, you know, you are, you've got the support, you know, if you've got some collection, you know, they can try do a range if there is some stenosis. If the blood flow through the, you know, hepatic art is not great, they can do and they can go and do some plastic, you know, their support is, is, is, is as important as the experience of the surgeon. You know, if I would divide it, you know, how important I would say it's like 40% or 30% for the surgeon, 30 person for the um interventional radiology and, and, and something for the others. So I think one of the downsides um I would say, and just to be open about this is that the lack of a proper interventional radiologist. And I said I'm not pointing finger, you know, I'm just being transparent and intervent radiology is very important in transplant program. And even if it is still like not very well established, I think it needs to be um kind of going virally, you know, with the experience of the surgeon and, and that definitely has a huge impact on the outcome. Uh Thank you. I think those are very, very comments and very practical um uh insights. I see Doctor Mansour, Nasir is here. Mansour uh is a very uh it's uh I think he's young if I, I'm sure he's young, but he's very dynamic and he is very skilled and he works in Tashkent City. So Mansoor uh just share your experience, please. Just unmute yourself. Hello. Hello, everybody. It's OK. Can you hear me? Yes. Yes, yes. Yeah. Um Yeah. Yeah. I'm a pediatric surgeon from uh TKI Uzbekistan. We are about to start our liver transplant program. So we are actively collaborating with uh Seoul National University Hospital. So I believe everyone knows that legendary Professor Lee and Professor Soul, they are uh masters in the liver transplant program. So uh very great comments. Uh first, it's not about just uh uh transplant, solid organ, it's uh creating the system. And the, the next one is the role of interventional radiologist. Um because um it can be the crucial to deal with early postoperative complications. So the surgery is just the easiest part. First of all, the selection of the patient and uh prepare, prepare the patient in postoperative care, most important things. Um And of course, um our experience um we do not start it yet in uh infants which uh requires in many p um exercises procedures as well. But we started do um anecdotally with this few cases, but we are about to start the system doing the few cases. It's not enough. The system is renal work. Sorry, I just missed you for a while there. You were saying in what, what is your age range and your weight for the ones you're starting now. Um uh what, what, what is the age of patients? I'm seeing you, you're studying it in the younger or the smaller patients. What is your age range and uh your weight? So, so um we are a referral center for all biliary uh problems or liver, hepatic liver problems. And we do uh kidneys um without any problem, we don't have a problem with kidneys or um for Children. Our limit now we are limiting six from six years. We do uh patients from, from 6 to 18 years. But uh we are about to start it. We have a lot of the long list of cases. Um one year uh or uh 87 months for the patient who referred us with a biliary atresia without si so we cannot do them. We have to go for a liver transplant. Now, we are collaborating with uh uh foreign countries. We are sending them to another country, but our plan is to start to end of this year uh for the patients uh above six ki kilogram. Mhm OK. Mansour th thank you and, and best of luck for your uh transplant program there is uh thank you very good for everyone. Yes, thank you, man. There is a comment from Dr John Seira, a senior pediatric surgeon from Uganda that this service is needed in most African countries. But it's a problem that we don't have supporting systems and uh we need to work together to, to support each other and maybe develop transplant programs. I see. I think it's Professor Sharon Cox, if I'm correct. So, Professor Cox being the in charge of the department of pediatric surgery, uh sharing any insight about solid organ transplants. You have been in the department for over 20 years. Uh So what has changed? What is your future plan? No, I think has outlined it nicely. Um And, and yes, we are working towards upskilling and actually creating a team, you know, recently we lost um a lot of skills and sort of one time it's taking a while to recruit. But um once we, we get the team together, Omar is coming back, we've got Tazara who's going to be doing some further um work and learning on, on transplant. Um You know, I think the, the future does hold um a sort of uh uh program um that includes living related eventually um liver transplants. Um I think our kidney program is, it's keeping up with the patients that we put on the list very, very nicely. Um And yeah, I think, I think, you know, moving forward, I think a lot of it is um building the team, having enough staff to be able to get the, get the organs, procure the organs and then still, you know, put, put the um transplant the organs into the recipients. Um Yeah, I think a lot of what Omar said is very true. If we are going to continue in the service here, we do need to upscale um on the in terms of the interventional radiology um aspects which we are in fact working on in terms of building building our interventional service. Um again, that takes a while, it takes a while to get pediatric skills. It takes a while to get a service and certainly austerity measures measures have not helped us recently, every single thing, I mean, we, we cutting posts more than employing people right now because of the austerity measures. So it it is a problem but there is a plan and we will slowly work, work towards it. Um Again, you can't create a service too quickly either because then you leave out steps and, and vital, vital um sort of um people staffing skills that need to be, need to be there. So it's, it's gonna be slow, but it's going to be thorough. Ok, Sharon. Thank you very much. Um uh mmm, you can uh unmute yourself and make a short comment. Doctor. M hi, everybody just to congratulate on her lovely presentation. Um I'm currently the South African Transplant Society chair. So always excited to hear when there are talks about transplantation. And I think what's really good is that pediatrics is really growing in terms of this field. So um really it's to be the chair of the society even as a pediatrician. And I think what everybody has said, it's all about teamwork it this one field where you really can't manage uh with just one or two people. I think Sharon's outlined it very nicely and I think we work very well together, not just pediatricians and surgeons, but the whole team and also adults and pediatric combined. So we are very reliant, not only on our adult surgeons, but also on our adult um physicians, both nephrologists and hepatologists. And I think this is really a team sport. Um And when we have tough times together, we also celebrate together, so really proud of, of what we are doing at Red Cross. We are doing um kidney, we are doing liver. We've done three or four hearts in the last three years. We've also started our first adolescent lung transplant and we're also doing quite a significant number of stem cell transplants. But that all takes work and effort and it's really great to be able to spread the good news. And just thanks to Zama for putting such a lovely talk together. Thanks a lot. Thanks. M um I see. Doctor Nero Patel is here. Doctor Patel is a pediatric surgeon at Wana. Um uh he probably uh is aware e even though he doesn't work at do garden, uh you know, any insights from Joburg. Uh No, uh I, yeah, I'm not part of the transplant program. I do some of the HPV stuff at VA but uh I just want to say thanks to Ta and Omar. Um what a great discussion about what a team effort it is and, and, and, and um the fact that it is a high risk um endeavor and how you need everyone to be on board. I think that's like such an important lesson, not just in transplant, but in all pediatric surgery because so many of our patients are so sick. So I II thoroughly enjoyed the discussion. That's, that's the only comment that I can make. Uh It was really awesome. Thanks very much. Thank you, Nera. Um I just want to see if doctor No, Masha is still here. Uh Knox, if you are here, you can just unmute and make a comment. She was here. I don't see her here now. Um If not doctor Maa, is he here? Hello, if you're here, just unmute and make a comment. Sure, thanks. Well, uh thanks man for the, for the nice English. Yeah. Um I II think I'm reflecting on what everyone is saying, man and yourself that um it's a multidisciplinary team effort. And um what I've seen unfortunately is that um where you are born determines your outcome. Unfortunately, you're born in Cape Town, you're born in Johannesburg. Your outcome will do far better than if you are born in the Eastern Cape Limpopo Northwest or wherever. Not because there are poor skilled people there. It's just that the referral pattern makes it challenging. Yes, we want to be able to select candidates who would survive because you don't want to have a high mortality rate at the end of the day. Yes, but I always find it very odd when um you get uh kind of canceled because you happen to live 100 and 50 kilometers from the airport and you can't get there in time, which I think um it's good that um Red Cross is actually pursuing the living related donor because II feel that's a game changer because then there's that it eliminates that one factor of saying that you will not be able to get to our institution in time by allowing us to package the patient and package the donor, which at most of the time is the family member, which is the the mom or the father to the institution where um transplant can um proceed uh safely. Yeah, obviously we've, we, we do a lot of talking with uh the joburg team and the Red Cross team regarding our patients for transplant. And um it's quite a rigorous um effort to try and actually make sure they're well optimized, which is fair in doing that. And obviously, we want to have them in the best and optimum position, they can be to be able to actually have a successful transplant uh at the end of the day. Um But I think um definitely Red Cross pursuing the living related donor and pushing more on that will definitely decrease the waiting list um because most likely in the country if um I'm not familiar what happens much in, in the K ZN, but in Joburg and yeah, where you have live related donors, you find that your, your increase or your number of transplants you do particularly for, for livers just shot up when they actually had that avenue. And obviously, if they're shooting up the numbers, it means that the number of kids or candidates out there will be less, which is fantastic, meaning that less kids will demise because of liver failure or having a prolonged delay in getting a new liver. So I think um a little challenge to, to, to Sharon. And the Red Cross team is to kind of push on the liver related donor so that we can send you guys lots and lots of gifts so that we can have fantastic outcomes at the end of the day. But that's my five senses. Thanks. OK, thank you, say. Um I think Theresa uh your concluding remark. Um I think definitely let's continue on a collaborative effort um to try to increase um our donors. I think I also just put in the chat about uh nurse coordinators and transplantation are important. But I think collaboration and networks and awareness with regards to donors and that we all try to register and become organ donors as it's Organ Awareness Month. Thank you very much for the opportunity to present. Thank you and for all those who are still in the meeting, please die the first weekend of May 2025. We are hosting the B conference of the South African Association of Pediatric Surgeons at PK Beach Resort, which is just outside East London. And uh it's going to be, it's going to be an exciting event. You can see there are eight experts all over the world who are lined to be the invited guests. And we are going to have an advanced laparoscopic workshop on Thursday and then 2.5 days of conference. So please diar and please attend in a month's time. We will have a talk by Dr Shair who is the head of pediatric ent surgery at the Red Cross Children's Hospital in Cape Town, about upper airway obstruction in Children. And they will also be talking about the aerodigestive team in lower and middle income countries and that will be part of the Z meeting of our department and also a webinar for the global initiative for children's surgery. So we will circulate the invoice about a week ahead of the time and the recording of this meeting will be available later today or tomorrow. So sa thank you very much all the best. We are eagerly waiting. You confirming that you are accepting lid donors. And uh I wish you well for your transplant fellowship and, and transplants. Thank you very much. All of you. Bye bye. Thank you prof.