Although statistics show that Iran has an estimated cases of 15,000 liver failure annually, and more than 5,000 Iranians die every year due to this disease, but Dr. Reza Malekzadeh, the deputy health minister of Iran, says that the country has been able to overcome all shortcomings and difficult obstacles, and by accomplishing more than 6,000 successful liver transplants, it has achieved stunning records in saving the lives of many of the people who die from this disease in 25 years of struggle.

According to the Digestive Diseases Research Institute of Tehran University of Medical Sciences, after more than five decades of the world's first successful liver transplant, conducted by Dr. Thomas Starzl, as well as the discovery of the miraculous drug "cyclosporine" and its use in the 1980s, liver transplantation was accepted as a common practice in the treatment of patients with liver failure in the world.
International data show that, on average, more than 25,000 successful liver transplants occur annually, and this figure is rising every year.

Twenty-six years after the lasting achievement of medicine in the first successful liver transplant in the world, Shiraz in southern Iran, with carrying out the first liver transplant by Dr. Ali Malek Hosseini in the year 1993 (1372), linked the patients with liver failure requiring liver transplantations to the "Namazi hospital", where later became the most important liver transplantation and education center for training of dozens of liver surgeons by the" father of liver transplantation in Iran" at national and international levels. With his support and guidance, Iran witnessed the formation of eight other liver transplantation centers in Tehran, Mashhad, Kerman, Isfahan, Ahvaz, Tabriz and Rasht, along with the development of scientific capabilities, skills and equipment for liver transplantation in each of these centers.

Now, the Iranians are proud that after 25 years of uninterrupted efforts by specialists and surgeons and with the advancement of knowledge of liver transplantation and its integration with the rich culture of organ donation, their country which has been ranked in the top 10 countries of this advanced medical science, is standing on the roof of the area in the liver transplant from brain death patients.

The results of the first study on two decades of liver transplantation in Iran

Dr. Ali Malek Hosseini , distinguished Professor of Shiraz University of Medical Sciences, Dr. Reza Malekzadeh, director of the Digestive Diseases Research Institute and distinguished Professor of Tehran University of Medical Sciences, Dr. Ali Jafarian, surgeon and the professor of Tehran University of Medical Sciences, Dr. Bijan Eghtesad, organ transplantation specialist from Cleveland University (in US) and 20 of their colleagues in Iran's liver transplant teams have studied the extent of Iran's progress and success in liver transplantation.

The number of liver transplants performed in Iran

Dr.  Reza Malekzadeh

According to the results of this study, 6,301 liver transplants has been performed in Iran in the last 25 years (from 1993 to 2018), of which 5, 819 liver transplants were performed from brain death patients and 482 were done from live donors (only relatives of the recipient).

The head of the Iranian Association of Gastroenterology and Hepatology described this amount of liver donation from brain death patients in the country as an amazing, unique and praiseworthy record.

He said that of the total liver transplants done in Iran, 5166 and 1135 cases were related to adults and children, respectively.

Then, Dr Malekzadeh mentioned the number of the performed liver transplantations based on the 9 active centers in the country and said: "Shiraz with more than two decades of activity, has the largest number of transplantations which is 4871, then Imam Khomeini hospital in Tehran with 850 and Taleghani hospital in Tehran with 160 transplantations have the first and second rank in Tehran province. Also, 261 transplantations have been performed in Mashad, 62 in Kerman, 70 in Isfahan, 11 in Ahvaz, 10 in Rasht and 6 transplantations have been done in Tabriz. Of course, the success rate of each of these centers in children and adults liver transplantations is different.

According to Dr. Malekzadeh, over the past two decades, among the nine active centers of the country, only Shiraz organ transplant center performed 482 liver transplants from living donors, which is a very difficult and advanced surgery.

 Dr. Fazel, Dr. Starzl and Dr. Malekhosseini

The year 1396 should be considered a jump year for the liver transplant in Iran. In this year, Shiraz broke the world record of the "Pittsburgh organ transplant center in the US" in liver transplantation from brain death patients, and stood on the roof of the world.

Dr. Ali Malek Hosseini described this Shiraz record-breaking achievement as saying: "The Shiraz Organ Transplant Center as the oldest and largest organ transplant center in Iran broke the record of 561 annual liver transplants belonging to the Pittsburgh American Center for Transplantation by performing 638 liver transplants last year."

According to the "father of liver transplantation in Iran", the Organ Transplant Center of Shiraz also has had many successes in kidney and other organs transplantations. For example, 4469 kidney transplants, 154 kidney- pancreas transplants, 64 pancreas transplants, 33 intestine transplants and 21 multiple organ transplants in the abdominal region have been performed so far.

Dr. Malekzadeh, the head of the Digestive Diseases Research Institute of Tehran University of Medical Sciences, also explained about the age of liver transplant recipients in nine active Iranian centers: "Our study results show that in the last two and a half decades, the age group of 46 to 55 years old had the highest liver transplantations (about 20%) and then, individuals aged 36 to 45 years old, 26 to 35 years old, under 12 years of age, 56 to 65 years old, 19 to 25 years old, 12 to 18 years old, and over 65 years of age had the highest liver transplantations respectively."

Unique record of Iran in the 20-year survival rate of liver transplant recipients

The privileged professor of Tehran University of Medical Sciences declared the survival rate of 1, 5 and 10 years in adults receiving liver transplants 85%, 77% and 71%, and survival rate of 1, 5 and 10 years in children 76%, 67% and 56% respectively, and added that generally, over a 20-year period, 77.4% of transplanted patients survived, which is a unique record for liver transplantation in the world over the course of 20 years.

The most prevalent causes of liver transplantation based on the results of 9 active centers in Iran

The author of the study "Liver Transplantation in Iran" based on the results of this study on the most important causes of liver transplantation among adults and children in 9 active centers of the country reported that: "

cryptogenic hepatitis B (with the fatty liver as the most common cause), inflammation of biliary tract, autoimmune hepatitis, hepatitis C, hepatocellular carcinoma, Wilson's disease (a kind of inherited metabolism disorder), Crigler–Najjar syndrome (lack of necessary enzymes for bile secretion from liver), non-alcoholic fatty liver hepatitis and primary biliary cirrhosis have been the most important factors of hepatic failure and ultimately adult liver transplantation in six liver transplantation program implementation centers.

He mentioned biliary obstruction, Wilson's disease, hereditary intrahepatic cholestasis, cryptogenic hepatitis B (with the fatty liver as the most common cause), tyrosinemia (congenital metabolic abnormality), autoimmune hepatitis, Crigler–Najjar syndrome (lack of necessary enzymes for bile secretion from liver), hypercholesterolemia (high blood cholesterol), infantile hepatitis and inflammation of biliary tract as the most important liver transplantation factors in children in Iranian liver transplantation centers.

The main causes of liver failure in Iran

However, Dr. Malekzadeh said that hepatitis B and C are the most important causes of liver failure and early death due to it. He said that “One million and 500000 people in Iran now carry HBV and 300000 people are HCV carriers.”
The gastroenterologist and hepatologist mentioned hepatic cirrhosis as one of the most important complications of hepatitis B, hepatitis C and non-alcoholic fatty liver if untreated, and said: “Unfortunately, the hepatic cirrhosis caused by non-alcoholic fatty liver which is mainly due to overeating, inactivity and obesity is increasing in Iran.”

Contribution of diagnostic factors in increasing liver transplantation due to viral hepatitis

The gastroenterologist and hepatologist pointed to a significant issue in the field of hepatic failure due to viral hepatitis and said: "A significant number of liver transplantations performed in Iran have been due to liver failure caused by hepatitis, which unfortunately have been due to the “late diagnosis and late treatment” or “early diagnosis, but late treatment due to problems with the patients location and the lack of access to liver transplantation centers with specialized services”; of course we cannot ignore the impact of potential lags in finding transplantable livers from donors which is caused by the difficult conditions of this type of transplant that causes patients to procrastinate transplant actions.

Premature death of more than half of the people with chronic liver diseases in the country

According to the head of the Iranian Association of Gastroenterology and Hepatology, chronic liver diseases are among the most important causes of premature deaths in Iran, so that 64% of people who die of these diseases in the country are under 70 years of age and 22% are below 50 years old who die so prematurely!

The death of 5400 Iranians due to chronic liver diseases during the past year

He pointed to the latest statistics of deaths from liver failure in both genders in Iran during the year 1396 and said that last year, 5400 people died in the country due to chronic liver diseases, of which 3,000 individuals (56%) were under 70 years of age and 1,000 people (19%) were under 50 years old who suffered from premature and very premature deaths.

Iranians’ livers have become fattier by obesity and inactivity

Dr Malekzadeh, warned about the prevalence of obesity in Iran, and mentioned it as an important risk factor for the development of fatty liver and said: "Unfortunately, the contribution of fatty liver to the incidence of chronic liver failures in Iran is increasing and it is safe to say that reducing overeating and increasing mobility are two very essential requirements for the health of the Iranians’ livers.

The importance of controlling overweight is so much that, according to Dr. Malekzadeh, the obesity damage to the liver is greater than hepatitis C damage to the liver; therefore, a part of the treatment for patients with chronic liver diseases is using medicines, and the other part is the treatment of obesity in overweight patients.

A look at Iran's longest steps in preventing premature liver deaths with control, treatment and transplantation

Although premature deaths due to liver failure are one of the main concerns of the health system of Iran, outstanding successes in preventing and controlling viral hepatitis which causes the disease, and also achievements in the field of liver transplantation competitive with developed countries, have made our country a pioneer.

Iran in the field of prevention, in the first step, started to eradicate hepatitis B and with four methods of “vaccination of infants”, “vaccination of unvaccinated adolescents and adults”, “preventing the transmission of hepatitis B from mothers to infants” and “effective treatment of all identified carriers of hepatitis B with the active disease” used all its efforts to control this disease and became closer and closer to the goals set by the health system and the World Health Organization.

In the next step, Iran achieved a definitive, complete, easy and inexpensive treatment with a great success with the production of effective anti-hepatitis C oral drugs and saved thousands of patients from the risk of liver failure, liver transplantation, and even premature death due to that with the lowest possible costs compared to the world's staggering costs, and along with this important event, they began actions for high-risk groups including IV drug users, prisoners and HIV patients to control hepatitis C and introduce the patients to the healthcare centers to receive free care services.

Iran's hope for eradicating hepatitis B and C in the next 15 years

These steps which made an easily treatable disease from the hepatitis C giant, according to Dr. Malekzadeh, the deputy minister of health, were so important that made Iran hopeful to eradicate hepatitis B and C as two very effective factors in liver failure, during a 15 years program.

Another attempt by Iran was to save the acute liver failure patients who had a survival chance of less than 20 percent in the absence of liver transplantation.

Dr. Ali Malekhosseini

Dr. Ali Malek Hosseini, told about liver transplant sufferings in the country, and named the following items as the sum of the conditions in Iran before the extraordinary jump in liver transplantation: intense and painful public unawareness about brain death and the possibility of organ donation of these patients even among educated people; the lack of a religious judgment (Fatwa) for organ transplantation from brain death patients; the lack of an organ donation law; financial deficiencies caused by devastating imposed war; inadequate hospital beds and equipment; shortage of nurses, specialists and surgeons as well as trained staff for systematic support of the organ donation procedure.

But, according to the “father of liver transplantation in Iran”, these sufferings did not last long. In 1368, by issuing the religious judgment (Fatwa) of Imam Khomeini regarding the possibility of organ donation of brain death patients, which Dr. Iraj Fazel had a very effective role in pursuing until its issuance, and following that, with the passing of the law of the organ donation of brain death patients by the parliament, Iran's longest step was taken to save patients in need of transplantation, and Iran was able to continue its path of success by educating people and employing trained staff to identify patients.

The increase in the number of brain death patients' identification units to 53 units and the unique record in liver donation

Dr. Malekzadeh, the deputy minister of health, also described the achievements of Iran for the rise of the “liver transplant”. He said: “We now witness a significant increase in the number of brain death patients identification units to 53 units, and this effort has caused 90% of the liver transplantations in the country be performed with the organ donation of brain death patients, and also we have 700 liver donation of brain death patients annually, which is a unique record in the world.

Increasing access to dead liver donors has also increased the access to dead kidney donors for patients in need, and ultimately has reduced the pressure on patient’s relatives for kidney transplantation.

Establishing a system for registration of the patients in need of liver transplantation

Establishing a system for registration of the patients in need of liver transplantation was another Iran’s action which according to the Iranian Association of Gastroenterology and Hepatology, helped to better organize the distribution of livers for transplantation based on the needs of different regions of the country.

Increasing the chance of survival and quality of life for recipients of liver transplants

Also, according to Dr Malek Hosseini, despite the problems in the low survival rate of patients in the early years of the activity of liver transplantation centers in our country, the quality of life and survival of patients who received liver transplants now has improved with advancements in surgical techniques and using higher quality immune system enhancers to prevent transplant rejection, and successful liver transplantations with a higher survival rate for patients in need of this type of treatment in Iran is increasing.

Increasing the access of all patients to the liver transplantation services

Dr. Malekzadeh, the deputy minister of health, also believes that while almost 95 percent of Iran's population including farmers, workers, government employees and other sectors of the population, is covered by health insurances, Iran's health system has reduced disparities in access of the various social and economic classes to liver transplantation services.

He said the Ministry of Health has also made extensive efforts to completely cover the costs of hospitalization of brain death donor patients, as well as full coverage of insurance and offering very convenient financial and equipmental support for hundreds of patients in need of liver transplantation.

The deputy minister of health also mentioned the establishment of the largest charity subspecialty hospital for organ transplantation in the Middle East and said: "Excellent motivations to save lives of patients in need of liver transplantation in Iran caused the establishment of the" Bu-Ali Sina" hospital, the charity subspecialty hospital for organ transplantation, in Sadra, Shiraz, as the largest hospital for organ transplantation in the Middle East; so that all of transplantations in Shiraz are currently being performed in this hospital, which 90% of the cost of its construction was paid by the  charities and improved patients after their liver transplantations.

Reducing the cost of long trips for liver transplantation

The head of the Iranian Association of Gastroenterology and Hepatology said: "On the other hand, the increase in the number of liver transplantation programs and its development in different regions of Iran have reduced the need for long trips for liver transplantation and subsequent medical care."

International advancements of Iran in liver transplantation services

Dr. Malekzadeh did not consider Iran's progress in liver transplantation exclusive to national services, and emphasized that the organ transplantation center of Shiraz have transported liver transplantation services abroad including the countries of the region and Asia: Iraq, Syria, Lebanon, Tajikistan, Afghanistan, Pakistan , Azerbaijan, and so on, and in addition to performing liver transplantation operations and training surgeons and staff, it has also played a very significant role in the establishment of liver transplantation centers in these countries.

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