Sustainable Training Strengthens Kidney Transplant Capacity in Resource-Limited Systems

US funding of worldwide aid and global health has decreased dramatically in recent years.¹

Billions of dollars have been cut from programs developing clean water infrastructure and from programs providing preventive care and treatment of infectious diseases such as HIV and malaria.¹ Clinicians working in the global surgery space seek to improve healthcare outcomes and achieve equity for all who require surgical care. 

The development of surgical capacity is a critical component of combating the global burden of disease. Numerous studies have revealed that capacity for treatment of surgical disease is deficient in developing countries, which leads to increased mortality.² It is estimated that surgical care treats 20%-30% of the global burden of disease. Despite this reality, global surgery receives less than 1% of total global health funding.³ 

To sustain global surgery initiatives, we must adapt to the current paucity of funding by leveraging our existing resources to drive the worldwide development of surgical care. This approach includes narrowing our focus to surgical treatments that will continue to have a wide impact on a particular country’s overall health.

Physicians who participate in surgical missions provide operations that local citizens may not have access to because of a skills and knowledge gap or lack of resources.

Mission work, although undoubtedly beneficial, is not sustainable for the mission providers or the patients and communities they serve. Missions depend on altruistic or private donations while communities can only receive care when the mission is available with little to no follow-up after the surgical mission.

Global CKD Burden Exposes Inequities in Care

It is estimated that 850 million people worldwide are living with chronic kidney disease (CKD).⁴

Disability-adjusted life years (DALYs) due to CKD disproportionately affects populations in low- and middle-income countries (LMICs) due to the lack of adequate healthcare infrastructure to support those living with the condition.⁴

The primary management of advanced CKD and end-stage renal disease (ESRD) continues to rely on decades-old care pathways of dialysis and kidney transplantation. In developing countries, patients with ESRD die prematurely and experience diminished quality of life due to the lack of access to high-quality dialysis care.⁵

The prevalence of CKD and ESRD, specifically in sub–Saharan Africa, is undetermined because of the lack of renal registry data. In Zambia, dialysis is paid out of pocket by the patient.⁶ In countries that do not have access to kidney transplantation, patients and their families are subjected to a large financial burden to support their loved ones. Families that have higher incomes can either maintain dialysis or obtain their kidney transplant in neighboring countries, which in turn promotes transplant tourism. This reality perpetuates the widening health disparity seen throughout the continent.

Value of Hands-On Training

The ACS H.O.P.E. Kidney Transplant Capacity Initiative is the largest multidisciplinary and multi-institutional group of healthcare providers focused on developing safe and sustainable kidney transplant programs in LMICs. The mission is to train and upskill local providers to provide safe, sustainable, and reliable care. We provide training and education in several forms, ranging from virtual lectures to hands-on skills training with daily management of surgical and medical patients.

Traditional training models bring trainees to high-volume centers where they gain experience and skills with the goal of bringing this knowledge back to their local communities. This training pathway does not address the inherent barriers of practicing in a resource-limited country. Surgical infrastructure and resources at a high-volume center are developed and more readily available than a center located in a developing country. 

In this traditional model, the responsibility then lies solely on the newly trained surgeon to develop surgical infrastructure in their community while simultaneously developing their own surgical skills. This traditional training approach was implemented in Zambia a decade ago, but the initiative failed due to resource limitations and other challenges.

In-person and hands-on training are essential for the Kidney Transplant Capacity Initiative to succeed because it allows us to work with local collaborators and overcome barriers to providing care. This approach enables local providers to advocate for specific resources necessary to achieve their goal. 

Kidney Transplantation Is Primary Cure for ESRD

Kidney transplantation significantly lowers mortality rates, decreases the chance of cardiovascular events, and improves quality of life when compared to dialysis alone.⁷ 

Unfortunately, despite the lifesaving benefit of transplantation, only 314 (less than 1%) of 111,135 kidney transplants completed worldwide were performed in Africa in 2023.⁸ 

In the developing world, pre-existing and longstanding barriers to developing sustainable kidney transplant programs include (but are not limited to) lack of adequate government and individual financial resources, skepticism and local cultural attitudes toward transplantation, poor health literacy, and lack of legislation and policies that advance organ transplant care.

ACS H.O.P.E.

Creating surgical capacity for sustainable surgical programs in the developing world requires extensive multidisciplinary collaborative efforts.

Despite reduction in US aid, surgical societies such as the ACS continue to promote global surgery and health equity. Specifically, the ACS Health Outreach Program for Equity in Global Surgery (ACS H.O.P.E.) is one of the largest and most effective global surgery programs available to US surgeons. ACS H.O.P.E. provides surgeons with opportunities for domestic and international volunteerism with a focus on collaboration and community-based interventions.

The ACS H.O.P.E. pillars of development include clinical care, research, and quality initiatives with the goal of identifying local champions who will lead these efforts with assistance from ACS surgeons. This program has developed collaborations with several international partners, including Hawassa, Ethiopia; Lusaka, Zambia; and Kigali, Rwanda. Several of these clinical programs provide acute care surgery, laparoscopy, hepatobiliary surgery, cardiac and thoracic surgery, pediatric surgery, and transplant surgery. 

Ultimately, the goal of these partnerships is to exchange knowledge and collectively advance the field while developing sustainable surgical programs.

Building on the well-established ACS H.O.P.E. infrastructure, the Kidney Transplant Capacity Initiative has successfully developed a kidney transplant program. The initial focus of this transplantation program is to provide clinical care. But as the case volume increases, the focus will expand to include the development of quality initiatives and research.

Given the lack of established deceased donor infrastructure in most low-income countries and LMICs, the focus has been on creating living kidney donation surgical programs.

The Kidney Transplant Capacity Initiative consists of transplant surgeons and nephrologists that work directly with their respective counterparts at the University Teaching Hospital (UTH) in Lusaka, Zambia. Since we began in 2024, we have performed 17 living donor kidney transplants. Two of these transplants were in pediatric patients, which were the first pediatric transplants performed in the country. Three of these donors underwent laparoscopic nephrectomy which also were a first in the country. All these operations were performed alongside Zambian surgeons using UTH resources and equipment. 

Our work does not stop once the patient leaves the OR. Transplantation relies heavily on multidisciplinary care, and so we promote a culture of communication and collaboration between the respective UTH teams. An example of equitable knowledge transfer occurs when UTH surgeons, who have more experience in open nephrectomy, work with US surgeons trained exclusively in laparoscopy. 

While the benefits of minimally invasive surgery are well established, its use in developing countries remains limited. This reality is partly because of the lack of consumables necessary to perform laparoscopic surgery. Our primary objective for the living donor has been to perform open nephrectomies through a flank incision. This approach has been shown to be more sustainable and in line with the resources and experience at UTH. 

Partnerships at Home and Abroad

Kidney transplant capacity necessitates a multidisciplinary alignment and an expensive system of support services and resources, including OR equipment, skilled nursing, medications (immunosuppression), and infrastructure for both pre- and postsurgical evaluation.

We have identified local champions from all necessary specialties including surgery, nephrology, anesthesia, intensive care unit nursing, and OR nursing and staff. These local champions are not only trained in their respective fields but are also essential in navigating the hospital and healthcare system.

Furthermore, involvement of local stakeholders is essential for navigating the sometimes-unfamiliar local government and legal systems that play a pivotal role in the sustainability of surgical programs in underresourced countries. 

Transplantation is a specialty that relies heavily on multidisciplinary support, from not only medical and surgical experts, but also social workers, pharmacists, nursing staff, and coordinators. In this regard, leveraging expertise from established global academic transplant centers remains crucial for success.

The development of the Kidney Transplant Capacity Initiative is the collaborative efforts of multiple transplant centers, physicians, transplant staff, and their respective international societies. For more information about participating in global health initiatives, visit facs.org/acshope.

Disclaimer

The thoughts and opinions expressed in this article are solely those of the authors and do not necessarily reflect those of the ACS.

Dr. Thomas Pham is a clinical associate professor of surgery and surgical director of pediatric kidney transplant and living donor kidney transplant in the Division of Abdominal Transplantation at the Stanford School of Medicine in Palo Alto, CA.

Dr. Tyler York is a transplant surgery fellow in the Division of Abdominal Transplantation at the Stanford School of Medicine in Palo Alto, CA.

References

1. Cavalcanti DM, de Oliveira Ferreira de Sales L, da Silva AF, et al. Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: A retrospective impact evaluation and forecasting analysis. Lancet 2025;406(10500):283-294.
2. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
3. McIntosh SA, Hudson G, Jiang M, et al. Global funding for surgical research between 2016 and 2020: Content analysis of public and philanthropic investments. Br J Surg. 2025;112(6):znaf089.
4. Bello AK, Okpechi IG, Levin A, et al. An update on the global disparities in kidney disease burden and care across world countries and regions. Lancet Glob Health. 2024;12(3):e382-e395.
5. GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2020;395(10225):709-733.
6. Bosomprah S, Bjonstad EC, Musuku J, et al. Burden of chronic kidney diseases and underlying causes in Zambia: Evidence from the global burden of disease study 2019. BMC Nephrol. 2023;24(1):39.
7. Tonelli M, Wiebe N, Knoll G, et al. Systematic review: Kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant. 2011;11(10):2093-2109.
8. International Report on Organ Donation and Transplantation Activities 2023. Global Observatory on Donation and Transplantation: 2023. Available at: https://www.organdonationalliance.org/wp-content/uploads/2024/12/2023-data-global-report-17122024.pdf. Accessed April 17, 2026.