Dear Naziha Thanks for your interest in this complex topic 1. How many commercial transplants since 2015 have been done in Pakistan on people from Kuwait? have asked one of my staff to update the data. Will send tomorrow. Lam attaching data till 2014: 2, To what extent is this an increase over the previous years esp since 2010 when the law against unrelated organ transplants was enacted in Pakistan? You can see from attached slide that no patient went to Pakistan from 2008 to 2011. This is because of international pressure (Istanbul Declaration) and local pressure (; and new law). This effect was not sustained and numbers soon started to increase year after year. The centers involved found new ways o hide their illegal acts. 3. Where did these operations take place and what is the quality of the procedure? Most centers hide their names or even city in which transplant is performed. We think mostly in Rawalpindi and Lahore (e.g . May be there is no center by this name). Some patients do well but others end up with complications and loose transplanted kidneys. Most patients are told to return back to Kuwait within few days after surgery, often with catheters and drains still in place. Once the patient is out of their sight they are not their responsibility anymore. This is very dangerous for transplanted patients with low immunity to infection.4, What steps, if any, did the transplant facility take to ensure discretion - eg operation being done at night, in a house rather than a medical facility etc? Most patients say they were instructed to wear local dress and were taken to hospital using a different rout each time. They were not aware of names of hospital or facility but mentioned names of doctors although we think they could be fake names. Patients are often reluctant to provide information (probably instructed not to do so) 5, In what way does it impact the health system in your country? We are providing an excellent and free service to all residents of Kuwait and do have good results but like elsewhere we have shortage of donors. Most patients want an easy way out to get rid of dialysis, and we cannot blame them especially when they do not have related donors and cannot wait for 2-3 years to receive a kidney from a deceased donor. Money is not a problem for most of them. ‘However we have to deal with the complications of surgery performed elsewhere when we have little, if any, details of the donor, operative findings or difficulties and post operative course of the patient. Sometimes patient is told operation was successful and kidney is working well when this is not true and when we try to explain the facts they do not trust us. Best regards Mustafa Dr Mustafa Al-Mousawi, MBBS (Low) LRCP, MRCS(Lon),FRCS(Glasg) President, Kuwait Transplant Sociesy.