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Organ transplant in Brazil
Organ Transplant in Brazil J.O. Medina-Pestana, M.L.S. Vaz, and S.I. Park
B
RAZIL is a country with 160 million inhabitants distributed within an area of 8,200,000 km2 which is divided into 27 states. The Brazilian economy is ranked eighth in the world with an annual gross domestic product (GDP) of US$ 635 billion (2000), of which only 5% (⫾US $30 billion), is allocated to the public health system. According to the latest statistics, there are about 45,000 patients registered in the Brazilian chronic dialysis program, which is fully financed by the public health system. The Health Ministry has recently regulated the creation of organ donation networks in all of the states health departments. Organ procurement organizations are primarily linked to university hospitals. Regional lists of transplant candidates in each state were established, and the organ allocation is centralized and supervised by the Attorney General’s office. The law for organ donation (Law #9434, February 1997 and law #10211, March 2001) reflects local social values, prevailing the need of required consent based on written family authorization. The diagnosis of encephalic death is legally recognized, and is based on clinical examination and at least one medical test, showing the absence of cerebral blood flow. The transplant of organs between living donors is also state-regulated, requiring judicial authorization in cases of donation between non-family members. There has been no suspected or confirmed reference to organ commercialization in the last 4 years. The number of authorized centers and transplants performed have been steadily increasing in the last years. The first intestinal transplant was performed in December 2000 at Hospital Santa Casa de Sa˜o Paulo. The
number of solid organ transplants performed in 1997 was 2,127, compared with 3,485 in 2000. The majority of transplant physicians have had their postgraduate medical training in Europe or in the United States, financed by Brazilian government agencies. Table 1 shows the number of authorized centers and the number of transplants performed in 2000, as well as the amount including hospital expenses and professional fees in US$ paid by the public health system for each procedure. Compared to the United States or Europe, the percentage of renal transplants with living donors is considerably higher, but the figures for cadaver donors are increasing. While the number of transplants with living donors appears to have reached a plateau, the numbers with cadaver donors are still growing, and it is projected to increase four-to five-fold in the coming years, as organ procurement network programs are expanded and become more organized. The distribution of kidney transplant and dialysis programs is not homogeneous among the five Brazilian political regions. As expected, the most developed regions (Southern and Southeastern) present the highest average of kidney transplants and dialysis performed (Table 2) (Fig 1). Family refusal for organ donation follows the same profile, being 30% to 40% in the previously mentioned regions, but greater than 70% for the rest of the country.
From the UNIFESP, Sa˜o Paulo, Brazil. Address reprint requests to J.O. Medina-Pestana, Rua Borges Lagoa, 960 - 11° andar, 04038-000, Sa˜o Paulo/SP, Brazil.
Table 1. Total Number of Transplanted Organs, Number of Authorized Centers, and Reimbursed Values by the Public Health System in Brazil in 2000 for Each Procedure
Organ
Living Donor
Cadaver Donor
Authorized Number of Centers
Heart Liver Pancreas Pancreas/kidney Lung Kidney
0 43 0 0 0 1631
110 437 9 37 24 1194
36 36 4 10 8 153
Number of Transplants
Value paid for Each Procedure (US$)
11,121.24 25,949.73 4,189.08 13,640.35 18,535.45 9,636.38
Source: ABTO, Decree # 92 2001-Jan-19.
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 441–443 (2002)
0041-1345/0⫺2000/$–see front matter PII S0041-1345(02)02588-5 441
442
MEDINA-PESTANA, VAZ, AND PARK
Table 2. Total Number of Kidney Transplants and Dialysis Performed Relative to Number of Inhabitants in Brazil and for Each Region in 2000
Population (Million)
Number of Kidney Transplants Performed
Number of Dialysis Performed
Number of Transplants per Million of Inhabitants
Number of Dialysis per Million of Inhabitants
169.0 72.3 25.0 11.6 39.6 13.0
2825 1769 514 244 240 58
45796 25441 8844 2542 8893 947
17 24 21 21 6 4
271 352 354 219 225 73
Brazil Southeast South West– center Northeast North Sources: ABTO, SBN.
Fig 1. Total number of kidney transplants and dialysis performed, related to number of inhabitants in Brazil and in each region in 2000.
Table 3. Total Number of Renal Transplants Performed by Country Member, per GDP per Capita, and per Million of Population, in 1999 (Last Data Available for All Countries)
Country
Population (Million)
GDP (US$ Billion)
Total Number of Transplants
Number of Transplants per Million of Population
Brazil USA Spain Mexico Germany France UK Canada Australia Portugal
172.86 275.56 39.99 100.35 82.79 59.33 59.51 31.28 19.16 10.05
558.2 9.237 647 483.3 2,603 1.697 1,254 663.3 518 385
2825 12162 2006 630 1895 1760 1432 1025 518 385
16 44 50 6 23 30 24 33 28 38
Number of Transplants per $1000 GDP per Capita
605 359 132 127 74 74 59 49 24 34
Sources: ABTO, U.S. Bureau of the Census, Handbook of International Economic Statistics, International Congress of Transplant Society, Daily Congress Newsletter, 30 August-2000, “Revista Conjuntura Economica.”
ORGAN TRANSPLANT IN BRAZIL
443
The public health system pays for more than 95% of the transplants performed in Brazil. Transplants performed in private institutions usually charge health care providers or the patient up to two times more. The public health system also provides all registered immunosuppressive drugs to all patients indefinitely, including cyclosporine A, FK 506, mycophenolate-mofetil, and antilymphocyte antibodies (OKT3, anti-IL-2R). This government-sponsored program of drug supply is similar to that found with drugs used to treat AIDS, which has placed Brazil among countries with the highest efficacy in controlling HIV syndromes.1 Thanks to this public network, the results achieved by the Brazilian transplant program has surpassed all expectations, taking into consideration the amount of resources destined to the public health system. Currently, Brazil is second in absolute number of kidney transplants in the world (Table 3) (Fig 2). When the absolute number of transplants is corrected per million of inhabitants, Brazil falls to the 9th place (Fig 1). When absolute numbers of transplants are corrected to GDP per capita, Brazil becomes the country with the best performance in the world (Fig 1). The world’s largest active kidney transplant center is currently located in Sa˜o Paulo (UNIFESP, Sa˜o Paulo Federal University), which performed 427 and 507 kidney transplants in 1999 and 2000, respectively. These high numbers were made possible due to the opening of a new kidney disease facility (The Kidney and Hypertension Hospital, which opened in August 1998) dedicated mainly to kidney transplantation and related procedures. The transplant surgeons and physicians are represented by a national organization (ABTO, Associac¸˜ao Brasileira de Transplante de Orga˜os), which has recently set up a national transplant registry and is working to analyze many transplant outcome variables. Brazil, with all its shortcomings, has achieved an outstanding performance in the area of transplants, similar to what is observed for the treatment and control of AIDS. The regulation, allocation, financing, and execution of these programs have been enabled by the enlightened and active participation of the public health system. REFERENCE 1. Rosenberg: New York Times: Section 6, p 26, col 1, Jan 28, 2001
Fig 2. Total number of renal transplants performed (graphic A), and number related to GDP per capita (graphic B) and to number of inhabitants (graphic C) comparing Brazil with 10 other countries during 1999 (last data available for all the countries).
B
RAZIL is a country with 160 million inhabitants distributed within an area of 8,200,000 km2 which is divided into 27 states. The Brazilian economy is ranked eighth in the world with an annual gross domestic product (GDP) of US$ 635 billion (2000), of which only 5% (⫾US $30 billion), is allocated to the public health system. According to the latest statistics, there are about 45,000 patients registered in the Brazilian chronic dialysis program, which is fully financed by the public health system. The Health Ministry has recently regulated the creation of organ donation networks in all of the states health departments. Organ procurement organizations are primarily linked to university hospitals. Regional lists of transplant candidates in each state were established, and the organ allocation is centralized and supervised by the Attorney General’s office. The law for organ donation (Law #9434, February 1997 and law #10211, March 2001) reflects local social values, prevailing the need of required consent based on written family authorization. The diagnosis of encephalic death is legally recognized, and is based on clinical examination and at least one medical test, showing the absence of cerebral blood flow. The transplant of organs between living donors is also state-regulated, requiring judicial authorization in cases of donation between non-family members. There has been no suspected or confirmed reference to organ commercialization in the last 4 years. The number of authorized centers and transplants performed have been steadily increasing in the last years. The first intestinal transplant was performed in December 2000 at Hospital Santa Casa de Sa˜o Paulo. The
number of solid organ transplants performed in 1997 was 2,127, compared with 3,485 in 2000. The majority of transplant physicians have had their postgraduate medical training in Europe or in the United States, financed by Brazilian government agencies. Table 1 shows the number of authorized centers and the number of transplants performed in 2000, as well as the amount including hospital expenses and professional fees in US$ paid by the public health system for each procedure. Compared to the United States or Europe, the percentage of renal transplants with living donors is considerably higher, but the figures for cadaver donors are increasing. While the number of transplants with living donors appears to have reached a plateau, the numbers with cadaver donors are still growing, and it is projected to increase four-to five-fold in the coming years, as organ procurement network programs are expanded and become more organized. The distribution of kidney transplant and dialysis programs is not homogeneous among the five Brazilian political regions. As expected, the most developed regions (Southern and Southeastern) present the highest average of kidney transplants and dialysis performed (Table 2) (Fig 1). Family refusal for organ donation follows the same profile, being 30% to 40% in the previously mentioned regions, but greater than 70% for the rest of the country.
From the UNIFESP, Sa˜o Paulo, Brazil. Address reprint requests to J.O. Medina-Pestana, Rua Borges Lagoa, 960 - 11° andar, 04038-000, Sa˜o Paulo/SP, Brazil.
Table 1. Total Number of Transplanted Organs, Number of Authorized Centers, and Reimbursed Values by the Public Health System in Brazil in 2000 for Each Procedure
Organ
Living Donor
Cadaver Donor
Authorized Number of Centers
Heart Liver Pancreas Pancreas/kidney Lung Kidney
0 43 0 0 0 1631
110 437 9 37 24 1194
36 36 4 10 8 153
Number of Transplants
Value paid for Each Procedure (US$)
11,121.24 25,949.73 4,189.08 13,640.35 18,535.45 9,636.38
Source: ABTO, Decree # 92 2001-Jan-19.
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 441–443 (2002)
0041-1345/0⫺2000/$–see front matter PII S0041-1345(02)02588-5 441
442
MEDINA-PESTANA, VAZ, AND PARK
Table 2. Total Number of Kidney Transplants and Dialysis Performed Relative to Number of Inhabitants in Brazil and for Each Region in 2000
Population (Million)
Number of Kidney Transplants Performed
Number of Dialysis Performed
Number of Transplants per Million of Inhabitants
Number of Dialysis per Million of Inhabitants
169.0 72.3 25.0 11.6 39.6 13.0
2825 1769 514 244 240 58
45796 25441 8844 2542 8893 947
17 24 21 21 6 4
271 352 354 219 225 73
Brazil Southeast South West– center Northeast North Sources: ABTO, SBN.
Fig 1. Total number of kidney transplants and dialysis performed, related to number of inhabitants in Brazil and in each region in 2000.
Table 3. Total Number of Renal Transplants Performed by Country Member, per GDP per Capita, and per Million of Population, in 1999 (Last Data Available for All Countries)
Country
Population (Million)
GDP (US$ Billion)
Total Number of Transplants
Number of Transplants per Million of Population
Brazil USA Spain Mexico Germany France UK Canada Australia Portugal
172.86 275.56 39.99 100.35 82.79 59.33 59.51 31.28 19.16 10.05
558.2 9.237 647 483.3 2,603 1.697 1,254 663.3 518 385
2825 12162 2006 630 1895 1760 1432 1025 518 385
16 44 50 6 23 30 24 33 28 38
Number of Transplants per $1000 GDP per Capita
605 359 132 127 74 74 59 49 24 34
Sources: ABTO, U.S. Bureau of the Census, Handbook of International Economic Statistics, International Congress of Transplant Society, Daily Congress Newsletter, 30 August-2000, “Revista Conjuntura Economica.”
ORGAN TRANSPLANT IN BRAZIL
443
The public health system pays for more than 95% of the transplants performed in Brazil. Transplants performed in private institutions usually charge health care providers or the patient up to two times more. The public health system also provides all registered immunosuppressive drugs to all patients indefinitely, including cyclosporine A, FK 506, mycophenolate-mofetil, and antilymphocyte antibodies (OKT3, anti-IL-2R). This government-sponsored program of drug supply is similar to that found with drugs used to treat AIDS, which has placed Brazil among countries with the highest efficacy in controlling HIV syndromes.1 Thanks to this public network, the results achieved by the Brazilian transplant program has surpassed all expectations, taking into consideration the amount of resources destined to the public health system. Currently, Brazil is second in absolute number of kidney transplants in the world (Table 3) (Fig 2). When the absolute number of transplants is corrected per million of inhabitants, Brazil falls to the 9th place (Fig 1). When absolute numbers of transplants are corrected to GDP per capita, Brazil becomes the country with the best performance in the world (Fig 1). The world’s largest active kidney transplant center is currently located in Sa˜o Paulo (UNIFESP, Sa˜o Paulo Federal University), which performed 427 and 507 kidney transplants in 1999 and 2000, respectively. These high numbers were made possible due to the opening of a new kidney disease facility (The Kidney and Hypertension Hospital, which opened in August 1998) dedicated mainly to kidney transplantation and related procedures. The transplant surgeons and physicians are represented by a national organization (ABTO, Associac¸˜ao Brasileira de Transplante de Orga˜os), which has recently set up a national transplant registry and is working to analyze many transplant outcome variables. Brazil, with all its shortcomings, has achieved an outstanding performance in the area of transplants, similar to what is observed for the treatment and control of AIDS. The regulation, allocation, financing, and execution of these programs have been enabled by the enlightened and active participation of the public health system. REFERENCE 1. Rosenberg: New York Times: Section 6, p 26, col 1, Jan 28, 2001
Fig 2. Total number of renal transplants performed (graphic A), and number related to GDP per capita (graphic B) and to number of inhabitants (graphic C) comparing Brazil with 10 other countries during 1999 (last data available for all the countries).