Organ Donation in Latin America

The psychology, legality, ethics and medical aspects of organ donation by minors

Any individual who has not attained the chronological age of legal majority as per national law is termed a minor. The concept of living donation (LD) has always been a subject of ethical debate and further compounding the controversy is the question of LD by minors. The decision for a minor to donate poses a special challenge as it involves a close family unit of parent-child relationship. Such an emotionally loaded situation wherein questions of attachment, perceived duties, moral obligation are likely to cloud a truly informed consent on the part of the minor to donation, who may find themselves in a vulnerable position. Furthermore, a minor's cognitive ability to comprehend the gravity of LD and when required defy parental coercion need to be elucidates before a minor is accepted for LD. Experts have set out stringent conditions which need to be met prior to the exceptional circumstance that a minor is considered for organ donation. Such donations should require parental permission, child's assent and the involvement of a paediatric-trained donor advocacy team. This article debates the question of minors acting as live donors from ethical, medical, psychosocial and legal viewpoints with an aim to present internationally defined circumstances when a minor may morally participate as a LD, thereby laying the foundation for future deliberations in this regard using traditional metrics to juxtapose divergent courses of action.

International pediatric transplant association (IPTA) guidance on developing and/or expanding pediatric solid organ transplantation programs in low- and middle-income countries

Pediatric solid organ transplantation (SOT) is a preferred treatment for medically suitable children with end-stage organ failure. Still, many of them have no access to transplantation owing to socioeconomic constraints or lack of transplant facilities in low- and middle-income countries (LMIC). Establishing pediatric SOT programs in LMIC offers children the opportunities to receive transplant care in more familiar home environments as well as help curtail transplant tourism and improve transplant outcomes as pediatric transplantation would be performed ethically and legally. The International Pediatric Transplant Association (IPTA) is a professional organization aiming to promote safe, ethical, and high-quality pediatric transplantation worldwide. This society paper describes major obstacles to pediatric SOT in LMIC and provides guidance on developing and/or expanding pediatric SOT programs in such countries. We also summarize available resources from the IPTA Outreach Program to help establish and support pediatric SOT programs in LMIC.

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

International Population Study in Spain, Cuba, and the United States of Attitudes Toward Organ Donation Among the Cuban Population

Cuban immigrants constitute an important group in both the United States and Spain, with different behaviors toward organ donation having been described among the different Latin American nationalities. We analyzed the attitude toward organ donation among the Cuban populations in Cuba, Spain, and Florida. The study population was Cuban immigrants over 15 years of age residing in Cuba, Spain, and Florida, with samples randomly stratified by age and sex. A validated questionnaire on psychosocial aspects of organ donation (PCID-DTO Rios) was used. Census was used as the sampling base in all 3 countries; however, additionally, in Spain and the United States (Florida), we sought the support of immigration support associations to determine the Cuban population without legal documentation. The questionnaire was completed anonymously and self-administered. The completion rate of the study was 74% (4123/5574) among 424 surveyed in Spain, 1224 in Florida, and 2475 in Cuba. The attitude in favor of donating their own organs upon death was 60.6% of those surveyed in Spain, 37.6% in Florida, and 68.9% in Cuba, or 58% of the global sample. Multivariate analysis showed that country of residence was an independent factor associated with attitude toward organ donation (odds ratio, 1.929). Other factors associated with attitude were sex, educational level, performance of prosocial activities, knowledge of the brain death concept, religion, the couple's opinion toward donation, fear of mutilation after donation, and attitude toward manipulation of the body after death. The attitude toward organ donation among Cubans in their country of origin and immigrants in Spain was similar, being significantly different from those who emigrate to Florida, where the attitude is much less favorable.

Assessment of Knowledge and Attitudes Toward Organ Donation Among School Teachers: First National Survey Study

BACKGROUND AND AIM

The most important factors affecting organ donation are socioeconomic, educational, and cultural factors. The aim of this study was to evaluate the attitudes, knowledge levels, and behaviors of school teachers toward organ donation METHODS: This study surveyed 2400 school teachers working in official public schools. Turkey was divided into 26 regions based on the similarity of social, economic, and geographic factors identified by the Turkish Statistical Institute. Teachers were distributed equally in the city center and towns based on population. The survey procedures were carried out using computer-assisted personal interviewing.

RESULTS

Among teachers, 89.6% had a bachelor's degree and 8.5% had a master's degree. In addition, 32.5% worked in primary schools, 33.1% worked in secondary schools, and 34.4% worked in high schools. Furthermore, 0.7% had donated an organ; 66.5% were not considering organ donation in the future, of whom 9.0% indicated religion as the reason for not donating an organ, and 34.8% did not indicate any reason. In addition, 96.6% considered organ donation to be proper behavior for humanity and 68% believed that organ donation is appropriate in religious terms.

CONCLUSIONS

This study showed that school teachers have inadequate knowledge and attitudes toward organ donation. Encouraging children and adolescents to make a well-informed decision about organ donation and to register this choice will depend largely on preparing school teachers with adequate knowledge and motivation toward creating generations with a positive attitude toward organ donation.

Prevalence and Potential Correlates of Family Refusal to Organ Donation for Brain-Dead Declared Patients: A 12-Year Retrospective Screening Study

BACKGROUND

This study was designed to determine prevalence and potential correlates of family refusal to organ donation for patients declared brain dead thorough a 12-year retrospective data analysis.

METHODS

Of 111 cases declared brain dead by our hospital within a 12-year period between 2008 and 2019, a total of 82 potentially brain-dead organ donors were included in this retrospective study. Data on sociodemographic characteristics, length of intensive care unit stay, cause of death, decedent's wishes, interview time, family decision, and reasons for refusal were recorded.

RESULTS

The rate of family refusal to organ donation was 51.2% and because of religious concerns (64.3%) in most of cases. The likelihood of family consent to organ donation was significantly higher for an adult vs a child (60.0% vs 25.9%, P = .004) and for a schooler and adolescent age vs a younger child (55.6 vs 22.5%, P = .004). Patients who were declared brain dead after nontraumatic intracranial hemorrhage (60.4%) vs encephalitis (18.2%) had higher rates of family consent to organ donation (P = .023).

CONCLUSIONS

In conclusion, our findings revealed family refusal to organ donation in at least half of cases and higher likelihood of family consent to organ donation depending on age of patient (adult vs children) and cause of death (brain injury vs encephalitis). The religious concerns and distrust in the health care system were the 2 major causes of family refusal, whereas no significant difference was noted across different family refusal reasons in terms of sociodemographic factors, length of intensive care unit stay, awareness of decedent's wishes, or time of family interview.

Rapid or Slow Time to Brain Death? Impact on Kidney Graft Injuries in an Allotransplantation Porcine Model

The use of donors deceased after brain death (DBD) with extended criteria in response to the shortage of grafts leads to the removal of more fragile kidneys. These grafts are at greater risk of not being grafted or delayed function. A better knowledge of the pathophysiology of DBDs would improve this situation. There is a difference between the results from animal models of DBD and the clinical data potentially explained by the kinetics of brain death induction. We compared the effect of the induction rate of brain death on the recovery of post-transplant renal function in a pig model of DBD followed by allografts in nephrectomized pigs. Resumption of early function post-transplant was better in the rapidly generated brain death group (RgBD) and graft fibrosis at three months less important. Two groups had identical oxidative stress intensity but a greater response to this oxidative stress by SIRT1, PGC1-α and NRF2 in the RgBD group. Modulation of mechanistic target of rapamycin (mTOR) stimulation by NRF2 would also regulate the survival/apoptosis balance of renal cells. For the first time we have shown that an allostatic response to oxidative stress can explain the impact of the rapidity of brain death induction on the quality of kidney transplants.

A comparative study of renal care in Brazil and Mexico: hemodialysis treatment from the perspective of ESRD sufferers

Renal replacement therapy is the indicated treatment for individuals with chronic kidney disease (CKD) to survive. However, not all sick people have access to the same treatment. This study compares renal care in two developing countries with different health systems. Specifically, it explores hemodialysis treatment from the perspective of low-income individuals. A qualitative, comparative study was performed in Brazil and Mexico. Using purposive sampling, the research was based on open-ended interviews with nineteen participants with kidney failure undergoing hemodialysis treatment in public hospitals and ten relatives. According to our results, Brazilian participants perceived hemodialysis care as satisfactory because of health personnel courtesy as well as free access to dialysis treatment, prescription drugs, hospitalization and transportation. However, they reported deficiencies in the care they were receiving due to shortages of specialists, prescription drugs, laboratory tests and transportation. Mexican participants, in contrast, highlighted the catastrophic costs of medical care because they had no free access to renal therapy, nor adequate financial resources. Our findings suggest that low-income Brazilian CKD sufferers experience renal care differently, as they are more satisfied and face less obstacles with hemodialysis compared with those of Mexico. More studies on the topic are needed.

Slow induction of brain death leads to decreased renal function and increased hepatic apoptosis in rats

Background

Donor brain death (BD) is an independent risk factor for graft survival in recipients. While in some patients BD results from a fast increase in intracranial pressure, usually associated with trauma, in others, intracranial pressure increases more slowly. The speed of intracranial pressure increase may be a possible risk factor for renal and hepatic graft dysfunction. This study aims to assess the effect of speed of BD induction on renal and hepatic injury markers.

Methods

BD induction was performed in 64 mechanically ventilated male Fisher rats by inflating a 4.0F Fogarty catheter in the epidural space. Rats were observed for 0.5, 1, 2 or 4 h following BD induction. Slow induction was achieved by inflating the balloon-catheter at a speed of 0.015 ml/min until confirmation of BD. Fast induction was achieved by inflating the balloon at 0.45 ml/min for 1 min. Plasma, kidney and liver tissue were collected for analysis.

Results

Slow BD induction led to higher plasma creatinine at all time points compared to fast induction. Furthermore, slow induction led to increased renal mRNA expression of IL-6, and renal MDA values after 4 h of BD compared to fast induction. Hepatic mRNA expression of TNF-α, Bax/Bcl-2, and protein expression of caspase-3 was significantly higher due to slow induction after 4 h of BD compared to fast induction. PMN infiltration was not different between fast and slow induction in both renal and hepatic tissue.

Conclusion

Slow induction of BD leads to poorer renal function compared to fast induction. Renal inflammatory and oxidative stress markers were increased. Liver function was not affected by speed of BD induction but hepatic inflammatory and apoptosis markers increased significantly due to slow induction compared to fast induction. These results provide initial proof that speed of BD induction influences detrimental renal and hepatic processes which could signify different donor management strategies for patients progressing to BD at different speeds.

Pediatric liver transplantation in Latin America: Where do we stand?

LT started in LA in 1968, and pediatric LT records are available starting in the 1990s. Currently, eight countries perform pediatric LT in LA. Registries by national organizations fail to report robust data on pediatric LT. The aim of this paper was to report on the pediatric LT activity in LA. Data were gathered retrospectively through information available in the national registries websites and from local centers. Of the eight countries that report pediatric LT activity, Brazil, Argentina, Mexico, and Colombia have adequate registries of the numbers of LT performed. These countries concentrate most of the activity for pediatric LT. A total of 4593 pediatric LT were reported in LA. Websites for national organizations do not provide open data on post-transplant survival rates or waiting list mortality. The information herein is based on reports by local centers. Overall, survival from select centers is similar to that reported on North American and European registries, between 80 and 90% in the first year post-transplant. In conclusion, pediatric LT activity is growing in LA, especially in Brazil and Argentina. However, the lack of an appropriate LA registry restricts the assessment of quality and therefore restricts interventions aimed at quality improvements in different regions.

Inequalities in the Access to Advanced Therapy in Heart Failure

At present, heart failure (HF) is a worldwide problem, characterized by a high morbidity and mortality. In industrialized countries or regions, such as the United States, Canada, and western European countries, HF has a prevalence of 1.5% to 2.7%. Chile represents a growing economy in Latin America; however, the relatively high cost of more advanced therapies, in addition to other variables (ie, adequate and timely evaluation by HF specialists), makes access difficult for patients with HF. In this article, the authors review the principal difficulties in accessing advanced HF therapies in Chile, as a model of developing country.

The need for kidney transplantation in low- and middle-income countries in 2012: an epidemiological perspective

Epidemiological and demographic transitions are shifting the burden of modifiable risk factors for chronic and end-stage kidney disease to low- and middle-income countries (LMIC). This shifting burden of disease--combined with economic transitions and health system reforms--has led to the rapid growth of dialysis populations in LMIC including Malaysia, Tunisia, Turkey, Chile, Mexico, and Uruguay. Yet, compared to 1.5 million on dialysis in LMIC, only approximately 33,000 kidney transplants were performed in 2012. Reasons include health system factors (personnel, infrastructure, system coordination, and financing) and cultural factors (public and professional attitudes and the legal environment). The size of the dialysis populations, however, is generally a poor indicator of the potential need for kidney transplantation in LMIC. Population needs for kidney transplantation should instead be assessed based on the epidemiology of the actual underlying burden of disease (both treated and untreated), and the costs and benefits of treatment as well as prevention strategies relative to existing service provision. Here, we review current data on the global burden of end-stage kidney disease and the distribution of major risk factors, and compare this to access to kidney transplantation in 2012.

The Latin American population in Spain and organ donation. Attitude toward deceased organ donation and organ donation rates

The Latin American (LA) population has similarities with the Spanish population which makes its integration into Spanish society easier.

OBJECTIVE

to analyze the attitude toward organ donation among Latin American citizens residing in Spain, to determine the psychosocial variables which affect this attitude, and to examine the correlation between donation rates of LA citizens in Spain and in their countries of origin. A random sample of LA residents in Spain was taken and stratified according to the respondent's nationality (n = 1.314), in the year 2010. Attitude was assessed using a validated questionnaire (PCID-DTO Dr Rios). The survey was self-administered and completed anonymously.

STATISTICAL ANALYSIS

Student's t-test, the χ(2) test, and logistic regression analysis. There was a 94% completion rate (n = 1.237). Attitude toward donation was favorable in 60% of cases (n = 745), 12% (n = 145) were against, and 28% (n = 347) were undecided. The following variables were associated with attitude toward donation: sex (P = 0.038), level of formal education (P < 0.001), country of origin (P = 0.002), attitude toward the donation of a family member's organs (P < 0.001), having discussed donation with the family (P < 0.001), carrying out prosocial activities (P = 0.025), attitude toward cremation of the body (P < 0.001), attitude toward burial of the body (P < 0.001), attitude toward having an autopsy carried out (P < 0.001), previous experience of the organ donation and transplantation process (P < 0.001), fear of mutilation after donation (P < 0.001), knowledge that the Church has a positive attitude toward organ donation and transplantation (P < 0.001), knowledge of one's partner's attitude toward organ donation (P < 0.001), and a belief that one might need a transplant in the future (P < 0.001). The donation rates in this population group in Spain are higher than those recorded in their countries of origin (55.76 vs. <10 pmp; P < 0.001). The attitude toward organ donation among LA citizens residing in Spain is slightly worse than that reported in the native Spanish population and is determined by many psychosocial factors. The donation rates of LA citizens in Spain are higher than those in their countries of origin.

Viviendo con trasplante renal, sin protección social en salud: ¿Qué dicen los enfermos sobre las dificultades económicas que enfrentan y sus efectos?

El trasplante es el mejor tratamiento para la insuficiencia renal, de acuerdo con la biomedicina; sin embargo, es una tecnología cara. Este artículo examina las dificultades económicas y sus efectos en personas con trasplante renal, pero sin protección social en salud. Para el estudio se desarrolló una investigación cualitativa en México. Participaron 21 pacientes trasplantados; se aplicaron entrevistas semiestructuradas, y se realizó un análisis de contenido. Los resultados muestran que las personas enfermas enfrentan dificultades económicas, debido a los costes de las terapias renales, particularmente, de las medicinas. Todo ello tiene efectos negativos: las personas con pocos recursos dejan el tratamiento con medicamentos, abandonan el protocolo, no asisten a las consultas médicas y disminuyen los gastos domésticos, incluyendo el de alimentación; además de suponer una merma en los ingresos familiares. En conclusión, el trasplante renal empobrece a las personas enfermas sin protección social en salud; es urgente la implementación de un sistema de protección social para esta población.

Liver transplantation in Latin America: the state-of-the-art and future trends

We reviewed the current status of liver transplantation in Latin America. We used data from the Latin American and Caribbean Transplant Society and national organizations and societies, as well as information obtained from local transplant leaders. Latin America has a population of 589 million (8.5% of world population) and more than 2,500 liver transplantations are performed yearly (17% of world activity), resulting in 4.4 liver transplants per million people (pmp) per year. The number of liver transplantations grows at 6% per year in the region, particularly in Brazil. The top liver transplant rates were found in Argentina (10.4 pmp), Brazil (8.4 pmp), and Uruguay (5.5 pmp). The state of liver transplantation in some countries rivals those in developed countries. Model for End-Stage Liver Disease-based allocation, split, domino, and living-donor adult and pediatric transplantations are now routinely performed with outcomes comparable to those in advanced economies. In contrast, liver transplantation is not performed in 35% of Latin American countries and lags adequate resources in many others. The lack of adequate financial coverage, education, and organization is still the main limiting factor in the development of liver transplantation in Latin America. The liver transplant community in the region should push health care leaders and authorities to comply with the Madrid and Istambul resolutions on organ donation and transplantation. It must pursue fiercely the development of registries to advance the science and quality control of liver transplant activities in Latin America.

An international comparison of deceased and living organ donation/transplant rates in opt-in and opt-out systems: a panel study

BACKGROUND

Policy decisions about opt-in and opt-out consent for organ donation are based on limited evidence. To fill this gap we investigated the difference between deceased and living organ donation rates in opt-in and opt-out consent systems across a 13 year period. We controlled for extensive covariates and estimated the causal effect of consent with instrumental variables analysis.

METHOD

This panel study used secondary data analysis to compare organ donor and transplant rates in 48 countries that had either opt-in or opt-out consent. Organ donation data were obtained over a 13-year period between 2000 and 2012. The main outcome measures were the number of donors, number of transplants per organ and total number (deceased plus living) of kidneys and livers transplanted. The role of consent on donor and transplant rates was assessed using multilevel modeling and the causal effect estimated with instrumental variables analysis.

RESULTS

Deceased donor rates (per-million population) were higher in opt-out (M = 14.24) than opt-in consent countries (M = 9.98; Β = -4.27, 95% confidence interval (CI) = -8.08, -0.45, P = .029). However, the number of living donors was higher in opt-in (M = 9.36) than opt-out countries (M = 5.49; B = 3.86, 95% CI = 1.16, 6.56, P = .006). Importantly, the total number of kidneys transplanted (deceased plus living) was higher in opt-out (M = 28.32) than opt-in countries (M = 22.43; B = -5.89, 95% CI = -11.60, -0.17, P = .044). Similarly, the total number of livers transplanted was higher in opt-out (M = 11.26) than opt-in countries (M = 7.53; B = -3.73, 95% CI = -7.47, 0.01, P = .051). Instrumental variables analysis suggested that the effect of opt-in versus opt-out consent on the difference between deceased and living donor rates is causal.

CONCLUSIONS

While the number of deceased donors is higher than the number of living donors, opt-out consent leads to a relative increase in the total number of livers and kidneys transplanted.

Increasing liver transplantation waiting list mortality: a report from the Australian National Liver Transplantation Unit, Sydney

BACKGROUND

We aimed to describe the demand for liver transplantation (LTx) and patient outcomes on the waiting list at the Australian National Liver Transplantation Unit, Sydney over the last 20 years.

METHODS

We performed a retrospective analysis with the data divided into three eras: 1985-1993, 1994-2000 and 2001-2008.

RESULTS

The number of patients accepted for LTx increased from 320 to 372 and 548 (P < 0.001) with the number of LTx being performed increasing from 262 to 312 and 452 respectively (P < 0.001). The median adult recipient age increased from 45 to 48 and 52 years (P < 0.001) while it decreased in children from 4 to 2 and 1 years respectively (P = 0.001). In parallel, the deceased donor offers decreased from 1003 to 720 and 717 (P < 0.001). Methods to improve access to donor livers have been used with the use of split livers, extended criteria and non-heart beating donors, resulting in increased acceptance of deceased donor offers by 65% and 115% in the second and third eras when compared with the first era (P < 0.001). However, the adult median waiting time has increased from 23 to 41 and 120 days respectively (P < 0.001). This was associated with increased adult mortality on the waiting list from 23 to 40 and 122 respectively (P < 0.001).

CONCLUSIONS

Despite the increasing proportion of donor offers being used, the waiting list mortality is increasing. A solution to this problem is an increase in organ donation to keep pace with the escalating demand for LTx.

The rate of organ and tissue donation after brain death: causes of donation failure in a Romanian university city

AIM

To evaluate the rate of organ donation after brain death in 2 tertiary care medical centers of a Romanian city, the reasons for donation exclusion (donors or organs), and identification of potential strategies for improvement.

MATERIAL AND METHODS

The study retrospectively evaluated potential organ donors with brain death (BD) who were identified between January 2006 and June 2009 in an university city of Romania. The potential donors were considered patients with severe intracranial pathology and clinical signs of brain death who were reported to the regional transplant team. The BD declaration was completed according to the Law of Transplant Procurement and Management in Romania: clinical signs of brain stem death, apnea test, and flat EEG, criteria that must be fulfilled twice at a 6 hour interval. According to Romanian law, family consent is mandatory for organ harvesting.

RESULTS

The study included 35 potential donors, of whom 22 had a declaration of BD. Failure of potential donors to be declared BD was caused by positive viral serology (n = 7), improvement in clinical status (n = 2), sudden cardiac arrest (n = 2), and refusal of physician in charge (n = 2). Among the 22 with a BD declaration, organ harvesting was performed in only 12 cases due to family refusal (n = 10). In 4 cases the planned organ harvesting was aborted owing to unexpected intraoperative findings.

DISCUSSION

Factors that generate the low rate of organ procurement include local organizational particularities, a high rate of viral infections, poor education, (both of lay persons and of medical personnel), restrictive criteria for BD declaration and the mandatory need for family approval.

CONCLUSION

The rate of donation in this university city of Romania is still low. Several strategies have been identified to improve the rate: better identification of potential donors, better management, and education of the public and of health care personnel.

Global trends in the rates of living kidney donation

As the worldwide prevalence of end-stage renal disease increases it is important to evaluate the rate of living kidney donation in various countries; however there is no comprehensive global assessment of these rates. To measure this, we compiled data from representatives, renal registries, transplant networks, published reports in the literature, and national health ministries from 69 countries and made estimates from regional weighted averages for an additional 25 countries where data could not be obtained. In 2006, about 27,000 related and unrelated legal living donor kidney transplants were performed worldwide, representing 39% of all kidney transplants. The number of living kidney donor transplants grew over the last decade, with 62% of countries reporting at least a 50% increase. The greatest numbers of living donor kidney transplants, on a yearly basis, were performed in the United States (6435), Brazil (1768), Iran (1615), Mexico (1459), and Japan (939). Saudi Arabia had the highest reported living kidney donor transplant rate at 32 procedures per million population (pmp), followed by Jordan (29), Iceland (26), Iran (23), and the United States (21). Our study shows that rates of living donor kidney transplant have steadily risen in most regions of the world, increasing its global significance as a treatment option for kidney failure.