Most of the organs offered for transplantation in Brazil between 2014 and 2021 were not used, according to a survey carried out by technicians from the Ministry of Health and researchers from the Foundation for Teaching and Research in Health Sciences (Fepecs), in Brasília, based on data from the National Transplant Center (CNT) on the supply of solid organs —heart, lung, liver, kidney and pancreas— to states and the reasons for refusal.
Of the 22,824 offers made by the CNT in the period, 14,341 (63%) were rejected by the teams that perform these surgeries. The results were published in April in an article in preprint format, not yet peer-reviewed.
More than half of the refusals (59%) were due to the donors’ clinical conditions, either because they were old, comorbidities or some type of infection, among other health problems. In 9% of cases, the organ had injuries or morphological changes that prevented it from being used.
Refusals associated with logistical problems accounted for only 6%, contrary to common sense, which usually points to them as one of the main obstacles to carrying out transplants that require the transport of organs between different locations.
A significant part of the refusals (21%) occurred for unspecified reasons, “which will be analyzed in more detail”, says nurse Patrícia Freire dos Santos, a technician from the Ministry of Health and main author of the survey, who did not evaluate the offer of organs made by the state transplant centers and their outcomes.
Preliminary data suggest that they involve problems arising from inequalities in the distribution of specialized services in this type of procedure in the country. “Some states simply don’t have transplant centers”, highlights Freire, who is a former coordinator of the CTN.
She cites the example of Amazonas, which does not perform heart transplants and, therefore, does not have its own waiting list for this organ. “Amazonian patients diagnosed with terminal heart failure are enrolled on waiting lists of states that perform this procedure”, she clarifies.
Organ transplantation in Brazil today takes place through a single waiting list, organized from state, macro-regional and national lists, in addition to other institutional mechanisms. According to Ordinance No. 2,600, of October 2009, every hospital with an Intensive Care Unit (ICU), a reference in urgency and emergency, or that already performs some type of transplant, must have a committee to identify potential donors.
Whenever a new organ is identified, the search for a compatible recipient is carried out first in the list of its state of origin — that is, a kidney from a donor in São Paulo will be offered first to patients in the state.
The regional lists are organized by the State Transplant Centers, which do not always find a compatible recipient. In some cases, the centrals themselves refuse the organ, considering it to be inadequate or for other reasons, such as lack of staff to fetch the organ or available operating room, for example. In this case, it is forwarded to the CNT, which will offer it to other states, according to the national waiting list.
“The criteria used by the local teams can vary”, explains physician Bernardo Sabat, coordinator of the Pernambucana Team for Capturing Abdominal Organs for Transplantation, who did not participate in the survey. “Some accept certain organs from older people, for example. Others are more rigorous in this regard.”
Every heart identified for transplant in Amazonas, for example, goes straight to the national list, being soon offered to other states. “It so happens that the time of ischemia of the heart [período em que o órgão pode ficar sem irrigação sanguínea e manter suas atividades fora do corpo humano] is only four hours, which prevents it from being transported to distant regions”, says Freire.
It is true that it could be offered to nearby states, such as Acre, Rondônia and Roraima, but these also do not perform organ transplants. In turn, teams from states that perform this type of procedure, mostly concentrated in the South and Southeast, choose to refuse the agency because they know that it will not arrive in good condition. “This makes the hearts of the Amazon very little used in the country.”
The problem extends to other organs, such as the lung, whose transplantation is currently only performed in the states of São Paulo, Rio de Janeiro, Paraná, Rio Grande do Sul and Ceará. With an ischemia time of four to six hours, the organ is frequently rejected when its origin is from more distant regions. Not by chance, heart and lung are among the solid organs with the highest refusal rate.
States can use aircraft from the Brazilian Air Force (FAB), national companies and state security forces to transport organs. “Even if we were able to reduce travel time, the ideal would be for them to be used in their own states of origin”, comments Freire.
For this to happen, it would be necessary to strengthen the capacity of the states to perform transplants, which would result in a greater use of the organs offered and a reduction in the waiting list in the country.
Even initially accepted organs may not be used. In the preprint published in April, Freire and his team reported that of the 8,483 (37%) organs admitted for transplantation, 6,433 (76%) were actually implanted. The other 2,050 (24%), despite initial acceptance, ended up not being used.
“It is possible that the teams identify abnormalities in the organ of the deceased donor during the surgery for its removal”, clarifies Bernardo Sabat. “In that case, they are discarded.” According to Freire, there are also situations in which the organ is compromised due to poor conservation conditions.
Discarded organs are sent for anatomopathological examination, where they are processed and analyzed. The results are presented in a report. “This document guarantees that the discarded organ was not transplanted into someone outside the waiting list”, explains Sabat. “It is also a way to prevent it from being diverted and sold.”
Despite the obstacles, the survey coordinated by Freire indicates that the supply of solid organs for distribution among the states has been growing. There were 3,375 in 2021, an increase of approximately 56% compared to 2014.
These values, however, are far from meeting the demand. According to data from the Ministry of Health, at the end of 2022, the national waiting list for solid organs had 34,830 people enrolled. In the same year, only 7,473 transplants were performed, showing the disproportion between demand and supply.
Taking into account the state lists, the number of people on the waiting list rises to 52,989, the largest contingent since 1998, according to more recent data from the Brazilian Association of Organ Transplantation (ABTO).
“The programs had to shift health professionals to care for patients with Covid-19, resulting in a drop in the number of transplants in the country”, highlights doctor Gustavo Fernandes Ferreira, president of ABTO.
Brazil performed 6,302 organ transplants in 2019, according to data from the latest Brazilian Transplant Registry, published by ABTO and which counts the organs offered by state centrals. In 2020, with the onset of the pandemic, that number dropped to 4,826 and, in 2021, to 4,777. This contingent rose again in 2022. “We are having to restructure the country’s entire capacity for organ donation and transplantation”, he comments.
Also, the number of families that do not authorize the donation of organs and tissues from relatives diagnosed with brain death, in decline since 2015, has grown again from 2021, reaching 46% in 2022, the highest percentage in the last eight years.
In general, Brazil is a reference in organ donation and transplantation, guaranteed in full and free of charge by the Unified Health System (SUS), responsible for financing and performing more than 88% of transplants in the country. About 12 thousand surgeries of this type were performed by SUS from January to November 2021. In 2020, there were about 13 thousand procedures. In absolute numbers, Brazil is the second largest transplanter in the world, behind only the United States.
There is still a lot of room to move forward. The population’s access is far from equitable and there is a lack of efficient mechanisms capable of reducing the difficulties in accessing this treatment, which affect mainly the population living in regions far from transplant centers. Training strategies have also proved to be insufficient to remedy existing deficiencies, such as the low rates of brain death notification.
“It is necessary to increase the awareness of the medical profession in pursuing the diagnosis of brain death”, emphasizes physician Paulo Manuel Pêgo-Fernandes, from the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo (FM-USP).
In Brazil, organ donation can only be made by individuals with a diagnosis of brain death attested by a specialist and confirmed six hours later with clinical and imaging examinations.
“It happens that way to shield the system and there are no questions regarding its reliability and the irreversibility of the diagnosis of death”, he explains. “It is a conservative system, which ends up erring in excess, restricting the possibilities of transplantation, since many doctors forget or fail to make this type of diagnosis because they are working in overloaded hospitals.”