Living Kidney Transplantation in Brazil: Unwanted Procedure of Choice in View of Cadaver Organ Shortage V.D. Garcia, C.D. Garcia, E. Keitel, M. Abbud-Filho, H.H. Campos, and J.O.M. Pestana B RAZIL IS THE LARGEST and most populous coun- try in Latin America, with 8.5 million km 2 and 172 million inhabitants. Politically and administratively Brazil is divided into five geographical regions and 27 states. There is a lot of inequality in every area, including dialysis and transplants (Table 1). There is universal public health coverage in the country since 1988. Most organ transplants programs in Brazil began in the 1960s: kidney (1964), liver (1968), heart (1968), pancreas (1968), small bowel (1968), and lung (1989). The first transplant legislation was passed in 1968, the Brazilian Transplant Society was created in 1986, and regional trans- plant organizations were established in 1980s, 1 but the National Transplant Organization was only created in 1997. 2 There are 54,000 patients on dialysis, a prevalence of 300 per million population per year (pmp/y), and about 17,000 new patients beginning dialysis each year, an incidence of 100 pmp/y. 3 There are 22,000 patients with functioning kidney grafts. The government pays for dialysis, transplant, and immunosuppressive drugs for all patients. 4 Legislation for cadaver donors requires informed consent from the family. For living donors, relatives to the fourth degree and spouses are allowed. For unrelated donors, it is necessary to obtain previous judicial authorization. The annual expenditure of the Public Health System is US$8000 million. The direct costs for dialysis are US$300 million and for transplant about US$100 million. There is a National Transplant Organization (Sistema Nacional de Transplan- tes—SNT), which is responsible for transplant policy. And there are 20 regional organizations in most of the states, which promote organ procurement and allocation. SITUATION OF KIDNEY TRANSPLANTATION There are 145 kidney transplant centers who performed progressively increasing numbers of kidney transplants in the last years; 30,000 kidney transplants have been per- formed since the beginning of activities, 35% of them from cadaveric donors. 2,5 In the last 4 years, there has been an increased rate of cadaveric donors, of kidney transplants from living or cadaver donors, and of liver and pancreas transplants, but not heart transplants (Table 2). 5 In total number of transplants, Brazil (3099 kidney transplants in 2001) is the fourth country, after United States (12,450 in 2001), China (5501 in 2000), and India (3406 in 2000). But per million population, the Brazilian rate of kidney transplants is low (18 pmp), namely, about 30% of that needed to stabilize the waiting list (60 pmp), 1 which increased from 4000 in 1992 6 to 25,100 in July 2002 (data from SNT). Of 10,000 brain-death-estimated persons (60 pmp/y), only 3890 were notified to organ procurement personnel in 2001 (39% of estimated—25 pmp), and 840 became donors (22% of notified—5 pmp). The causes of nondonation were medical contraindications (39%), familial refusal (30%), and logistic problems (9%). 5 In Brazil, now, 104 patients pmp/y are beginning dialysis each year, 3 and 4 pmp/y are returning to dialysis after graft loss; 66 pmp/y leave dialysis, 48 pmp because of death (prevalence in dialysis of 323 pmp and annual mortality of 14.9%) 3 and 18 pmp because of transplant. 5 Therefore, there is an annual increase of 42 patients pmp/y in dialysis, and the annual rate of kidney transplant needed to stabilize the waiting list is 60 pmp; the rate performed (18 pmp) being less than the annual increase (42 pmp). From the Complexo Hospitalar Santa Casa de Porto Alegre — RS (V.D.G., C.D.G., E.K.); Instituto de Urologia e Nefrologia de Sa ˜ o Jose ´ do Rio Preto—SP (M.A.-F.); Faculdade de Medicina da Universidade Federal do Ceara ´ —CE (H.H.C.); and Escola Paulista de Medicina—SP (J.O.M.P.), Porto Alegre, Brazil. Address reprint requests to Valter Duro Garcia, Rua Correa Lima 1493, 90850-250 Porto Alegre, Brazil. E-mail: vdurogarcia@terra.com.br Table 1. Demographic Data, Including Dialysis Prevalence and Number of Kidney Transplants, in Brazilian Regions Region Population (Millions) GDP per Capita (US$) Dialysis Prevalence (pmp) Kidney Transplant (pmp) North 13 1750 105 4 Northeast 43 1250 216 7 Midwest 13 2810 275 18 South 26 3200 392 23 Southeast 76 3690 416 26 Brazil 172 3258 323 18 0041-1345/03/$–see front matter © 2003 by Elsevier Science Inc. doi:10.1016/S0041-1345(03)00134-9 360 Park Avenue South, New York, NY 10010-1710 1182 Transplantation Proceedings, 35, 1182–1184 (2003)