High-volume kidney transplantation in a developing economy.

The Forum article by Medina-Pestana provides evidence that, with conviction and considerable organizational effort, high-quality kidney transplantation services can be successfully applied within a developing economy. He has described a sustained effort including training of physicians and surgeons (usually in the United States or Europe), as well as governmentand university-based support for the development of their program. With talent and outstanding organizational skills, their program has succeeded in listing 70% of patients with renal failure for transplantation, performing more than 650 kidney transplantation procedures at the Hospital do Rim in São Paulo, Brazil, during 2004. They also recognized the critical need to support organ donation as a central component of their plan. The regional Organ Procurement Organization covers 7 million people, and organ donation activity increased from 43 yearly donors during 1999 to 104 in 2004. Additionally, the remarkable success of the living-donor program, comprising more than twice the deceased donor transplant volume, deserves special attention. Again, an effective and efficient organizational infrastructure seems to have been established. This includes a dedicated pretransplantation team of physicians, social workers, psychologists, and appropriate administrative support staff to evaluate all patients, setting a transplant date within 30 – 60 days from the initial intake visit. The result has been remarkable, with 443 living kidney donations in 2004. Recognizing that living-donor organ donation can offer the potential to impact the critical donor organ shortage, pressure in this area has mounted worldwide. Ethical concerns about justice and human rights raised in this regard led the World Health Assembly of the World Health Organization, at its eighth plenary meeting in Geneva, to pass a new resolution, updating its 1991 position (1). Notably, living donation was discouraged in the 1991 resolution, but the 2004 document “urges that Member States. extend the use of living kidney donations when possible” (1). The resolution additionally called for implementation of effective national oversight, cooperation in formulating recommendations and guidelines to harmonize global practices, consideration for the organization of ethics commissions, and the undertaking of measures to protect the poorest and most vulnerable groups from “transplant tourism” and sale of tissues and organs (1). Similarly, the Ethics Committee of the Transplantation Society convened a forum on the care of the live kidney donor in Amsterdam, The Netherlands, in April 2004. They developed a consensus statement on proper and ethical standards to guide appropriate care of living kidney donors (2). Medina-Pestana discussed many of the ethical considerations guiding their living-donor program, and their process was consistent with a principled and ethical approach. As described, national law in Brazil limits donation to related (first through fourth degree) individuals or spouses. No unrelated or exchange donations are permitted. Individuals must reach 21 years of age before donation is legally permitted, and the program discourages donation by those who are younger than 30 years of age. There is no upper age limit, but the functional requirements are well defined. These include a minimum measured 24-hour creatinine clearance of 80 mL/ min per 1.73 m. Donor candidates who are more than 50 years of age undergo routine coronary angiography, with results driving the discussion regarding surgical risk. Although potential long-term consequences after kidney donation, especially in view of progressively longer life expectancy, were briefly mentioned, discussion about issues such as progressive coronary disease, hypertension, diabetes, or obesity among donors over time was not considered in detail. Overall, outcome statistics provided evidence that this represents a very high-quality effort. The immunosuppression regimen consisted primarily of cyclosporine or tacrolimus with azathioprine and prednisone, with mycophenolate mofetil or mycophenolic acid sodium restricted to patients with elevated panel-reactive antibodies, undergoing repeat transplantation, and at high risk of delayed graft function. Fewer than 10% of recipients received any form of induction therapy, and sirolimus was used only for patients involved in clinical trials or patients in whom calcineurin inhibitors were avoided or minimized. The incidence of acute rejection during the initial posttransplantation year was 22% for recipients of living related-donor organs, 27% for recipients of living unrelated-donor organs, and 26% among recipients of deceased-donor allografts. Patient and graft survival for recipients of living-donor transplants was reasonable (96.3% and 87.3%, respectively, at 3 years), but 3-year results for deceased-donor recipients were on the low side (86.7% and 71.3%, respectively). There appeared to be a very high rate of delayed graft function ( 60%). One might speculate that a more liberal approach to use of induction, plus an alternative maintenance regimen substituting for azathioprine, might result in reduction in the incidence of acute rejection, potentially with improved patient and graft survival (3). Although considerable infrastructure is required to establish a transplantation service, and this must be considered within the context of a larger global health care imperative, it is evident that kidney transplantation improves quality of life and extends longevity (4). In his 2002 Presidential Address to the Transplantation Society, Groth (5) observed that the steady increase in global transplantation activity should be recognized and facilitated. He called for establishing a global worldwide partnership, seeking to make organ transplantation available as a patient service. This global partnership has Section of Organ Transplantation and Immunology, Yale University School of Medicine, New Haven, CT. Address correspondence to: Marc I. Lorber. Received 5 January 2006. Accepted 17 January 2006. Copyright © 2006 by Lippincott Williams & Wilkins ISSN 0041-1337/06/8111-1521 DOI: 10.1097/01.tp. 0000214936.77784. eb