Jose Medina Pestana - Brazil - Tuesday 29 - Graft and Patient Outcomes

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- The Brazilian kidney transplant program has grown substantially over the last 20 years, performing over 5,000 transplants annually now compared to less than 500 in 1990. - Brazil performs relatively well in deceased donor transplants compared to other countries, though there is still a need to reduce geographic disparities and improve outcomes for certain ethnic groups. - Living donor transplants in Brazil have also increased dramatically since the 1970s, though reliance on deceased donors remains higher than other countries.

- THE BRAZILIAN KIDNEY TRANSPLANT PROGRAM OUTCOME PROF. JOSE O. MEDINA-PESTANA, FRCS Federal University of São Paulo Head of Transplant Division Hospital do Rim e Hipertensão– São Paulo

4630 ANNUAL NUMBER OF RENAL TRANSPLANTS PERFORMED – LAST 20 YEARS 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: Brazilian Association for Organ Transplantation (ABTO ) 576 1811 1683 2912 1641 933 873 FAMILY CONSENTED DONATION FAMILY CONSENTED DONATION PRESUMED

CATEGORIES OF NON-HEARTBEATING KIDNEY DONORS (MAASTRICHT, 1995) Kootstra G et al. Transplant Proc 1995 Oct;27(5):2893 CATEGORY STATUS OF POTENTIAL DONOR I Dead upon hospital arrival II Resuscitation attempted without success III Awaiting cardiac arrest IV Cardiac arrest while brain dead

ANNUAL PROPORTION OF TRANSPLANTS WITH EXPANDED CRITERIA DONORS - HOSPITAL DO RIM E HIPERTENSÃO Expanded Criteria donor -DCE – UNOS policy (115) (210) (190) (200) (216) (291) (459) (370) 7 5 4 4 4 11 16 23 24 21 26 26 31 93 95 96 96 96 89 84 77 76 89 74 74 69

Total of effective deceased donors (pmp) Performed Deceased kidney transplant (pmp) * Source: www.tpm.org and ABTO COMPARATIVE PERFORMANCE OF ORGAN PROCUREMENT AND DECEASED KIDNEY TRANSPLANTS IN 2009 Portugal 44.8 Spain 56.0 USA 35.4 Brazil * 15.8 Spain 34.4 Portugal 31.0 USA 26.1 São Paulo 22.5 Brazil * 10.1 São Paulo 34.4

n of living donor kidneys transplants (pmp) n of living and deceased donor kidney transplants (pmp) COMPARATIVE PERFORMANCE OF LIVING AND LIVING+DECEASED KIDNEY TRANSPLANTS – YEAR 2010 Spain São Paulo Netherlands USA Brazil Spain Netherlands USA São Paulo Brazil 18.2 52.6 5.0 25.3 20.8 9.1 49.8 48.6 56.2 24.8

CHALLENGES IN THE TRANSPLANT PROGRAM ,[object Object],[object Object],[object Object],[object Object],[object Object]

ANNUAL NUMBER OF RENAL TRANSPLANTS PERFORMED AT FEDERAL UNIVERSITY OF SAO PAULO – UNIFESP ( 19 76-2010) Medina-Pestana JO. In: Clinical Transplants 2010 . p 107-26 1030

Brazilian population 193 m São Paulo State 42 m - 21% 34% of Brazilian GDP 46% of n-kidney transplantes

ANNUAL NUMBER OF RENAL TRANSPLANTS PERFORMED IN BRAZIL LIVING DONORS – ( total - 30.513) 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 1965- 1978 1979- 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Living Donor Deceased Donor REQUIRED CONSENT PRESUMED CONSENT REQUIRED CONSENT Estimated Source: ABTO 1736 hospital Comission for donation

Number of effective deceased donors (pmp) Number of deceased kidney transplants (pmp) Spain Netherlands USA São Paulo Brazil Netherland Spain USA São Paulo Brazil COMPARATIVE ANALYSIS ON THE PERFORMANCE OF ORGAN PROCUREMENT AND DECEASED KIDNEY TRANSPLANTS (2010 data) 22.5 34.4 34.4 13.0 26.1 10.1 44.8 23.3 35.4 15.8

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Jose Medina Pestana - Brazil - Tuesday 29 - Graft and Patient Outcomes

1. - THE BRAZILIAN KIDNEY TRANSPLANT PROGRAM OUTCOME PROF. JOSE O. MEDINA-PESTANA, FRCS Federal University of São Paulo Head of Transplant Division Hospital do Rim e Hipertensão– São Paulo

2. 4630 ANNUAL NUMBER OF RENAL TRANSPLANTS PERFORMED – LAST 20 YEARS 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: Brazilian Association for Organ Transplantation (ABTO ) 576 1811 1683 2912 1641 933 873 FAMILY CONSENTED DONATION FAMILY CONSENTED DONATION PRESUMED

3. CATEGORIES OF NON-HEARTBEATING KIDNEY DONORS (MAASTRICHT, 1995) Kootstra G et al. Transplant Proc 1995 Oct;27(5):2893 CATEGORY STATUS OF POTENTIAL DONOR I Dead upon hospital arrival II Resuscitation attempted without success III Awaiting cardiac arrest IV Cardiac arrest while brain dead

4. ANNUAL PROPORTION OF TRANSPLANTS WITH EXPANDED CRITERIA DONORS - HOSPITAL DO RIM E HIPERTENSÃO Expanded Criteria donor -DCE – UNOS policy (115) (210) (190) (200) (216) (291) (459) (370) 7 5 4 4 4 11 16 23 24 21 26 26 31 93 95 96 96 96 89 84 77 76 89 74 74 69

5. Total of effective deceased donors (pmp) Performed Deceased kidney transplant (pmp) * Source: www.tpm.org and ABTO COMPARATIVE PERFORMANCE OF ORGAN PROCUREMENT AND DECEASED KIDNEY TRANSPLANTS IN 2009 Portugal 44.8 Spain 56.0 USA 35.4 Brazil * 15.8 Spain 34.4 Portugal 31.0 USA 26.1 São Paulo 22.5 Brazil * 10.1 São Paulo 34.4

6. KIDNEY ALLOCATION: EQUITY ACCESS REGARDING GENDER PROFILE OF PATIENTS TRANSPLANTED AND ON WAITING LIST AT STATE OF SÃO PAULO (41 MILLION HAB) FROM 2002 TO 2010 N=25,125 N=3,943 41.1% 58.9% 40.7% 59.3% *p>0.05

7. N=25,125 N=3,943 68.8% 11.0% 18.1% 69.4% 11.0% 17.9% 2.1% 1.7% KIDNEY ALLOCATION: EQUITY ACCESS REGARDING ETNICITY PROFILE OF PATIENTS TRANSPLANTED AND ON WAITING LIST AT STATE OF SÃO PAULO (41 MILLION HAB) FROM 2002 TO 2010

8. N=25,125 N=3,943 3,9% 26.6% 14.8% 23.6% 16.0% 9.9% 3.9% 1.3% 1,0% 9.6% 24.6% 15.7% 9.5% 10.2% 24.9% 4.5% KIDNEY ALLOCATION: EQUITY ACCESS REGARDING AGE PROFILE OF PATIENTS TRANSPLANTED AND ON WAITING LIST AT STATE OF SÃO PAULO (41 MILLION HAB) FROM 2002 TO 2010

9. n of living donor kidneys transplants (pmp) n of living and deceased donor kidney transplants (pmp) COMPARATIVE PERFORMANCE OF LIVING AND LIVING+DECEASED KIDNEY TRANSPLANTS – YEAR 2010 Spain São Paulo Netherlands USA Brazil Spain Netherlands USA São Paulo Brazil 18.2 52.6 5.0 25.3 20.8 9.1 49.8 48.6 56.2 24.8

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16. ANNUAL NUMBER OF RENAL TRANSPLANTS PERFORMED AT FEDERAL UNIVERSITY OF SAO PAULO – UNIFESP ( 19 76-2010) Medina-Pestana JO. In: Clinical Transplants 2010 . p 107-26 1030

17. Brazilian population 193 m São Paulo State 42 m - 21% 34% of Brazilian GDP 46% of n-kidney transplantes

18. ANNUAL NUMBER OF RENAL TRANSPLANTS PERFORMED IN BRAZIL LIVING DONORS – ( total - 30.513) 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 1965- 1978 1979- 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Living Donor Deceased Donor REQUIRED CONSENT PRESUMED CONSENT REQUIRED CONSENT Estimated Source: ABTO 1736 hospital Comission for donation

19. Number of effective deceased donors (pmp) Number of deceased kidney transplants (pmp) Spain Netherlands USA São Paulo Brazil Netherland Spain USA São Paulo Brazil COMPARATIVE ANALYSIS ON THE PERFORMANCE OF ORGAN PROCUREMENT AND DECEASED KIDNEY TRANSPLANTS (2010 data) 22.5 34.4 34.4 13.0 26.1 10.1 44.8 23.3 35.4 15.8

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Editor's Notes

DEVELOPING COUNTRIES HAS MOST EVERYTHING IS TO BE DONE OR TO BE LARGELY IMPROVED – ANOTHER PECULIARITY IS THAT INDIVIDUAL ACTITUDES MAKE STRONGER DIFERENCE THAN IN OTHER COUNTRIES WHERE INSTITUITIONS ARE CONSOLIDATED
In the last 5 years we could maximize our performance We are not promoting new forms of living donors like paired exchange, or altruistic donors or unrelated donors
THOSE ARE CATEGORIES THAT ARE RISKY AND CARRIES THE POSSIBILITY TO MACULATE THE CONFIDENCE IN THE TX PROGRAM - THE BENEFITS ARE NOT BIG ENOGH TO JUSTIFY THE RISKS. THE CARDIAC ARREST WHILE BRAIN DEAD IS THE ONLY SITUATION THAT IS ACCEPTABLE
PRIORITY TO ORGAN DONORS IN CASA THEY NEED
Este slide mostra a progressão do numero anual de transplantes realizados com doador vivo e falecido – observamos que cresce o numero de transplantes com doador vivo em função da maior inserção do assunto na comunidade, menor resistencia a doação e aprimoramento do sistema de captação de órgãos. Realizamos cerca de 40 transplantes combinados rim e pâncreas. Tambem realizamos cerca de 70 transplantes pediátricos anualmente. Há 10 anos este é o maior centro de transplantes renais do mundo ANIMAR ESTE IGUAL O BRASIL
NETHERLANDS HAS LESS DONORS THAN USA OR SPAIN - FEWER YOUNG PEOPLE ARE DYING AS A RESULT OF SEVERE INJURY OR CEREBROVASCULAR EVENT AND IMPROVEMENT IN THE MANAGEMENT OF THOSE CONDITIONS - SEVERE BRAIN INJURY

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Editor's Notes