Here's a call to allow kidney exchange in Brazil, to address the shortage of kidney transplants there.
Increasing transplantability in Brazil: time to discuss Kidney Paired Donation, by Juliana Bastos, David José de Barros Machado, and Elias David-Neto, Braz. J. Nephrol. • 17 Dec 2021 • https://doi.org/10.1590/2175-8239-JBN-2021-0141
"According to the 2020 Brazilian Dialysis Census, an estimated 45 thousand new patients started dialysis in the last year, totaling more than 144 thousand patients undergoing this therapy in the country. The estimated gross mortality of the patients varied between 18 and 20% in period 2016-2019.
"The number of KT performed in Brazil is increasing, although it is still less than half of the annual need estimated by the Brazilian Association of Organ Transplantation. Thus, the number of patients on the waitlist grows annually, having surpassed 26 thousand in 2020.
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"Brazilian legislation does not contemplate the possibility of KPD. Law no. 9.434 from February 4, 1997 states that the removal of tissues, organs and body parts of a person in exchancge for payment or promise of reward, as well as for frivolous motives, constitutes a criminal offence37. Although organ exchange could be understood as a "promise of reward", it is evident that the law seeks to prohibit the commercialization of organs. In February 2020, a bill was implemented (95/2020) to add to the aforementioned law the following article: "For the effects of this Law, it shall not be considered commercialization the reciprocal donation of organs and tissues (exchange transplantation), so long as it does not involve any monetary benefits stemming from the act"; among other alterations, legitimizing the legality of KPD38. Similar legal obstacles have been overcome in other countries to encourage donor exchange28. It is important to remember that in KPD, all donors are non-relatives. According to national legislation, they must have prior legal approval, granted by the hospital ethics committee and the organ procurement center.
"In 2018, the Brazilian Federal Council of Medicine issued a statement opposing the implementation of KPD in Brazil39. The document stated, among other things, that KPD was a controversial concept, still in development and implemented only in a few countries; that it would incur high costs due to the logistical difficulties of the country, with its continental dimensions; that the increase in CIT could affect graft survival; that it would benefit only "a minimal part of the population"; and that it would jeopardize the credibility of the transplant program in Brazil39, an analysis that must be re-evaluated in light of currently reported data.
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"We believe we have clarified in this review that, contrary to what has been said, KPD programs are no longer "controversial concepts in programs under development"(39 )but robust programs that are used almost everywhere in the world and show excellent results, comparable to other LDKT, despite focusing on a population with higher risk and a possible increase in CIT. Another critical issue relates to the main part of the affected population, the highly sensitized people who are sometimes referred to as non-transplantable. A national study in a single center estimated an increase of 7% in the total number of transplants with KPD (which is consistent with the results in the aforementioned countries), and an increase of more than 70% in the number of transplanted recipients with PRA > 80%41. If those figures were extrapolated nationally, for example, this would mean an increase of 420 LDKT in 2019.
"Thus, there seems to be no reason for Brazil not to join KPD, even if initially only locally and then implemented regionally/nationally according to the acceptance of the centers and the necessary logistical adaptation.
"At the HCFMUSP, KPD research seeks to determine the percentage of living donors rejected due to incompatibility and are eligible for KPD and to determine how many recipients would benefit from such a strategy. As part of this program, the first kidney exchange was carried out in Brazil in March 2020 and 28 additional pairs are currently under evaluation.
"Nowadays, all the leading countries in world are practicing this procedure and continue to develop it to include more recipients thanks to their excellent results.
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"Finally, it is essential to emphasize that KPD also benefits those on the waitlist who do not have a donor, as it reduces the number of recipients waiting for an organ from a deceased donor. We believe that the Brazilian transplant program is mature enough to take up the challenge of starting a KPD program, primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor."
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