Brazil Developing Solutions for Handling Limited Liver Transplantation Resources

Karen Dente, MD

June 26, 2007

June 26, 2007 (Rio de Janeiro) — At the 13th Annual International Congress of the International Liver Transplantation Society in Rio de Janeiro, experts highlighted the current problems that Brazil is facing in dealing with limited resources in securing liver organs for transplantation — a problem not unique to Brazil.

As in many other areas of the world, there is currently a shortage of organs in Brazil, with an estimated 3800 organs needed per year. To fairly match organs with recipients, organ allocation must be regulated.

In Brazil, however, liver transplantation has a history of being unregulated. It was only in 1997, when a more stable Brazilian government took over, that liver organ allocation was systemized by the creation of a central list initially based on chronological criteria for waiting. Since July 2006, organ allocation has been changed to reflect the model for end-stage liver disease (MELD) scoring system, as it has successfully been implemented in the United States.

The Brazilian implementation of MELD to allocate organs to recipients was an attempt to ensure that livers are prioritized for the sickest patients, independent of their waiting time. However, some believe that because extended criteria are applied to patients with malignant disease (diagnosis of hepatocellular carcinoma automatically adds 4 points to the MELD score, according to the model), a lot of patients with lower MELD scores who are in need of a transplant wait in vain for an organ, often dying while still on the waiting list. In fact, the introduction of the MELD allocation system in Brazil has not resulted in a reduction of waiting list mortality, which hovers around 20% annually.

Children, though, are at an advantage with the MELD system, as their score is multiplied by 3, thereby moving them up on the waiting list. "Brazil dislikes MELD because the distribution is not equal and gives preference to children," Fernando Bobadilla, MD, a pediatrician working to improve the treatment options for children with liver disease at Guillermo Almenara National Hospital, in Lima, Peru, told Medscape.

Peru does not currently have a MELD allocation system because of the small number of donor livers used and transplants performed overall. "Children with liver disease can often die within a year, and many transplant centers don't like this since they are interested in doing adult transplantations," Dr. Bobadilla said.

"The first thing we have to think about when matching organs is the condition of the recipient," said Eduardo Carone, MD, of Hospital Sirio Libanes, Sao Paulo, Brazil. This has led patients with low MELD scores having chances of receiving a transplant that are currently "very, very low."

The reality of the socioeconomic situation in Brazil makes transplantation an area ripe for exploitation and social injustice: The average family income of patients receiving a transplant is around US$600, and more than half of all transplant recipients are illiterate. This is also true of many other areas in the world that face funding problems for liver transplantation and that are lacking the infrastructure necessary to coordinate the complexities involved in performing a transplant.

The average cost for a transplant in Brazil is US$27,000, with living donor transplants averaging US$32,000 dollars. In Brazil, however, the costs of transplantation are supported almost entirely by public funding, which accounts for about 95% of the costs. Public funds do not, however, cover costs involved in preoperative and postoperative treatment, posing "an additional burden in the liver transplant area," according to Dr. Carone.

"The transplant list in Brazil has been increasing year by year, but numbers of patients waiting for an organ reached a plateau in the last 2 years, probably as a result of the MELD criteria," said Silvano M. A. Raia, MD, of the University of Sao Paulo, Brazil.

In the state of Sao Paolo, the waiting list is currently longer than in any other state in the country. "In our public hospital, we have a 1-year waiting list for receiving a donor for transplantation, compared to some private hospitals, which have a waiting list of only 2 to 3 weeks," said Dr. Raia. He feels that the distribution system still gives preference to private institutions, he said.

Because there are so many centers performing transplants throughout the country, the distribution of organs to the various centers is indeed uneven. About 38% of transplantation centers do fewer than 5 transplants per year. "We need fewer and better centers," concluded Dr. Raia.

The geographic location of a person's home determines whether they have an opportunity for receiving a transplant in the first place. There are currently 60 active transplant teams, with liver transplants centers located exclusively on the eastern coastal regions of Brazil — an area representing 140 million of Brazil's inhabitants — but there are no transplant centers for the 40 million people living inland to the west of these coastal regions throughout the rest of the country. This problem is not unique to Brazil. In the United States, geographic location also determines the likelihood of there being a quality liver transplantation center.

Brazil has faced difficulties in obtaining good data on transplant outcomes, leading to "the appearance that the only place where liver transplants in the country are performed is in Sao Paolo, which has the best outcome data in all of Brazil," according to Dr. Raia. "We have to create a better system to allow us to assess our results."

Starting in November 2006, a database was created for multiple transplantation center sites across the country to help pool data and analyze the effects of the MELD criteria. It aims to gather information on 200 patients and to have results in 8 months.

Commenting on this presentation on the last day of the congress, Richard Freeman, MD, from the Tufts-New England Medical Center in Boston, Massachusetts, said, "I was completely impressed with the presentation on what is going on in Latin America, not because the results were good or bad, but because you have some transparency." Dr. Freeman was involved in implementation of MELD scoring in the United States.

"I have never seen data like that presented in South America before on their allocation systems and so forth — and that is the key," Dr. Freeman said. "It has to be transparent. It allows you to measure it and improve it and everyone — the government, the patients, the doctors — can see what is going on."

International Liver Transplantation Society 13th Annual International Congress. Presented June 21, 2007.

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