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The long wait

The chance of receiving a liver transplant is dropping each year

negreirosAn equation demonstrates that it has become more difficult year by year for a liver transplant candidate to in fact receive the organ that could prolong his life. Keeping the current rhythm of attendance, the line that represents the waiting list is more distant and more than equivalent to the number of transplants carried out, in accordance with the mathematical model constructed by Eduardo Massad, from the Medical School of the University of São Paulo (USP), based on the liver transplant waiting list of the state of São  Paulo, which is responsible for half of the transplants carried out each year in the country.

“It’s an angelically simple formula”, comments Massad, a medical doctor, who also graduated in physics, and who over the last few years has been occupying himself in building up more refined equations to explain the rhythm of the progress of illnesses such as dengue fever or yellow fever. This time, working with another doctor from USP, Eleazar Chaib, he has put rationality into mathematical language: the waiting list of each year is the result of the sum of earlier cases, not attended to the previous year, added to the new cases, corresponding to the people who have been added onto the list. By subtracting the number of dead and those who received a transplant, he arrives at the final value.

Described in an article in Transplantation Proceedings,  published in December 2005, this formula demonstrates, via a graph, that the line corresponding to the waiting list is moving away at a growing rate than that representing the total of transplants, indicated for those who have hepatitis C, cirrhosis or some type of cancer. This phenomenon can be explained historically: over the last few years there have been more people entering onto the waiting list than those receiving a liver, one of the human body’s major organs. From 1998 until 2004 the number of transplants grew 1.84 times, while the people on the waiting list increased 2.73 times and those who died by 2.09 times. In 2005, of the 2,000 people registered in the country to receive a liver, 168 passed though the transplant stage and 608 died whilst waiting. “These dead people who has been on the waiting list are unacceptable”, wrote  Massad and Chaib in Transplantation Proceedings. In their opinion, the loss of lives could have been the result, initially, of an insufficient quantity of donors, which is growing slowly.

Luiz Augusto Pereira, the coordinator at the Transplant Center of the State of São Paulo, said that there is in fact a difference in phase between the number of receptors and donors of livers. “To increase the number of donors is an enormous challenge”, he comments. “To attend to everyone is impossible.” During a presentation in July at the State Health Secretariat of Sao Paulo, Jordi Vilardelli Bergadà, a consultant to the Spanish Transplant Coordination Service, demonstrated how his country managed to zero the waiting list and to begin each year only with new cases. Considered a success in this area, the Spanish adopted coordinated actions, based on favorable legislation for the donation of organs and a network of transplant coordinators who worked in strict collaboration with the medical teams. In the opinion of  Vilardell, the incessant formation of health professionals and the continual education of the population are equally important, underlining the donation of organs as a solidarity and altruistic gesture.

Other possible explanations raised by Massad and Chaib for the Brazilian situation is the under usage of medical centers and of teams qualified for liver transplanting. The removal of this blood red organ from a person recently brain dead and its installation in another, by interfering in almost all the organism’s other functions, is considered one of the most complex procedures in modern surgery. Its success depends on teams with 20 to 30 specialized professionals – nurses, doctors, psychologists and social assistants – and of a sophisticated logistic situation.

Notification network
In general lines, hospitals throughout most of the country inform the Notification, Capture and Distribution of Organs Center of their respective state when they find a potential donor, whilst a team maintains these organs functioning, confirm brain  death and accompany the exams to detect blood compatibility or infectious diseases, as well as searching for the family to authorize the donation of the organs. The State Centers collect the receptor following the guidelines of the National Transplants System (NTS), which can participate in the logistics in the cases in which the liver of a donor of one State is removed in another State.

Sérgio Mies, from the Albert Einstein Israeli Hospital, one of the centers qualified to transport a liver in the city of São  Paulo, points out distortions in this attendance structure. Firstly, five States – Acre, Amapá, Rondonia, Roraima and Tocantins – do not have Capture Centers for organs. As well as this, the São Paulo capital houses a little more than half of the 48 teams authorized to carry out liver transplants, while there are regions without any. According to Mies, with the population concentration it is difficult to justify this situation, because the Southeast Region is home to 45% of Brazilians, but responds to 63% of the transplants.

Even at that, the State of São  Paulo, with 10.4 liver transplants per year for each million inhabitants, finds itself behind Rio Grande do Sul, the State which carried out the most liver transplants per year in Brazil, and below the internationally recommended level – of 20 transplants per year per million inhabitants – so that the yearly waiting list can be entirely attended to.

“Liver transplant in Brazil is a victim of its very own success”, observed Dr. Mies. Since September 1985, when a team from USP’s Hospital das Clinicas exchanged the liver of a 20 year old student, until December of 2005 some 5,823 transplants of this organ were performed: only in the State of São Paulo the waiting list gains 150 new names per month. Thus a situation in which less than 10% of those interested are going through a transplant was created and the risk of dying while on the waiting list is three times greater than being attended to. The projections about the evolution of hepatitis C cases over the next few years indicate that this picture could get worse.

Roberto Schlindwein, the NTS coordinator at the Ministry of Health, believes that part of these distortions will come to be solved with the implementation of new criteria for organizing the waiting list, which came into effect in July: no longer by order of arrival, but by seriousness. “Attendance by chronological order attended to precocious indications for carrying out a transplant, but it was cruel for the patients in a more serious state of health, who will now be given priority.”, he says. Maria Cecília Correa, the Science, Technology and Strategic Consumables coordinator at the State Health Secretariat of Sao Paulo, added: “What we’re going to know in a short time is if this new waiting criteria is really better, taking into account the survival of the liver receptors”. It would also be a manner of checking the inclusion criteria on the waiting list, which currently depends on doctors.