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BACKGROUND Chronic kidney disease (CKD) has become a widespread pandemic and a significant public health concern. The surge in life expectancy, coupled with the increasing prevalence of chronic conditions, such as diabetes and arterial hypertension, has led to a global escalation in the number of patients with CKD across all stages.1 Kidney transplantation (KT) stands out as the most advantageous option for renal replacement therapy. Compared with dialysis, KT offers superior outcomes, including a reduced incidence of cardiovascular events, lower mortality rates, and improved quality of life.2 Despite the clear benefits, Brazil still faces challenges in meeting the demand for KTs, with the number of patients on the waiting list steadily growing and reaching almost 30 000.3 The discrepancy between demand and supply is not unique to Brazil and extends to high-income countries, including the United States. Kidney paired donation (KPD) represents a strategy to increase the number of living donor KTs (LDKTs), offering incompatible donor/recipient pairs the opportunity to get transplanted without the necessity for de-sensitization.4 Currently, these KPD transplants represent 8% of the total LDKTs in Europe5 and 18.9% in the United States.6 Here, we assess the situation of KPD in the countries affiliated with the Latin America and Caribbean Transplant Society (STALYC). We assessed available data from most South American and Caribbean countries by reporting KPD activity in countries affiliated with STALYC; a literature search was performed in both English and Spanish. Table 1 displays LDKT activities7 in these countries and their KPD records. Only a minority of countries (5/26.3%) maintain documented KPD activities, whereas 7 countries (36.8%) have established legal frameworks allowing KPD. TABLE 1. - KPD activity in Latin America and the Caribbean Country(N = 19) Population(millions) LDKT 2019(pmp) KDP activityregistered Legislation Argentina 45.6 7.8 Yes Permission for KPD (2018) Brazil 214 5.1 Yes (research) Permits nonrelated donorsa Costa Rica 5.1 8.6 Yes Permits nonrelated donors Guatemala 18.2 5.9 Yes Permits nonrelated donors Mexico 130.3 15.4 Yes Permits nonrelated donors Chile 19.2 5.4 No Permission for KPD (2017) Ecuador 17.9 0.3 No Permission for KPD (2011) Panama 4.4 2.9 No Permission for KPD (2010) Paraguay 7.2 0.9 No Permission for KPD (2017) Peru 33.4 1.6 No Permission for KPD (2013) Venezuela 28.7 1.6 No Permission for KPD (2011) Bolivia 11.8 6.0 No Permits nonrelated donors Colombia 51.3 3.6 No Permits nonrelated donors Cuba 11.3 2.2 No Only related donors El Salvador 6.5 6.7 No Permits nonrelated donors Nicaragua 6.7 1.4 No Only related donors Dominican Republic 11 4 No Permits nonrelated donors Trinidad and Tobago 1.4 2.9 No Permits nonrelated donors Uruguay 3.5 5.7 No Only related donorsa aBill legitimizing KPD awaiting vote.KPD, kidney paired donation; LDKT, living donor kidney transplant; pmp, per million population. Guatemala was the first country to publish a scientific report on KPD in 2018,8 with 4 kidney paired transplants performed between 2010 and 2017. Two reports from Argentina on local news websites reported 2-way exchanges involving 2 pairs in 20159 and 2018.10 Costa Rica published a 2-way exchange on the hospital's social media page in 2016,11 whereas a 2-way exchange transplantation was performed in Brazil in 2020.12 Mexico is leading the reported KPD activity with a first experience involving 4 pairs in a chain beginning with an altruistic donor13 reported in 2019. A more recent publication reported on 22 pairs transplanted with longer chains and excellent results.14 It is interesting to note that there are 6 countries—Panama, Ecuador, Venezuela, Peru, Chile, and Paraguay—with laws explicitly permitting KPD. Thus far, there has not been a report on KPD in those countries, which is likely due to the relatively recent publication of these legislations, all of which occurred after 2010. SUMMARY AND CONCLUSIONS Addressing the global CKD and organ transplantation crisis necessitates comprehensive efforts in public health, healthcare infrastructure, and awareness campaigns. Finding ways to increase the availability of donor organs, improving access to KT, and promoting preventive measures to reduce the prevalence of CKD are critical steps to alleviate the disease burden. The "Aguascalientes Document,"15 drafted in 2010 during the Transplantation Bioethics Forum and supported by STALYC, acknowledges the legitimacy of KPD. Nevertheless, the implementation of KPD remains limited to isolated cases and has thus far not been embraced by many STALYC-affiliated countries. Although KT is feasible, available, and increasingly used in all Latin American countries, its growth rate (19.1 per million population pmp in 2010; 22 pmp in 2019) remains far below the demand to meet the increasing prevalence of patients on waiting lists.16 Moreover, there is a sizable disparity among transplantation activities by country and region, ranging from 0 to 35 pmp,16 impacting the successful implementation of KPD programs. Noting that STALYC countries have highly heterogeneous transplant programs, many already have, at least in theory, sufficient expertise and maturity to develop a paired transplant program. A recent publication has shed light on the potential of KPD in low-to-middle income countries (LMICs), strongly advocating for the promotion and encouragement of KPD programs, including considerations of cost advantages.17 Of additional relevance, valuable recommendations on initiating KPD programs in LMICs include starting with smaller chains, considering simultaneous surgeries, and implementing effective organ transport strategies.17 By adopting these strategies, LMICs can address compatibility issues and enhance their organ transplantation capabilities. Considering that KT is the superior and more cost-effective treatment option for patients with CKD, it is puzzling that the initiation of KPD programs remains limited in a region primarily composed of LMICs. Although some countries may have implemented KPD programs without publication, genuinely active programs beyond Mexico remain missing. It is crucial to emphasize that in most of these countries, deceased donor transplantation also falls significantly short of estimated needs.3,7 The entire infrastructure surrounding transplantation, including both living and deceased donors, continues to require substantial improvements. Particularly for KPD, initiatives such as educational campaigns for physicians, recipients, and donors, as well as investments in logistics and software in addition to a legal framework, need to be encouraged. Similar to KPD programs in Europe,5,18 collaborative efforts across countries could benefit smaller countries. Transplant societies, including STALYC, could play a vital role in supporting the advancement of paired donation, ensuring improved access to transplantation for their populations, especially with living donors.
Bastos et al. (Fri,) studied this question.