GENERAL AND DEMOGRAPHIC INFORMATION
Colombia is located on the Northern tip of South American. The country is bordering Middle-America, Venezuela, and the Pacific and Atlantic Ocean in the north, Ecuador, Peru and Brazil in the South (Figure 1). Colombia has approximately 50 Mio inhabitants (49 293 087 as of 2018) living in a 1 142 000 km2 surface area that is equivalent to the geographic area of Texas and New Mexico. Regionally, Colombia is divided into 32 states in addition to the Capital District.1,2 The country has 6 different organ procurement regions. Approximately 95% of the population has health insurance coverage.
HISTORY OF TRANSPLANTATION IN COLOMBIA
Organ transplantation in Colombia started as early as 1965 at the San Juan de Dios Hospital, Bogota with 5 deceased donor kidney transplants under the leadership of the Nephrologist Dr. Enrique Carvajal Arjona, and the Surgeon Dr. Fernando Gomez Rivas. At the time, organs had been procured from donors after cardiac death as the definition of brain death had not been established. The mainstay of immunosuppression had been based on azathioprine and prednisolone. Both transplant pioneers left Colombia in the following years, putting a hiatus on progress.
The first publication on brain death and its legal implications in Colombia appeared in March 1973, in the journal of the Academia de Medicina de Medellín.3
By August 1973, a deceased donor kidney transplantation program started at San Vicente de Paul Hospital in Medellin under the leadership of Drs. Jaime Borrero, Jorge Luis Arango, and Alvaro Velasquez. Dr. Velasquez had been trained by Dr. Thomas Starzl at the University of Colorado. The group in Medellin expanded their activities with the implementation of live donor kidney transplants in 1974, deceased donor liver (1979), cardiac (1985), lung (1988) and combined heart and lung transplants in 1989. Cardiothoracic programs had been initiated in cooperation with the hospital Santa Maria in Medellin.
The first combined kidney/pancreas transplant had been performed at the San Pedro Claver Clinic in Bogota, D.C. (1988); the first trachea transplantation has been done at San Vicente de Paul hospital in 2002.
As of today, the country has 22 kidney transplant programs in 6 cities, 8 liver (in 4 cities), 8 heart (in 4 cities), 4 lung (in 3 cities), 3 pancreas (in 2 cities), and 3 intestinal transplant programs (in 2 cities) (Table 1).
- The first law in organ transplant has been issued in February 1979 in Colombia.
- The National Health Institute (Instituto Nacional de Salud) is in charge of the organ and tissue transplant network that has been established in 2004. There is a mandatory reporting of every donor (both live and deceased) and every transplant. Although transplant activities are well reported, there is only limited information available on long-term transplant outcomes.
A presumed consent legislation has been introduced in 2016 and is practiced since 2017. Early results show an increase in transplant activity by 24.5% ( Table 2).
Legislation prohibiting organ transplantation for noncitizens has been introduced in 2004. This law allows deceased donor transplants in foreign patients only if there is not a Colombian citizen waiting for an available organ. Moreover, non-Columbian citizens can only receive living related transplants with permission by the government. In 2016, only 10 foreign patients have been transplanted in Colombia, all having received living donor kidney transplants with the permission by the health authorities of both, their home country and Colombia's National Health Institute. In 2017, only 5 foreign patients (4 livers and 1 kidney) were transplanted, all with living related donors (Figure 2).4
Thus, Colombia has spearheaded the international movement combating transplant tourism.
Colombia's transplant activity is mainly based on deceased donations (Figure 2). Donors per million population (donors/pmp) peaked from 2008 to 2010, however, declined from 2010 to 2014. More recently (2015-2017), rates of deceased donations have recovered slightly (Figure 3). This upward trend is explained, at least in part, by extending the age-limit for donation while more extended criteria donors have been accepted. Deceased donor rates have increased from 7.8 donors pmp to 8.8 donors pmp in 2017.5
Organ transplantation in Colombia has increased over the last decade and more than 18 000 transplants have been performed since 1966 (76% of those being kidney transplants; Table 3); more than 17% of recipients received liver transplants. It is important to mention that those numbers are based on personal information because there is currently no national registry collecting data on outcomes. In parallel, live donor transplants have increased; by 2016, 16.1% of kidney transplants and 16.3% of liver transplants had been from living donors.4
More than 27 000 patients are currently undergoing dialysis in Colombia. Although there is an almost complete health coverage in the country, only 2316 (8.44%) patients are currently waitlisted for renal transplants (Figure 4).6
CHALLENGES AND OPPORTUNITIES MOVING FORWARD
The implementation of a mandatory database for all organ transplants and living donors will be critical in assessing transplant outcomes, allowing center-specific quality assessments and improvements while assuring the safety of live-donor procedures. With only a fraction of dialysis patients listed for renal transplantation, it will be important to assess the candidacy of all patients. Governmental support and a broad assessment of eligibility including political and social obstacles will be relevant in achieving these goals.
Donors after cardiac death (DCD) constitute a significant source of organs in North America and in some European countries. Colombia has of yet not legislated to the procurement of organs from DCD donors.
To identify and optimally manage deceased donors, it will be critical to implement a close communication between emergency medicine, intensive care physicians and procurement coordinators.
To increase kidney transplantation, Colombia considers compensating donors for lost wages covering healthcare, costs for transportation, and other costs of the donation process.
Implementing paired kidney exchange programs will not only be a way to increase transplant rates but also to improve opportunities for sensitized recipients and those with blood group incompatible donors in a cost-effective way.
To increase liver, cardiac, and lung transplant rates, it will be important to get the attention of internal medicine specialists to achieve a more effective, rapid, and early referral to transplant programs.
For deceased donor liver transplants, it will be relevant to consider organs from older and less than optimal donors while contemplating an increase in the number of live donor liver transplants.
For pancreas and intestinal transplants, a broader education will be necessary to educate patients on the benefits of those procedures.
Colombia has made great strides in moving organ transplantation forward. Nevertheless, end-stage organ failure rates are on the rise, and it will be important to offer transplantation to any patient eligible.
To increase transplant opportunities, it will be important to identify any potential donor while implementing DCD donor programs and paired kidney exchange registries.
A mandatory registry for any organ donor and transplant will be of critical importance to optimize quality while implementing process improvements.
The authors acknowledge the support of ACTO (Colombian transplant association) for providing information on historical registries for transplantation in Colombia, the National Health Institute (INS)—RedDataINS in providing access to transplantation data; Drs Martha Lucia Ospina, Health Institute Director and Adriana Segura Vasquez, technical subdirector of the Red Nacional de Trasplantes y Bancos de Sangre (INS), and to the Colombiana de Trasplantes for the support in working on this manuscript.