Mexico, officially called the United Mexican States, is in the southern part of North America. It is a democratic republic comprised of 32 states, in addition to its capital, Mexico City.
The Mexican territory has an area of 1 964 375 km2, which makes it the 14th biggest country in the world and the third largest in Latin America. Mexico borders the United States of America in the north and Guatemala and Belize in the south (Figure 1). It is the 11th most populous country in the world, with an estimated population of over 132 million people (as of 2018). Although most people speak Spanish, the official language, there are 67 indigenous dialects. In 2015, the Human Development Index was 0.762, ranking Mexico as number 77 worldwide. The Mexican economy is the second largest in Latin America and the 11th in the world.1,2
Life expectancy is close to 77 years with a per capita annual income of US $14 590. Total health expenditure is 6.35% of the GDP with a government contribution of only 49%, ranking Mexico lowest among OECD countries; 51% of health expenditures are out-of-pocket payments. Per the Global Burden of Disease Study, ischemic heart disease, chronic kidney disease, and diabetes are the most frequent causes of death in Mexico2-4
HEALTHCARE IN MEXICO
Healthcare is provided by a mix of Social Security services for formal employees (in most cases, extended to their families), traditional public sector services for the poor and private services for those who can afford it. The country’s Social Security system includes 5 sectors: the health institution of Mexico (IMSS, the country’s largest provider), a sector for administrators (ISSSTE), the army (SEDENA), the navy (NAVAL), and the public oil company (Petroleos Mexicanos [PEMEX]). Organ donation and transplantation is fully covered in social security institutions.
The Secretary of Health oversees public hospitals dedicated to the care of patients without access to the social security system. With a few exceptions, public hospitals are not supported with a dedicated budget for organ donation and transplantation. Seguro Popular (SP) is providing the main funding source for public hospitals. SP, however, does not support organ donation and transplantation, except for renal transplantation in minors. Private services are also available to those who can afford them either through private insurance or out-of-pocket payments.2,3
The National Transplant Center (CENATRA, Centro National de Trasplantes) is a decentralized agency under the umbrella of the Secretary of Health that governs organ, tissue donation, and transplantation in Mexico. CENATRA promotes organ donation, education of transplant professionals, certification of transplant centers while documenting all donation and transplant activities through the National Transplant Registry.
CENATRA is neither directly involved with organ donation or transplantation nor with the distribution and allocation of deceased donor organs; Mexican law refers those decisions to each hospital transplant committee. CENATRA, however, is responsible for overseeing that regulations are fulfilled in collaboration with COFEPRIS, the regulatory federal agency that approves and supervises all transplant centers. CENATRA has representations in each state of the country.
The Mexican Board of General Surgery certifies all kidney and liver transplant surgeons since 2016. Currently, 16 transplant centers in Mexico have been accredited for fellowships in kidney and/or liver transplantation.
Although there are no relevant legal, regulatory, social, or religious obstacles for deceased donations (DDs), Mexico has only a DD rate of 4.3 per million population (pmp), significantly inferior to the mean (8.2 pmp) for Latin America.3,5-8 There has not been a significant improvement in donation rates during the last 40 years.5,6 Noteworthy are significant regional variabilities, with regional variances of 0 to 12 donors pmp.5,6
Low DD rates are at least partly explained by a fragmented and poorly coordinated healthcare and organ donation system with a significant uncovered economic burden of donation and transplantation. Moreover, organ transplantation is only poorly positioned in the overall therapeutic armamentarium.
Interestingly, recent data reveal a change in the ratio of living versus deceased donor kidney transplantation. Nationally, 71% of all kidney transplants are from living donors. Significant differences are observed among providers with living donor rates in hospitals supported by social security (75.7%), private (82.5%), and public hospitals (53%), indicating the relevance of organizing and supporting organ donation in Mexico. It is also notable that unrelated living donation rates account for 11.3% of total living donations with significantly higher rates in private compared with public hospitals (27.4% vs 7%).5,6
Approximately 77% of more than 50 000 kidney transplants performed in the past 55 years have been obtained from living donors with an overall rate of 18 living donors’ pmp.5-7,9,10 Living donation rates have been as high as 90% in 1976, with a relative increase in deceased donor transplants during the most recent decade changing the ratio of living versus deceased donor transplants to 70:30 (Table 1).5,6
Although the benefits of living donated kidney transplants are recognized, there is an overall concern that the poorly developed deceased donor organ system is putting an excessive pressure on the utilization of LD as the main source of kidney transplants with a risk of coercion and commercialization (Table 1) and uncertain safety for suboptimal donors.11
The first successful kidney transplant in Mexico was performed in 1963 from a living donor. Despite low DD rate, overall renal transplant rates have been 22.7 pmp in 2017,7 comparable to rates in high Human Development Index countries and representing one of the highest rates in Latin America.7,9 A total of 3150 kidney transplants were performed in 2017, demonstrating greater than 50% increase compared with 2098 kidneys transplanted in 2007 (Table 2). In 2017, 78% of all kidney transplants were performed in public institutions.5,6 Currently, more than 15 000 patients are registered on the waiting list for deceased donor kidney transplantation.6 Notably, this number does not represent the number of patients in need for kidney transplantation with 160 000 patients currently on renal replacement therapies. Approximately, 50% of end stage renal disease patients do not have access to the Social Security system, limiting their opportunities for transplant or dialysis.3,10,12,13
Thus, limited access to transplantation may, at least in part, explain the excessive mortality and disability associated with renal failure in Mexico.4,10
The first successful liver transplant has been performed in 1987. Until June of 2018, 2247 liver transplant have been reported, including 152 (6.8%) living donor liver transplants; the rate of DD liver transplants has been 1.4 pmp. Liver transplant activities are evenly distributed between hospitals supported by social security, public, or private funding (37%, 33%, and 30%, respectively). The clear majority of liver transplants (92%) have been performed at transplant centers in Mexico City, Guadalajara, and Monterrey. The amount of liver transplants performed does, by far, not meet the demand, estimated at an annual rate of 2100 (Table 2).4-7,9
Since the first heart transplant in 1988, 551 cardiac transplants have been performed in Mexico, representing a cardiac transplantation rate of 0.3 pmp in 2017 compared with rates of 1.8, 2.1, and 2.6 pmp in Brazil, Uruguay, and Argentina, respectively. Noteworthy, world leading heart programs report rates between 6 and 10 pmp. Approximately 82% of heart transplants are performed in social security hospitals (Table 2).4-7
Small amounts of other transplants have been performed in the country, including lung (19 transplants), pancreas,2 kidney-pancreas,14 and small bowel.1 Those procedures have been performed at several institutions in Mexico. Activities have mostly been related to individual or institutional enthusiasm and not necessarily on a structured public health approach15,16 with the economic burden for institutions seen as a barrier for development and growth.
There have also been recent activities in the newly developing field of vascular composite tissue transplantation with a bilateral upper limb transplantation performed at the Instituto Nacional de Ciencias Medicas y Nutrición in Mexico City in 2012.14
TRANSPLANT REGISTRIES AND QUALITY ASSESSMENT
Mexico has a centralized waiting list for organ and tissue transplantation; the responsibility of organ distribution and allocation, at the same time, is with individual transplant institutions. Registration for transplantation is mandatory by Mexican law. Although organ allocation and transplantations are registered, outcomes data are currently limited to efforts of individual transplant centers.
ORGAN TRAFFICKING IN MEXICO
The Mexican law explicitly prohibits any form of commercialization in organ or tissue transplantation; the transplantation of non-Mexican citizens is regulated by law, and Mexico has endorsed the Declaration of Istanbul. Moreover, with the participation of the Secretary of Health, the regulatory Agency COFEPRIS (Federal Commission for Preventing Sanitary Risks), and the attorney general, a “Protocol of Action in Transplant and Organ, Tissue and Cell Donation,” has been implemented. Moreover, the Mexican Transplant Society in collaboration with Latin American and Caribbean Transplantation Society have promoted the “Document of Aguascalientes” as a position statement against organ trafficking.17
Mexico has a reasonably well-developed live donor kidney transplant system, yet overall, transplantation has not been established as the treatment of choice for end-stage organ failure, largely linked to a poorly developed deceased donor transplant system. Limitations for the treatment of end-stage organ failure are linked to high mortality rates. Improvements will require a structured nationwide organ donation and procurement program. Moreover, insurance coverage for all aspects of the transplant care will be necessary.
The authors express their special gratitude to National Transplant Centers and Dr. Jose André Madrigal for their support in providing and facilitating access to transplant data.
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4. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1459–1544.
6. Centro Nacional de Trasplantes: Estado actual de receptores, Donación y Trasplantes en México 2do Trimestre 2018. 2018. Available at www.gob.mx/rnt
7. Donation and Transplant Institute. International Registry in Organ Donation and Transplantation June 2018. 2018. Available at www.irodat.org
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