ECUADOR: GEOGRAPHY, DEMOGRAPHY, AND HEALTH CARE
Ecuador is located in the northwest region of South America. The country crosses the Equatorial line and has approximately 17 million inhabitants who live in an area of 283 560 km2. The country is divided into 24 provinces also including the Galápagos Islands (Figure 1).
Nearly 45 ethnic groups reside in Ecuador making the country one of the most ethnically diverse places in the world. Despite its linguistic diversity, the official language is Spanish. According to The Human Development Index, measuring the key dimensions of human development including life expectancy, education, and per capita income, Ecuador ranked 86th (out of 189 countries) worldwide in 2018.1
Health care in Ecuador is based on the “Red Pública Integral de Salud” (comprehensive public health network), which is integrated with the Instituto Ecuatoriano de Seguridad Social (IESS; Ecuadorian Institute of Social Security), Ministerio de Salud Pública (MSP; Ministry of Public Health), Instituto de Seguridad Social de las Fuerzas Armadas (ISSFA; Institute of Social Security of the Armed Forces), Instituto de Seguridad Social de la Policía (ISSPOL; Institute of Social Security of the Police), and the complementary network of health. With this model, the country seeks to provide health care and free services for all.
HISTORY OF ORGAN AND TISSUE TRANSPLANTATION IN ECUADOR
The history of organ and tissue transplantation in Ecuador began in 1964, when a group of doctors led by Dr Roberto Gilbert in Guayaquil performed the world’s first hand transplant. Although having been a surgical success, the graft was rejected as immunosuppression had not been advanced at this time. Nevertheless, the procedure established itself as a historical landmark demonstrating the technical success of the procedure.
The first solid organ transplant has been performed in 1976 as a live donor kidney transplant at the Hospital de Especialidades de las Fuerzas Armadas N°1. Since then, solid organ transplant activities increased gradually. In 2011, the National Organ Donation and Transplant Law had been approved, resulting in a significant increase in the rate of donation and transplantation with a focus on deceased donors. The first heart transplant has been performed in 1994, followed by first liver transplants (2009), simultaneous kidney–pancreas (2012), kidney–liver (2017), and lung transplants (2018).
The first law on organ transplantation had been passed by the Ministry of Public Health in 1994, recognizing both growing relevance and the necessity to ensure quality and process improvement.
The “Organismo Nacional de Trasplante de Organos y Tejidos” (ONTOT; National Organism of Organ and Tissue Transplant) was subsequently implemented in 1999 to assure procedural and bioethics standards. In 2011, the ONTOT was replaced by the “Instituto Nacional de Donación y Trasplante de Organos, Tejidos y Células” (INDOT; National Institute of Organ, Tissue, and Cell Transplantation). At present, INDOT implements public policies of donation and transplantation, supporting the National Integrated System of Donation and Transplants with the highest technical standards within the framework based on bioethical standards, equity, and transparency. Ecuador has also endorsed the Declaration of Istanbul on Organ Trafficking and Transplant Tourism.
The current law on organ, tissue, and cell transplantation defines the population’s right to obtain a better quality of life through transplantation. Presumed consent in addition to outlining a cooperation of public and private health institutions is provided.
INDOT is responsible for the accreditation of programs and institutions responsible for donation and transplantation assuring highest quality and best clinical outcomes. Ecuador is divided into 3 zones for organ procurement, with the main transplant programs located in Quito, Guayaquil, and Cuenca.
TRANSPLANT RATES (2007–2018)
A total of 5263 transplants have been performed in Ecuador from 2007 to 2018 (kidney 1334; liver 211; heart 5; kidney–pancreas 2; pancreas 2; lung 1; cornea 3391; and hematopoietic stem cells 317). Deceased donor kidney transplant rates have increased steadily from 1.27 pmp in 2007 to 13.33 pmp in 2018 (Table 1), reflecting a >10-fold increase. In parallel, living-donor kidney transplant rates declined from 2.81 pmp in 2007 to 1.29 pmp in 2018.2,3
RELEVANCE OF KIDNEY TRANSPLANTATION IN ECUADOR
Chronic kidney disease affects approximately 10% of the population necessitating to provide on renal replacement treatments including hemo, peritoneal dialysis, or kidney transplantation.
The Latin American Registry of Dialysis and Renal Transplantation lists a prevalence rate of 550 pmp on renal replacement therapy in Ecuador.4,5 In 2015, the Ministry of Public Health of Ecuador listed close to 10 000 (9635) patients on either hemo- or peritoneal dialysis accumulating to nearly $170 million in healthcare spending. Clearly, kidney transplantation does not only provide an optimized medical but also a better economic alternative.6
The first heart transplant was performed in the city of Guayaquil in 1994, which was followed by 4 more transplants. However, this program has not been active for >10 years.
The first and only lung transplant was performed in the city of Quito at an altitude of 2850 m above sea level, in 2018, in a female patient with idiopathic fibrosis secondary to rheumatoid arthritis.
In the year 2000 in the city of Guayaquil, the first pediatric liver transplant with a living donor was performed with the support of a delegation of French doctors; however, this important event did not have follow-up due to the conditions of the moment and the dependence of foreign collaboration, which forced it to remain as an anecdote in the history of transplants in Ecuador.
In 2009, in the city of Quito, the first liver transplant was performed with a successful cadaveric donor in the country, and beginning a new phase of transplants in Ecuador, in 2012 the first hepato-renal transplant was performed. In 2013, the liver transplant was resumed with a living donor in children. From the beginning, the Model for End-Stage Liver Disease system is used for the allocation of organs, and a single national waiting list is established. The 3 leading causes of liver cirrhosis with an indication of transplantation in our country are alcoholic, autoimmune, and nonalcoholic steatohepatitis. To date, >220 liver transplants have been performed.
The first pancreas transplant was performed in 2012 the same as it was with the kidney and became the first multivisceral transplant in the country. To date, only one more transplant was performed. The indication for these transplants was type I diabetes mellitus with chronic dialysis renal failure.
CHALLENGES AND OPPORTUNITIES FOR IMPROVEMENT
There is currently no opportunity for live-donor paired kidney exchanges in Ecuador. Implementing such a strategy may have beneficial effects on the rates of living-donor transplantation while providing sensitized or blood group incompatible patients an opportunity for treatment. Paired kidney exchanges appear of relevance as living donor rates in Ecuador are among the lowest worldwide.
Moreover, there is currently no legislation supporting the procurement of organs from donors after circulatory death. Globally, as reported by the Global Observatory on Donation and Transplantation, among 27 countries 6892 donors after circulatory death were reported in 2016 (19.8% of the total number of actual deceased organ donors).7 It is expected that Ecuador may learn from this experience and use it as an opportunity to implement donors after circulatory death organs for transplant.
Finally, although the rates of transplants from deceased donors have increased steadily in Ecuador, support of organ donation in hospitals outside of the main cities/centers will need to be implemented.
1. United Nations Development ProgrammeHuman development indicators, Ecuador
.2018Available at http://hdr.undp.org/en/countries/profiles/ECU
. Accessed February 2019
2. Instituto Nacional de Donación y Trasplante de Órganos, Tejidos y CélulasEstadísticas INDOT
.2019Available at http://www.donaciontrasplante.gob.ec/indot/estadisticas-indot
. Accessed February 2019
3. DONASUR.2017Available at https://www.donasur.net
. Accessed February 2019
4. Gonzalez-Bedat MC, Rosa-Diez G, Ferreiro A. El Registro Latinoamericano de Diálisis y Trasplante Renal: la importancia del desarrollo de los registros nacionales en Latinoamérica.Nefrol Latinoam20171412–21
5. Pecoits-Filho R, Sola L, Correa-Rotter R, et al; International Society of Nephrology Regional BoardKidney disease in Latin America: current status, challenges, and the role of the ISN in the development of nephrology in the region.Kidney Int2018941069–1072
6. Silva SB, Caulliraux HM, Araújo CA, et al. Cost comparison of kidney transplant versus dialysis in Brazil.Cad Saude Publica201632e00013515
7. Global Observatory on Donation and Transplantation.2016Available at http://www.transplant-observatory.org/countdcd
. Accessed August 2019