Profile of Organ Donors in Ceará, Northeastern Brazil, From 1998to 2012

S.F.R. Silvab,*, S.L. Silvab, A.C. Nascimentob, M.M. Parenteb, C.A. Albuquerqueb, A.A. Rodriguesb,H.H. Camposc, E.F.S. Machadoa, and E.R.B. Almeidaa

aTransplantation Center of Ceará, bUniversity of Fortaleza, and cFederal University of Ceará, Fortaleza, Ceará, Brazil

0041-1345/1http://dx.doi

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ABSTRACT

The use of cadaver donors for transplantation is often the only alternative in the treatmentof patients with organ failure. The purpose of this study was to draw a comprehensiveprofile of solid organ donors in Ceará, northeastern Brazil, from 1998 to 2012. The studywas retrospective and based on secondary data regarding sex, age, blood typing, and causeof brain death obtained from the solid organ donor database of the Ceará TransplantationCenter covering the period November 1998 to December 2012. During the study period,976 donors (69% male) were used. Donors were distributed in 4 age groups as follows:12.9% <18 years, 50.9% 18e40 years, 28.5% 41e60 years, and 7.7% >60 years. The averageage was 35 � 16 years. On the average, female donors were older than male donors (38.4 �17 y vs 33.5 � 16 y; P < .0001). Men were predominant in the age groups 18e40 y (75.3%;P < .0001) and 41e60 y (59.4%; P < .0001). The main causes of brain death were traumaticbrain injury (TBI) (56.7%) and stroke (33.1%). The former was more common in men (P <.0001), the latter in women (P < .0001). TBI was caused by traffic accidents (51.4%), ofwhich 50.7% were motorcycle accidents, and urban violence (22.6%), of which 71.2% wereassociated with firearms. The number of donations increased in the study period (11.2donors per million population in 1998e2002 to 68.1 in 2008e2012). In Ceará, solid organdonation is on the rise. The predominant donor profile was young men aged 18e40 yearswith brain death due to TBI caused by traffic accidents and urban violence.

*Address correspondence to Silvia Fernandes Ribeiro daSilva, University of Fortaleza, FortalezadCE, Brazil. E-mail:silviafernandes@unifor.br

ORGAN donation is an increasingly popular practice inBrazil, with 9.9 donors per million population (pmp)

in 2010, 10.7 pmp in 2011, 12.6 pmp in 2012, and 13.3 pmpin the first half of 2013. The number of transplantationsperformed has grown accordingly. Thus, over the past 3years, 20,667 solid organ transplants were performed inBrazil, of which 14,972 involved kidneys, 4,500 livers, 553hearts, 216 pancreas alone, 248 pancreas þ kidneys, and 178lungs. Most of these organs (73.3%) were obtained fromcadaver donors [1e3].Ceará, a state in northeastern Brazil, had the highest rate

(22.1 donors pmp) of effective organ/tissue donors innorthern and northeastern Brazil in 2012. In relation to thecountry as a whole, Ceará ranks 1st in liver transplants (18.9pmp), 2nd in heart transplants (3.3 pmp) and 5th in kidneytransplants (33.7 pmp) [3]. Despite the growing rates ofdonors and transplants, viable organs are not infrequentlylost owing to family refusal, cardiac arrest, and changes indonor profile associated with aging and circumstances of

4/$esee front matter.org/10.1016/j.transproceed.2014.05.008

brain death [2,4,5]. The purpose of the present study was todraw a comprehensive profile of organ donors in Cearáfrom 1998 to 2012.

METHODS

The study was retrospective and based on secondary data obtainedfrom the solid organ donor database of the Ceará TransplantationCenter from November 1998 to December 2012. The study protocolwas approved by the Research Ethics Committee of the Universityof Fortaleza (Unifor) and filed under entry 319/2009.

Demographic and clinical data were collected regarding sex, age,and cause of brain death. The subjects were distributed into 4 agegroups: <18 years, 18e40 years, 41e60 years, and >60 years. Donorsregistered with centers in other states were excluded from theanalysis. The collected data were organized in Excel 2010 spread-sheets. Qualitative variables were expressed as frequency, and

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Transplantation Proceedings, 46, 1692e1694 (2014)

Table 1. Distribution of 976 Solid Organ Donors Used by theCeará Transplantation Center From November 1998 to

December 2012, According to Sex and Age

Age Group Men Women Total P Value

<18 y 90 (71.4%) 36 (28.6%) 126 (12.9%) .606018e40 y 374 (75.3%)* 123 (24.7%) 497 (50.9%) <.000141e60 y 165 (59.4%)* 113 (40.6%) 278 (28.5%) <.0001>60 y 44 (58.7%) 31 (41.3%) 75 (7.7%) .0514Total 673 (69%)* 303 (31%) 976 (100%) <.0001

*P < .05.

Table 2. Cause of Brain Death From Traumatic Brain Injury (TBI)of 553 Solid Organ Donors Used by the Ceará TransplantationCenter From November 1998 to December 2012, According to

Gender

TBI Men Women Total

Traffic accident 228 (80.3%)* 56 (19.7%) 284 (51.4%)Run-over 53 (69.7%) 23 (30.3%) 76 (26.8%)Motorcycle 121 (84%) 23 (16%) 144 (50.7%)Car 54 (84.4%) 10 (15.6%) 64 (22.5%)

Fall 34 (89.5%) 4 (10.5%) 38 (6.9%)Urban violence 112 (89.6%)* 13 (10.4%) 125 (22.6%)

Battery 32 (94.1%) 2 (5.9%) 34 (27.2%)Firearm 78 (87.6%) 11 (12.4%) 89 (71.2%)Cold weapon 2 (100%) 0 (0%) 2 (1.6%)

Not specified 95 (89.6%) 11 (10.4%) 106 (19.1%)Total 469 (84.8%) 84 (15.2%) 553 (100%)

*P < .05.

PROFILE OF ORGAN DONORS IN CEARÁ 1693

quantitative variables were expressed as average � standard devi-ation. With the use of the statistical software Graphpad Prism, thedata were submitted to Fisher exact test and analysis of variance,followed by the Student-Newman-Keuls test. The level of statisticalsignificance was set at 5% (P < .05).

RESULTS

Throughout the period covered by the study, 976 solid organdonors were used in Ceará, with the following distribution:83 (8.6%) in 1998e2002 (11.2 donors pmp), 317 (32.6%) in2003e2007 (42.7 donors pmp), and 576 (58.9%) in2008e2012 (68.1 donors pmp). On average, donors were aged35 � 16 years (range, 1.5e77) and 69% were male. Theaverage age was higher for women (38.4 � 17 years) than formen (33.5 � 16 years; P < .0001). As presented in Table 1,497 (50.9%) of the 976 donors were in the age group of 18e40years. Of these, 75.3% were male (P < .0001).The main cause of brain death was traumatic brain injury

(TBI) (56.7%), followed by stroke (CVA) (33.1%). TBI wasmore common in men than in women (84.8% vs 15.2%; P <.0001), and CVA was more common in women (52.3% vs47.7%; P < .0001). Table 2 presents the types of TBI of 553donors according to sex. Most cases were traffic related(51.4%) or the result of urban violence (22.6%). Both weremore frequent in men than in women (P < .0001).

DISCUSSION

During the 15 years covered by the study, the distribution ofsolid organ donors in Ceará (11.2 donors pmp in 1998e2002compared with 68.1 donors pmp in 2008e2012) reveals asignificant increase in organ donations. The growing num-ber of organ donations is very likely the result of a numberof strategies implemented during the period covered by thestudy. For example: i) the establishment in 2005 andrestructuring in 2009 of the Intrahospital Commission forTissue and Organ Donations at the largest trauma hospitalin the state; ii) the implementation in October 2004 (whenOrgan Donor Day is celebrated nationwide) of the news-paper and television campaign “Donate from the Heart”;iii) the inclusion of additional professionals on the team ofthe Ceará Transplantation Center, including on-duty phy-sicians; and iv) expansion of the existing schedule of lecturesand debates on organ donation at schools and universitiesfor awareness building. In addition, in 2003 the BrazilianOrgan Transplant Association (ABTO) started a national

campaign with the slogan “become a donor, and tell yourfamily” to address the problem of family refusal arising fromignorance regarding the potential donor’s wishes.Some authors have described a change in the profile of

Brazilian organ and tissue donors due to the aging of thepopulation and the use of expanded-criteria donors [6,7].According to ABTO, in most Brazilian states donors are onaverage in the age group 41e60 years [2]. In contrast, theaverage age was 35 years in our sample of 976 donors, morethan one-half of whom (50.9%) were in the age group 18e40years. However, when the years 2010 (35.1 y), 2011 (38.5 y),and 2012 (38.2 y) were analyzed separately, a tendency to-ward increasing average age was observed. This tendencywas not visible in the analysis by age group: In 2012 and inthe first half of 2013, 46.6% and 46.7% of effective donors,respectively, were in the age group of 18e35 years [8].According to some authors, the female sex is predomi-

nant among Brazilian organ donors, but in our sample do-nors were predominantly male. This is supported by figurespublished by ABTO for most Brazilian states [6,7,9,10].In most Brazilian states, the incidence of TBI is decreasing

and that of CVA is increasing among organ donors owing tothe passage in 2008 of a zero-tolerance drinking-and-drivinglaw (Law 11.705), resulting in fewer traffic accidents withfatal victims [6e8]. Nevertheless, in this study and in a studyby Fusco et al (2009), TBI remains the main cause of deathamong organ donors [11]. In our sample from Ceará, TBIwas particularly frequent among male donors (P < .0001)aged 18e40 years (P < .0001), mainly as a result of trafficaccidents (especially motorcycles) and urban violence(especially firearms) (P< .05). Over the past 11 years, deathsby firearms have increased by 414% among Brazilians aged15e29 years, especially in state capitals, of which Fortaleza inCeará now ranks third. In addition, 20,597 traffic accidentswere registered in Fortaleza in 2012, corresponding to w56accidents per day [12]. Fatal victims were registered in 451 ofthose accidents, of which 124 (27.5%) involved motorcyclesand men in the age group of 20e39 years [13]. These cir-cumstances explain the high percentage of young menamong the organ donors in our sample.

1694 SILVA, SILVA, NASCIMENTO ET AL

In conclusion, the data collected for this study allowed usto draw a comprehensive profile of organ donors in Ceará.The high incidence of young male victims of urban violencein Ceará reflects serious urban security issues, suggestingthat authorities and policy makers commit themselves moreaffirmatively to solving this challenge through informedpublic debate and effective countermeasures.

REFERENCES

[1] Brazilian Organ Transplant Association (ABTO). RBT4(16), 2010.

[2] Brazilian Organ Transplant Association (ABTO). RBT4(17), 2011.

[3] Brazilian Organ Transplant Association (ABTO). RBT2(18), 2012.

[4] Moraes EL, Silva LBB, Glezer M, et al. Trauma and tissueand organ donation for transplant. J Bras Transpl 2006;9:561e5.

[5] Meers C, van Raemdonck D, van Gelder F, et al. Changein donor profile influenced the percentage of organs trans-planted from multiple organ donors. Transplant Proc 2009;41:572e5.

[6] Moraes EL, Silva LBB, Moraes TC, et al. The profile ofpotential organ and tissue donors. Rev Lat Am Enfermagem2009;17:120e4.

[7] Noronha MGO, Seter GB, Perini LD, et al. Study of theprofile of organ and tissue elective donors, and the reasons fornondonation, at the Hospital Santa Isabel, Blumenau, Santa Cat-arina. Rev AMRIGS 2012;56:199e203.

[8] Brazilian Organ Transplant Association (ABTO). RBT2(19), 2013.

[9] Paz ACAC, Ribeiro PCA, Mascarenhas MDM, et al. Char-acterization of donor organs and tissues for transplantation in thestate of Piauí from 2000 to 2009. Rev Enferm 2011;2:124e7.

[10] Freire ILS, Vasconcelos QLDAQ, Araújo RO, et al.Characterization of the potential donors of organs and tissues fortransplantation. Rev Enferm 2013;7:184e91.

[11] Fusco CC, Marcelino CAG, Araújo MN, et al. Profile ofeffective donors of multiple organs and tissues by the Organ Pro-curement Organization in a public institution of cardiology. J BrasTranspl 2009;12:1109e12.

[12] Waiselfisz JJ. Mapa da violência 2013: mortes matadas porarmas de fogo. Available at: http://mapadaviolencia.org.br/pdf2013/MapaViolencia2013_armas.pdf.

[13] Detran-CE. Departamento Estadual de Trânsito. Availableat: http://portal.detran.ce.gov.br/index.php/estatisticas.