Global Perspective on Kidney Transplantation: Ecuador

Introduction

Ecuador is located in South America and has a territorial area of 283,560 km². The population as of April 2022 is 17,933,987 (1) distributed in four natural regions: coast, mountains, east, and island. It is estimated that approximately 1.9 million inhabitants are affected by some degree of CKD. The Ministry of Public Health (MSP) has reported that as of December 2021, there were 17,278 patients on hemodialysis, with a prevalence of 957 per million population. In addition, there were 892 patients on peritoneal dialysis and 771 transplant patients (2).

Distribution of the Health System in Ecuador. Access to Dialysis and Transplant Services

The financing of health care in Ecuador is through a free public network and the private system. The public care system, which is the main financer, is carried out through the MSP, the Social Security System, and the Police and Armed Forces health systems.

CKD is listed as a catastrophic disease. The care of this group of patients in the public network generates an annual cost of about 650 million—a fact that has led to serious economic difficulties for access to drugs and coverage (3) (just 1% of the population account for 20%–22% of the public health budget). Private health services play an important role in relieving the state budget, which in 2020 and 2021 was also seriously affected by the coronavirus disease 2019 pandemic.

The National Institute of Donation and Transplantation of Organs, Tissues, and Cells (INDOT) is an entity attached to the MSP and is responsible for the regulation, coordination, control, promotion, surveillance, and evaluation of transplant activity in the country. According to the information issued by INDOT, on April 10, 2022, there were 282 patients throughout Ecuador on the National Waiting List for kidney transplantation (4). The average time on the waiting list is not known.

Background of Transplant Activity in Ecuador: Number and Results

In Ecuador, the first kidney transplant from a related living donor was performed in 1976 at the Armed Forces Hospital in Quito. From 1976 to 2001, transplant activity was carried out in several public and private institutions (pancreas transplants—kidney, pediatric, and cadaveric donor). In this period, 233 transplants were undertaken (predominantly in private centers [58%]), the majority of which were done in the Quito.

In July 1994, the first National Organ and Tissue Transplant Law was enacted, but it was only in July 1998 that the Organ and Tissue Transplant Law Regulations were published and, in December 1999, the Ministerial agreement was generated for creation of the National Organization for Organ and Tissue Transplantation (ONTOT) (5). The constant political changes in the country have not helped in giving clear and constant regulation in the area of transplants.

In 2001, a private institute was created (the Pro-Transplantation Group) that generated the first formal cadaveric harvest and donation program that definitively promoted transplant activity in the country. Until 2007, it was this group that almost exclusively carried out this treatment, completing 126 surgeries. However, Ecuador did not keep a record of this transplant activity, and the information was lost from official sources. As of 2007, there was greater political stability in Ecuador, and the foundations were laid for a better activity registration system in the country. This was published by a group of Ecuadorian authors pointing out that between 2007 and 2018, 1334 kidney transplants were performed, with the rate of transplants from cadaveric donors increasing from 1.27 to 13.33 per million population. At the same time, the living donor rate fell from 2.81 to 1.29 (6). In 2010, pediatric kidney transplants formally began (25 had previously been done sporadically), and in 2012, innovative procedures began, such as kidney-pancreatic and hepato-renal transplants.

On March 4, 2011, the new Organic Law on Donation and Transplantation of Organs, Tissues and Cells in Ecuador came into force. The General Regulations to the law have been in force since July 13, 2012, and these gave way to the transition from the ONTOT to the INDOT, created on July 14, 2012, as a regulatory entity attached to the MSP.

In 2019, 226 kidney transplants were performed (only four living donors), and in 2020–2021, as in the rest of the world, transplant activity in Ecuador suffered a marked decrease due to the coronavirus disease 2019 pandemic, with just 144 transplants taking place in total.

The current legislation allows the donation in life of up to the fourth degree of consanguinity, and donors must be >18 years of age and a spouse or stable partner who must be certified before a notary. The identification, procurement, maintenance, ablation, and distribution of cadaveric donor organs is regulated by INDOT, with the participation of accredited centers for organ ablation on a scheduled basis. Initially, the order of priority is for the region where the donor is identified. Then, if there is no suitable recipient, the organ will be offered at the national level. There is a priority criterion for people with ESRD who have previously been a donor, code 0, or children in cases where the donor is <30 yrs.

Across 46 years, 2089 kidney transplants have been documented: 558 live donor (27%) and 1531 deceased donor (73%). In the period 2002–2021, government support programs with deceased donors were formally started (Table 1).

Table 1.

Percent of live donor versus deceased donor transplants

Periods	Live Donor	Deceased Donor	Total
1976–2001	221	12	233
2002–2022	337	1519	1856
n	558	1531	2089
%	27%	73%	100%

Traditionally, kidney transplants are performed by vascular surgeons and urologists, and post-transplant recipients care is provided by nephrologists. The average length of stay in hospital after kidney transplantation is 7 days, provided there are no complications. Graft and patient survival are 99% at 1 year; no mortality data are available at 5 and 10 years.

Transplant costs are mainly covered by social security, followed by the public health system, police, and armed forces insurance. However, now it is more common to observe patients who are self-financed or with private insurance.

Possibilities for Improvement in Kidney Transplantation in Ecuador

It is important to emphasize the role that private institutions have played in the development of transplant activity in the country because public institutions have periodically suffered from shortages of medical and pharmacological resources, etc. Between 2007 and 2017, it was very difficult to keep private entities functioning due to bureaucratic activity and discrimination toward private medicine, which even led to some patients being transplanted in other countries such as Colombia and the United States. In the last 4 years, the different institutions have adopted a more collaborative approach. This has benefitted the country in terms of reducing the spend by public institutions and reinvesting taxes.

We need to create conditions that make it possible to lower the cost of medicines and medical and laboratory supplies through laws that reduce costs and import times. It is impressive to know that in a neighboring country, many of the exams, supplies, and medicines cost just a third of what they cost in Ecuador, which is why many patients bring medicines from abroad.

It is necessary to reestablish the Ecuadorian Transplant Society. During 2007–2017, scientific societies lost all ability to generate opinion or support in all professional fields. In medical terms, the role of the Ecuadorian Transplant Society has never been considered important, and that is why, especially, the statistical data were lost and only theses or isolated works remained that are only historical references, on the other hand, the contribution that can be given to guarantee the suitability of the medicines and supplies that they want to enter in terms of quality and safety.

The accreditation and reaccreditation processes must be simplified through a review of the forms used in the qualification, in addition to establishing a qualification on the basis of results rather than on numbers or a list of requirements.

We consider organ donors who have suffered cardiac arrest as a donor source that has not been used in Ecuador.

The biggest barrier to transplant development is the lack of medication, supplies, and reagents for specific tests. This implies high costs of medicines and supplies. Some tests are not regularly available, and when they are available, they are very expensive.

It would be important for the Ecuadorian Transplant Society to resume its activity of the control and development of transplants, ensuring better statistics, follow-up of survival, and promotion of new therapeutic and diagnostic advances in the country.

Disclosures

D. Jiménez reports participation in a speakers’ bureau for AstraZeneca. F. Jiménez reports participation in a speakers’ bureau for Boehringer Ingelheim.

Funding

None.

Author Contributions

D. Jiménez was responsible for visualization; F. Jiménez was responsible for conceptualization, data curation, formal analysis, and supervision, and wrote the original draft of the manuscript; and both authors were responsible for the methodology and reviewed and edited the manuscript.