In 1998, Brazil’s public healthcare system got its first specialized renal-transplant facility, the 70-bed Kidney and Hypertension Hospital (Hospital do Rim e Hipertensão, or HRIM). Established by the Federal University of São Paulo, in conjunction with the Oswaldo Ramos Foundation, HRIM set what seemed at the time an ambitious goal of eventually performing kidney transplants at the rate of one per day.
Today, the 151-bed hospital performs an average of more than three kidney transplants a day, seven days a week. HRIM has become a model of efficiency and positive outcomes for the procedure not only in São Paulo, but throughout Brazil, and even internationally. “The biggest benefit of our model is that it can be implemented in developing countries with limited availability of highly complex treatments,” says the hospital’s transplantation director, Dr. José Medina Pestana.
Early on, Pestana recognized that the key to success would be setting up a multidisciplinary “assembly line” approach that standardized and continually improved processes for every phase of the transplant pathway. That pathway starts with organ procurement, continues through patient admission and pre-op, and extends to post-op follow-up.
HRIM has followed this model in more than 11,000 transplants over the past 18 years, making the São Paulo facility the highest-volume publicly funded center of renal transplantation in the world. HRIM today has 5,303 candidates on a waiting list for kidney transplants, and another 338 for combined kidney and pancreas transplants. Heavy demand led HRIM in 2009 to establish a 60-bed satellite unit at Brigadeiro Hospital, which is now the Euryclides de Jesus Zerbini Transplantation Hospital in São Paulo. HRIM also treats cardiovascular disease, and all together sees some 10,000 patients a year.
Helping to fuel HRIM’s growth has been the fact that transplant costs are about 90-percent covered by Brazil’s public national health system, the Sistema Único de Saúde (SUS). Brazil’s public funding covers some 8,000 solid-organ transplants annually, of which 5,556 are kidney transplants, and includes paying for the life-long supply of medication needed to avoid organ rejection. To oversee that funding, the SUS in 1997 created a centralized transplantation-focused health ministry division, which regulates organ donation in all 27 Brazilian states. The country now has the second biggest national transplantation program in the world, behind only the U.S. And the SUS pays for more transplants than any government health system in the world.
Volume of transplant operations isn’t the only metric HRIM can boast about. Pestana reports that surgical complication rates hover at about 7 percent; that’s relatively low compared to the rate of major complications in inpatient surgical procedures in industrialized countries, which ranges from 3 percent to 22 percent. HRIM’s 30-day patient readmission rates have remained around 27 percent, a promising indicator given the high risk that kidney transplant recipients have of being readmitted, which ranges from 18 percent to 50 percent. Infection rates at the site of incision have decreased to 2.5 percent, and urinary tract infections are down to 4.4 percent. Graft survival rates from living donors have risen to 97 percent, and graft survival from deceased donors to 90. Patient survival from living donor transplants is 99 percent and from deceased donor transplants is 95 percent.
HRIM’s success in achieving these outcomes have helped to raise transplant standards throughout Brazil, and even throughout the Americas. And components of the streamlined, standardized transplant pathway model can be applied in other complex specialty-care treatments. Pestana highlights that the model has prompted the creation and expansion of other transplantation centers across Brazil.
The program has also spawned numerous collaborative research and educational opportunities. Results from clinical trials involving more than 3,000 HRIM patients between 1998 and 2015, for instance, have helped lead to the approval of new forms of immunosuppressant treatments by regulatory agencies in the U.S. and Europe. And in just the past two years, more than 1,000 researchers across Brazil, along with about 100 doctors from other countries in Latin America, have come to HRIM for educational programs.
HRIM’s accomplishments have been reflected in some of the recognition Pestana has been accorded around the world. He’s been elected a fellow of the British Royal College of Surgeons, for example, and is the only Brazilian ever to have been given a visiting professorship at Harvard Medical School. But Pestana insists he and his team remain focused on the original vision. “We’ve always wanted to improve public-patient access to the highest levels of advanced-renal-disease treatment,” he says. “We’ve done that in São Paulo, and now we see it happening in all of Brazil and beyond.”
— Tarsilla S. Moura
Tarsilla S. Moura is the managing editor at GHCi.