Analysis of Notifications Received by Central de Transplantes in the State of Roraima from 2017 to 2021

Objectives: To analyze brain death (BD) notifications received by Central de Transplantes (CET) in the state of Roraima (RR) from 2017 to 2021. Methods: This is a cross-sectional, quantitative, and observational study, where all notifications received by CET from 2017 to 2021 were analyzed, resulting in 120 patients from health the following centers: Hospital Geral de Roraima (HGR), Hospital Confederação Nacional das Cooperativas Médicas (UNIMED), Hospital da Criança Santo Antônio (HCSA), Hospital das Clínicas (HC), and Hospital Lotty Íris (HLI). The data were collected from the center’s data management system and passed on to the collection form developed by the researcher. Results: This study analyzed 119 notifications after excluding one due to conflicting data. There was a predominance of males (58%), with traumatic brain injury being the most frequent cause of BD. Six organ harvestings were carried out, all at the HGR. This study found no significant associations between organ procurement and sex, age, place of hospitalization, and year. Conclusion: There are considerable challenges concerning organ donation in RR, with a low uptake rate over five years. Only the HGR successfully carried out organ harvesting, while other reporting hospitals were unsuccessful. Improvements are needed, highlighting the importance of more studies for a more in-depth data analysis.


INTRODUCTION
Brazil has the most extensive public organ, tissue, and cell transplant program globally, with guaranteed access to the entire population via the Unified Health System (Sistema Único de Saúde-SUS).Thus, the country is one of the world's largest transplanters, occupying second place in the world ranking, behind only the United States of America.In 2022, 13,349 potential donors (PD) were notified in Brazil, of which 3,522 became effective donors.In the first half of 2023, 206 heart transplants were performed in the country, representing an increase of 16% compared to the previous year 1 .
Despite the high number of transplants carried out, the total number of effective donations is still below what is desired, with around 42,041 Brazilians waiting for an organ for transplant in 2024.This situation is equally critical in needier regions of the country, such as the North Region 2 .
In 2020, the North Region presented, among Brazilian regions, the lowest numbers of PD notifications per year [17.4 per million population (pmp)/year] and donations made (2.1 pmp/year).That year, in the comparison between the states of the Northern Region, Roraima (RR) was one of the states with the lowest number of notifications and donations made, ahead only of the state of Amapá 3,4 .
The primary candidates for PD are generally hospitalized patients with neurological problems, and the donation and transplant process involves a multidisciplinary team, requiring several actions with the aim of transforming the PD into an effective donor performing the transplant 4 .
Transplants are not performed in RR, and only organ and tissue harvesting occurs.The State Transplant Center (Central Estadual de Transplantes-CET) coordinates intra-hospital committees for organ and tissue donations ( Comissões Intra-Hospitalares para Doações de Órgãos e tecidos-CIHDOTTs) at the Roraima General Hospital (Hospital Geral de Roraima-HGR) and the Santo Antônio Children's Hospital (Hospital da Criança Santo Antônio-HCSA), notifying and harvesting locations 5 .
Considering these aspects, the premise of this study was to evaluate the reality of RR in terms of notification of BD, organ donation, and organ harvesting surgery.

OBJECTIVE
Analyze the BD notifications received by the RR CET from 2017 to 2021, checking the donor data, notifying the hospital, and determining the outcomes of such notifications.Identify the captures carried out and the reasons that led to non-reception.Identify the average times between opening, notification, and completion of the organ procurement process.

METHODS
This study is cross-sectional, retrospective, quantitative, and observational, carried out in Central de Transplantes (CET) of RR, with data collection from 120 patients admitted to HGR health centers, National Confederation of Medical Cooperatives (Hospital Hospital Confederação Nacional das Cooperativas Médicas-UNIMED), HCSA, Hospital das Clínicas (HC) and Hospital Lotty Íris (HLI), in the period from 2017 to 2021, referring to all notifications received by CET in the period.
For data collection, the author used a form developed by herself, which asks questions about the reason for brain death (BD) of effective donors, the number of notifications in the period, the number of completed processes, the number of collections carried out, the reasons for not capturing or non-completing the process, the patient's place of hospitalization, age, sex, the outcome of the process completion and other data that may be relevant to the research.
The opening concerns the beginning of the process in the hospital where the possible BD was identified.Next, notification of the opening of the process to the CET is carried out; the finalization, which provides for the conclusion of the processes; the capture, which occurs when the organ is captured and sent for donation; and the non-effectiveness, which occurs when there is no effective capture.The study was approved by the Research Ethics Committee (REC) of the State University of Roraima (Universidade Estadual de Roraima-UERR), with CAAE number 66910323.0.0000.5621.
The statistical analysis used Pearson's chi-square or Fisher's exact test in quantitative variables when the expected frequencies were less than 5.For quantitative variables, the Student's t-test was used in cases where the distribution approached a normal estudo não encontrou associações significativas entre a captação de órgãos e sexo, idade, local de internação e ano.Conclusão: Há grandes desafios em relação à doação de órgãos em RR, com uma taxa de captação baixa ao longo de 5 anos.Apenas o HGR obteve sucesso em realizar captações de órgãos, diferentemente de outros hospitais notificadores.São necessárias melhorias, destacando a importância de se realizarem mais estudos para uma análise mais aprofundada dos dados.
distribution.Otherwise, the non-parametric Mann-Whitney U test was applied.In all comparisons, the usual significance level of 0.05 was adopted.The statistical programs used were SPSS, version 21, and JAMOVI, version 2.2.5.
Qualitative variables were summarized using absolute and relative frequencies.Numerical variables were expressed using measures of central tendency, such as means, and measures of dispersion, such as standard deviations (SD), interquartile ranges, and minimum and maximum values.
Table 5 presents the characteristics of the patients whose organs were harvested.All captures occurred at HGR, and all processes were completed with organs offered to the National Transplant Center ( Central Nacional de Transplantes-CNT).Comparing RR data with those from Brazil, the study by Santos 7 sought to identify the temporal trend in the rates of effective organ and tissue donors and notifications and types of organs transplanted per million of the population in Brazil and detected a growing trend in PD and effective donors across the country, with an average annual increase of 2. 33 and 0.92, respectively.The region with the highest rate of PDs (83.8) and effective donors (34.1) was the South Region.The North Region had the lowest rates, with a rate of PDs of 20.2 and effective donors of 3.9, a persistent trend, as seen in the results obtained in RR.Still, in Santos' work 7 , the main reason for donating was family refusal, followed by medical contraindication, differing slightly from the RR results, which presented death and medical contraindication as the most frequent causes for non-registration (Tables 6, 7, and 8).
Although the patients were primarily male, the female sex prevailed in the collections, corroborating a similar study in which it was found that, in the PD of organs and tissues in which the donation occurred, the sex most frequently was female (61 .90%) 8.However, there were no differences in terms of uptake.In another similar study carried out in the Southern Region of Brazil, in which 102 PD records were analyzed, it was observed that 56.86% of patients were female, with a mean age of 49 years, in contrast to the results of this study.The causes of BD are similar to the RR results, in which the author found that 27.4% had SAH, 22.55% TBI, and 22.55% CHVA 8 .
Still, in the previous study, 31.67% of the declared reason for not donating was, mainly, family refusal, and 35% of the reasons for not donating were death before starting or completing the BD protocol, medical contraindication, a patient living in the community therapy that required judicial authorization to be a donor and registration on a non-donor ID card 8 .These results are similar to those found in RR, including the finding in this research of indigenous people living in villages as a factor in non-donation.In this case, the indigenous people obey the norms specific to their culture and, therefore, do not accept organ donations among their own.This study also demonstrated that 42 of the 102 patients were effective donors 8 ; Of the 119 notifications analyzed, only six donations were made, a NUMBER much higher than those found in RR.All captures were carried out at HGR. Table 4 compares the results of the analyses between TAPN and TAFP, and the average time between opening and notification was shorter in HGR compared to HCSA.This data indicates the possibility of greater agility in communication with other institutions listed in the HGR, facilitating the progress of the process.Even so, as already discussed, the number of donations made was tiny, considering the number of notifications.
Table 3 compares patients who underwent capture and did not obtain significant differences in the statistical test.There is a tendency for donors to be younger, and no donors under ten or over 60 years of age.Bertasi's study 9 presents results that confirm the tendency for the most significant number of donations to be made to young people.The author observed data from 1,772 PDs, in which, when comparing the age ranges of donors and non-donors, the most significant number of donations occurred in the range of 21 to 60 years old (519 donors in total), with a peak of donors in the range of 41-50 years old (165 donors).The number of donations reduced in the 61-70 age range, with 64 donations, and after the age of 70, only four donations were recorded.Up to 10 years of age, 21 donors were found, with the number increasing in the range of 11-20 years, in which 73 donations were made, demonstrating that the number of donors tends to be lower among those under 10 and over 60.
In Bertasi's study 9 , it was also observed that the majority of PDs were male (57.39%), as well as the data found in this study, with an average age of 42.55 years, slightly higher than that found in Table 1.About the causes of BD, the main one seen in this research was vascular, with 996 cases (56.21%), followed by traumatic in 501 (28.27%), neoplastic (central nervous system neoplasms) in 61 (3.44% ), infectious in 26 (1.47%) and 188 classified in the other category (10.61%).
As for the donors in this study, of the total, 681 (38.43%) were available for donation -293 (43.02%) female and 388 (56.98%) male -this finding is consistent with the described in Table 5, in which the majority of donors were female.Other data from the author are also similar to the RR results, where the main reason for not donating organs was family refusal (42.8%) followed by medical contraindication (25.75%), cardiorespiratory arrest (CPA) (21, 63%), positive serology (4.21%) and failure to complete the BD protocol; in 60 cases (5.49%) there was no reason for non-donation 9 .
In Table 4, an analysis was made between TAPN and TAFP, showing that HGR had the shortest times and was more agile in the process than other hospitals.HGR was still the main notifier and the only place among the five hospitals described in Table 4 to carry out the captures.HGR is the primary reference hospital in RR, where urgent and emergency care of medium and high complexity is provided.Located in the state capital, Boa Vista, the hospital receives patients from the capital from all municipalities in the state.Also, it serves patients from Venezuela and Guyana, countries that border RR.Due to its size and relevance, it became the hospital with the highest patient volume, notifying PD and making donations.The hospital still receives many investments in expansion and infrastructure, which can contribute to greater agility in the organ donation process 10 .
Carrying out the study in RR presented some limitations, including a need for more information on some patients in the system, conflicting information from patients, and changes in some variables, such as families who gave consent to the donation but Oliveira LCS, Mendes LLA, Brum MD, Lima MS, Lobo ACF, França JAPC, Santos Junior CH, Mota LEL, Maia Neto GP, Araújo JES, Rabelo MN, Paz TLP, Lustosa VHS, Santos BC, Linhares MM withdrew it after a few days.It is essential to highlight that patients who suffered CPA before harvesting did not donate corneas, as the state does not yet have the necessary infrastructure for this harvesting.However, since 2023, there has been a project to build and implement the Human Ocular Tissue Bank (Banco de Tecido Ocular Humano -BTOC), which already has a location where it will be built in the city of Boa Vista, according to information provided by the nurse responsible for the RR CET.In the researched literature, only some studies were found on the topic, some of which needed to be updated and, therefore, not included in this study.
Despite the limitations and difficulties inherent in the organ donation process, in RR and all Brazilian states, the effort and organization of institutions and the professionals involved in making the donations are clear.Therefore, it is very valid that studies on this topic are developed, preferably with a deeper analysis of the cases, and other hospitals and/or professionals are also sought to understand better all the factors influencing whether to donate organs.

CONCLUSION
Carrying out this study demonstrated that RR still needs to work on organ donation, with a deficient number of harvests carried out over 5 years.Of the hospitals mentioned in the study, only HGR was successful, with no captures in the other reporting hospitals.
Despite efforts, RR follows the trend of the North Region, which has the lowest organ donation rates in Brazil.However, there is an increasing agility in organ donation, from the opening to the procurement of organs/completion of the process, with the majority occurring on the same day or within 1 day.
In the acquisitions carried out, the majority occurred on the same day or within one day after the opening of the process, with the capture carried out in 2020, possibly due to the COVID-19 pandemic, the longest, with 4 days between opening and completion of the process.There was also the procurement of multiple organs and tissues from most donors, with only two donating just one organ.Although studies in the literature point to family refusal as one of the main reasons for non-harvesting of organs, in RR, death and medical contraindication were the most frequent causes, with family non-consent generally being the third most significant cause of non-harvesting.
It is concluded that several points need to be improved to modify the panorama presented in RR.More studies on the topic, with more in-depth data analysis, are vital to resolve the deficits listed here and others that may be identified and offer more support for creating new strategies to optimize the organ donation process in the state.

Table 1
presents the characterization of patients concerning age and gender.The mean age of the patients was 36.9 ± 19.8 years, ranging from 1 to 83 years.Regarding gender, men were predominant (58%).

Table 2 .
Reasons for BD.

Table 3
compares patients who had or did not have organ harvesting in terms of gender, age, place of hospitalization, and year of operation.All captures were made at HGR in 2018, 2019, and 2020.From a statistical point of view, no significant associations were found.

Table 3 .
Comparisons between groups that performed organ harvesting.

Table 4 .
Comparison between opening and notification times and opening and ending times of the capture process divided for the place of hospitalization.

Table 5 .
List of donors who underwent organ removal surgery.