Skin bank of Curitiba, Brazil: epidemiology of donors and recipients
Banco de pele de Curitiba, Brasil: epidemiologia de doadores e receptores

INTRODUCTION

Homologous skin grafting may represent the difference between the life and death of large burned patients. Its use consists of a precious treatment when an autologous graft is not available¹. Allogeneic skin grafting has been used since the nineteenth century, and after this long period, this practice proved to be a safe and effective procedure in the management of burns².

Although there are isolated reports in the literature, historically, the first to describe epidermal grafts in skin losses was Reverdin in 1869³. The procedure consisted of elevating the donor area’s skin with a needle, forming small peaks, whose ridge was cut horizontally, and the extracted fragment was then transferred to the receiving area⁴. However, the use of skin allografts specifically for burn treatment was described only in 1881 by Girdner⁵.

The loss of skin integrity promotes fluid loss, infections, hypothermia, impaired immunity, hypovolemia, and pain, among other complications^2-4. In patients with burns of great body extension and scarcity of donor area, the surgeon may opt for allogenous skin transplantation^2-4 this, in turn, reduces the loss of fluids and proteins by the injured areas, acts as a physical barrier against germs, modulates the wound bed to stimulate the physiological healing process and promotes analgesia⁶, reducing morbidity and mortality².

Despite the advantages of using allogenous grafts, tissue transplantation is not without risks, the main one being the transmission of infectious diseases. The tissue banks were created to perform the processing and storage of the allogenous skin. These banks operate through standards that ensure the tissue’s safety and quality, from its capture to the material’s distribution. This rigor is essential to ensure that skin transplantation is performed safely.

In 1997, through Law No. 9,434⁷, human organ and tissue transplantation was regulated in Brazil. The law establishes that the removal of tissues, organs, or parts of the human body post-mortem can only be performed after a diagnosis of brain death, confirmed by two physicians not participating in the removal and transplantation team, based on predefined clinical and technological criteria⁶. Since 2001, after Law No. 10,211⁸, there is a need for an informed consent form, with family consultation to authorize the donation.

Law No. 2,268 of 2017⁹, established that both the uptake and transplantation of organs and tissues could only be performed by specialized medical-hospital teams and institutions registered with the state health departments and the National Transplant System (SNT)⁸.

The Hospital Universitário Evangélico Mackenzie (HUEM)’s skin bank was inaugurated in June 2013, with its own facilities according to the standards of the SNT and, since then, performs collection and storage of skin in glycerol 90%⁶.

Skin donors are divided into two categories: brain death donors, who are multi-organ donors and comprise almost all skin bank donors, and donors in cardiorespiratory arrest¹⁰.

In 2019, according to statistics from the Brazilian Association of Organ Transplants (ABTO), the rate of organ and tissue donors increased by 6.5%. They stood out with notification rates of potential donors, the Federal District and Paraná, with a donation rate higher than 50% and with a family authorization rate higher than 70%. These values represent suitable donation parameters and have been used as a model by other states⁹.

Regarding cell and tissue transplants registered in 2019, there were 10,418 bone donors, 14,943 corneas, 3,805 bone marrow, and only 130 skin donors. However, there was an increase of more than 100% in effective donors compared to 2018, when 62 skin donors were registered¹¹.

OBJECTIVES

Analyze the epidemiological profile of skin donors and recipients from the skin bank of the Hospital Universitário Evangélico Mackenzie (HUEM) and its productivity, from its inauguration in 2013 to 2019.

METHODS

For epidemiological analysis of the skin bank of the HUEM, a consultation was made to the annual reports of the seven-year period (2013 to 2019), whose completion is part of the bank’s routine. These reports contain information on donors, gender, date of donation, captured skin area (cm²), available skin area (cm² and slides), area of donor skin (cm²), and data on tissue distribution.

The present study obtained approval by the research ethics committee of the Mackenzie Presbyterian Institute, under opinion number: 32582620.6.0000.0103/2020.

RESULTS

Between 2013 and 2019, skin uptake was performed from 187 donors, of which 114 (61%) were males and 73 (39%) females (Figure 1). These patients’ mean age was 41.07 years, with a registered minimum age of 16 years and maximum age of 60 years.

Figure 1 - Donor sex.

Figure 1 - Donor sex.

The number of donors averaged 21.3 per year. In 2015, there was a maximum peak of 29 skin donations and, in 2019, the lowest number recorded, only ten donors (Table 1). Of the total uptake, the tissues of 149 (79.7%) donors were used in transplants, and 38 (20.3%) were discarded for various causes, such as bacterial contamination.

Table 1 - Number of donors per year.

During seven years of operation of the HUEM skin bank, 201,000cm² of viable tissue were collected, resulting in the production of 3,770 skin slides. On average, 1,350.02cm² of tissue were removed from each donor, corresponding to approximately 25.3 tissue slides. The smallest area obtained from a patient was 407.9cm² of skin, while the largest area corresponded to 2,720cm². More than 90% of the collections performed included the dorsum regions, trunk, and anterior and posterior parts of the lower limbs.

Tissue samples collected from a single donor could be used by about 2.6 recipients on average, with maximum utilization of 8 recipients per donor. On average, each recipient used 19.43 skin slides and underwent about 1.68 grafting procedures, performed mainly in burned patients. The year in which procedures were performed the most was 2016, with 71 operations in 38 receivers. The least busy year was 2013, with 18 procedures in 13 receivers. The annual mean of procedures was 46.43 (Figure 2).

Figure 2 - Number of grafting procedures and number of recipients per year.

Figure 2 - Number of grafting procedures and number of recipients per year.

Since 2013, 325 allogenous grafts have been performed at HUEM that have benefited 194 people. Of these recipients, 124 (63.9%) were male, and 70 (36.1%) the feminine. The mean age of patients receiving the skin was 34.67 years, with a minimum age of 1 year and a maximum of 63 years.

Tissue uptake was performed mainly in the HUEM itself, accounting for 74 collections. There were also captures in other locations, Hospital Universitário Cajuru (HUC) with 61 collections, Hospital do Trabalhador (HT) with 24 collections, Hospital Nossa Senhora do Rocio (HNSR) with 24 captures, Hospital da Cruz Vermelha (HCV), and Hospital Angelina Caron (HAC) with 13 captures each, in addition to the Hospital São Vicente (HSV) with 10 collections (Figure 3).

Figure 3 - Tissue captures hospitals.

Figure 3 - Tissue captures hospitals.

Most of the skin captured, processed, and stored by the HUEM bank (about 91%) was used in grafting performed in the institution itself, in the plastic and burned surgery sector. Other hospitals in Paraná performed 7% of the operations. Only 2% of these procedures were completed outside the state.

DISCUSSION

Compared to a previous study conducted at the same institution in 2013, HUEM remains the main hospital for tissue collection in Curitiba and the metropolitan region. However, its percentage participation was reduced from 44%⁶ to 28% due to the increase in other services’ contribution. The mean age of donor patients increased from 36¹² to 41 years, and the minimum age (16) and maximum age (60) remained the same^6-12. The minimum amount of tissue removed from a single donor remained similar (422.2 to 407.9cm²). However, the maximum amount of tissue removed increased from 1,252 (in2013) to 2,720 cm^2,6-12 on the years of this study.

In 2019, the average amount of skin collected was 1,350.02cm² per donor, surpassing data from 2013, when 1,252.59cm² was recorded. The HUEM numbers are similar to the Porto Alegre skin bank, which obtained an average of 1,364.46cm² between 2008 and 2010¹³. This amount is still lower than that recorded in international banks, such as Helsinki, which captures 3,062cm² of skin per donor, the smallest amount of a single donor being 1,655 cm^2,14.

Regarding the recipients, men continue to have a higher prevalence (63.9%), as demonstrated in 2013 study⁶, when they corresponded to 66.7%. According to the research previously done in the same service, the average number of transplants performed per patient was 1.73^6-12 in 2013. This data is similar to that obtained in this research (2013 to 2019), which showed an average of 1.68 transplants per patient.

During these seven years of operation, the HUEM skin bank benefited 194 patients. HUEM continues to be the primary institution in performing tissue transplantation in Paraná. In 2013, still under the name Hospital Universitário Evangélico de Curitiba (HUEC), it covered 88.5% of skin transplants performed^6-12 and is currently responsible for 91% of these procedures.

HUEM’s skin bank performs an average of 21.3 captures per year. This number is similar to that found in the Hospital de Clínicas de São Paulo’s tissue database, which recorded an average of 25.3 captures per year between 2001 and 2006¹⁰. Between 2001 and 2008, the Helsinki skin collection center collected tissue from 7 to 20 donors, with an annual average of 14.4¹⁴.

CONCLUSION

The HUEM skin bank provided allografts that benefited 194 people in 7 years of operation. Most donors and recipients were male and approximately 40 years old. The number of captures performed by this skin bank was compatible with that of other institutions in Brazil.