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Organ Transplantation in Lithuania

Miglinas, Marius MD, PhD1,2; Vaiciuniene, Ruta MD, PhD3,4; Vickiene, Alvita MD1,2

doi: 10.1097/TP.0000000000002575
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1 Department of Nephrology and Kidney Transplantation, Centre of Nephrology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.

2 Faculty of Medicine, Vilnius University, Vilnius, Lithuania.

3 Nephrology Department, Hospital of Lithuanian University of Health Sciences Kauno klinikos, Kaunas, Lithuania.

4 Department of Nephrology, Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.

Received 19 November 2018

Accepted 10 December 2018.

The authors declare no funding or conflicts of interest.

Correspondence: Marius Miglinas, MD, PhD, Centre of Nephrology, Vilnius University Hospital Santaros Klinikos, Santariskiu 2, LT-08661 Vilnius, Lithuania. (marius.miglinas@santa.lt).

Organ transplantation has come a long way in Lithuania, a country with a population of 2.9 million.1 Lithuania is located on the Baltic Sea bordering Latvia, Belarus, Poland, and Russia (Figure 1).

FIGURE 1

FIGURE 1

Transplantation in Lithuania started with experimental research in the 1920s. V. Kuzma, a young and talented Lithuanian surgeon improved his skills in Vienna, Austria, working with Professor A. Eiselsberg in the field of tissue regeneration and transplantation. Their work linked them to Emmerich Ullmann, a Hungarian doctor and pioneer in transplantation who had contributed with the first successful kidney transplant in dogs (1902). In 1932, V. Kuzma returned to Lithuania, continued his work in transplantation and completed a PhD thesis “On the Issue of Renal and Urinary Tract Regeneration.” The Second World War and a most challenging period thereafter brought progress to a standstill and transplant activities resumed at Vilnius University in 1964. The first kidney transplantation from the deceased donor was performed in Vilnius in 1970.2

Isolation and a strict central regulation by the Soviet Union had been in the way of further progress. With the independence of the country in 1990, effective communication with established transplant centers was initiated. Subsequently, transplant volumes increased, outcomes improved, and organizational structure and legislation soon reached European standards.

Today, Lithuania has 2 transplantation centers in Vilnius and Kaunas, the largest cities of the country, where heart, kidney, liver, lung, bone marrow, cornea, and simultaneous organ (pancreas-kidney, heart-kidney, liver-kidney, and heart-lungs) transplantations are performed3,4 (Figures 2 and 3).

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

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KIDNEY TRANSPLANTATIONS

Kidney transplantation is the most common solid organ transplantation in Lithuania and has been successfully implemented as the treatment of choice for end-stage renal disease.

During the last 5 years, the average number of the deceased donor kidney transplantations performed per year has been 82.8 (28.6 per million population [pmp]).4 As a comparison, deceased donor kidney transplantations rates in Spain, Germany, and Russia were 63.3, 16.6, and 6.8 pmp, respectively.5

Living donor kidney transplants, although successfully established, are less frequent with 8.2 transplantations/year (2.8 pmp)4 (compared to Spain 7.2 pmp, Germany 6.8 pmp, Russia 1.4 pmp).5 To improve standards of renal transplantation and aiming for an increased volume, new initiatives have been implemented including preemptive living donor transplantations, desensitization of highly sensitized recipients, ABO incompatible transplantations, and refined immunological surveillance with monitoring of donor-specific antibody monitoring. Paired kidney transplantations have thus far not been performed, although the process has been established in 2013.

Kidney transplant outcomes in Lithuania have steadily improved with 1- and 5-year graft survival rates of 91% and 82% for deceased donor kidney transplants and 93% and 81%, respectively, for living donor kidney transplants. One-year patient survival rates have been at 97% for both, recipients of living and deceased donor transplants, while 5-year survival rates have been 91% and 96% for recipients of deceased and living donor kidneys, respectively.

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HEART TRANSPLANTATIONS

During the last 5 years, the average annual number of heart transplantations performed has been 11.6 (4.0 pmp)4 (compared to Spain 6.6 pmp, Germany 3.1 pmp, Russia 1.8 pmp).5 Survival rates of 1 and 5 years have been 70% and 58%, respectively.

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LIVER TRANSPLANTATIONS

First attempts to perform liver transplantation in Lithuania were made in 2000. Currently, liver transplantation is expanding rapidly. During the last 5 years, an average of 16.8 (5.8 pmp)4 liver transplantations have been performed (compared to Spain 26.9 pmp, Germany 10.0 pmp, Russia 3.0 pmp).5 Survival rates of 1 and 5 years have been 81% and 73%, respectively.

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OTHER SOLID ORGAN TRANSPLANTATIONS

Other solid organ transplantations including lung and combined heart-lung transplantations are performed only in Kaunas, while combined pancreas-kidney transplantations are performed in Vilnius, albeit significantly less frequently (1–2 transplantations/y).4

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BONE MARROW TRANSPLANTATIONS

Bone marrow transplantation (BMT) started in 1999 in Lithuania. Since then, more than 2000 BMTs have been performed. In average, 200 BMTs are performed including autologous, allogeneic related, unrelated, and haploidentical donor transplants. Cell transplant therapies include mesenchymal stromal cells, selected, virus specific, and genetically modified lymphocytes (T lymphocytes genetically modified to express the HSV-Tk gene with retroviral vector within TK008 clinical trial). The Lithuanian Unrelated Donor Registry is a member of World Marrow Donor Association and lists more than 11 000 donors available for Lithuanian as well as for international recipients including patients from Latvia, Russia, and Kazakhstan that have been transplanted at Vilnius University Hospital.

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REGULATIONS

Deceased organ donation is based on an opting-in principle requiring consent before death or the agreement with the next-of-kin. This approach assures that human tissue, cell, organ donation and transplantation is voluntary, without coercion and in accordance with the principles of anonymity, confidentiality, and respect for human dignity. Penalties are applicable for illegal removal or the sale of human tissue and organs.

All data on transplants, donors, and recipients are recorded in the Register of Donors and Recipients of Human Tissues and Organs. Organs are allocated according to a strictly regulated system based on blood group, HLA compatibility, waiting time, sensitization and age (for kidneys and pancreas), and disease severity (for heart, lung, and liver).

Like many other European States, Lithuania has a mandatory health insurance system. Thus, all Lithuanians must obtain health insurance coverage supported by 9% of their income. In return, all healthcare expenses are covered, including expenses associated with transplantation, posttransplant care, and long-term immunosuppression.

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CHALLENGES

Organ donation in Lithuania remains challenged by misconceptions and misbelieves among both the general population and medical professionals requiring educational efforts. The refusal of organ donation by the next-of-kin remains as high as 30%.6 Moreover, structures linking the identification of donors, treatment before organ procurement, and an enhanced communication to transplant centers require improvement to optimize the donor potential.

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ACHIEVEMENTS

The Lithuanian National Bureau of Transplantation founded Balttransplant in 2002, a nonprofit organization operating in Estonia, Latvia, and Lithuania, which organizes and facilitates organ donation in a concerted effort among the Baltic states.

The option of donation after circulatory death has been approved in 2015 and the first kidney from a donor after cardiac death has been performed in Kaunas at the Hospital of Lithuanian University of Health Sciences (2016).

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REFERENCES

1. World Health Organization. World Health Statistics 2016: monitoring health for the SDGs. 2017. Available at http://who.int/gho/publications/world_health_statistics/2016/en/. Accessed December 4, 2018.
2. Miglinas M, Rainienė T, Dainys B. Kidney transplantation in lithuania: more than 40 years of experience. Medicinos Teorija ir Praktika. 2012;18:592–596.
3. National Transplant Bureau under the Ministry of Health. Statistics of the recipients. 2018. Available at http://ntb.lrv.lt/en/statistics/recipients. Accessed December 4, 2018.
4. National Transplant Bureau under the Ministry of Health. Statistics of the transplantation. 2018. Available at http://ntb.lrv.lt/en/statistics/transplantation. Accessed December 4, 2018.
5. Domínguez-Gil B, Matesanz R. Newsletter Transplant: international figures on donation and transplantation 2017. EDQM. 2018;23:8–13.
6. National Transplant Bureau under the Ministry of Health. Statistics of the donation. 2018. Available at http://ntb.lrv.lt/en/statistics/donation-1. Accessed December 4, 2018.
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