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A Regional Report on the Evolution of Organ Transplantation in Estonia

Pall, Virge MD1; Laisaar, Tanel MD, PhD1; Ericzon, Bo-Göran MD, PhD2

doi: 10.1097/TP.0000000000002730
In View: Around the World
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1 Tartu University Hospital, Transplantation Centre, Tartu, Estonia.

2 Scandiatransplant, Aarhus, Denmark.

Received 20 March 2019.

Accepted 20 March 2019.

The authors declare no funding or conflicts of interest.

Correspondence: Virge Pall, MD, Tartu University Hospital, Transplantation Centre, 8 L. Puusepa St, 50406 Tartu, Estonia. (virge.pall@kliinikum.ee).

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ORGAN DONATION AND TRANSPLANTATION

Estonia has a population of 1.3 million with a density of 30 inhabitants/km2 (Figure 1). A limited donor pool challenges optimal matching, especially in urgent cases. Limitations, however, can be addressed by collaborating with other organ procurement organizations. During the last decade there has been a continuous improvement in the optimization of deceased donor organ procurement with the aim to provide access for Estonian patients to all organ transplants.

FIGURE 1

FIGURE 1

Estonia has been an independent state since 1918, interrupted by the half-a-century-long Soviet occupation following the World War II. Estonia restored its independence in 1991. For years, surplus kidneys have been exchanged between the Baltic states, although volumes have been small.

Based on the geographic location of Estonia the logistically preferred choice for collaboration, in the field of organ exchange, apart from the Baltic states, is Scandiatransplant and attempts have been made in the past to implement this collaboration.

Since 2000, Estonia averaged 24 deceased donors corresponding to 18.1 pmp with a significant variance of 10–35 deceased donors/a.4 Live donor kidney transplants have been less frequent with approximately 5 procedures/a.

Tartu University Hospital is the only transplant center in the Republic of Estonia. The first organ transplantation was performed here in 1968 using a deceased donor kidney. The first living-related kidney transplant took place a few years later in 1972 (Figure 2). A liver transplantation program was initiated in 1999 and the first lung transplantation was performed in 2010 (Figure 3).

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

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INTERNATIONAL COOPERATIONS

Starting in 2011, the Executive Board of the Tartu University Hospital prioritized organ transplantation. A separate center was established for transplant coordination; financing principles of organ donation and transplantation services were reviewed by the state. An international accreditation by the European Federation of Immunogenetics was obtained for the histocompatibility laboratory and negotiations with Scandiatransplant concluded successfully. A formal agreement on the exchange of surplus organs between Scandiatransplant and Estonia supported by the Ministry of Social Affairs was signed in January 2013.

Between 2013 and 2016, 37 donor procurements were performed in Estonia in close collaboration with Scandiatransplant; 77 donor organs were exported to centers in Scandinavia including Aarhus, Copenhagen, Gothenburg, Helsinki, Oslo, Stockholm, Skane, and Uppsala. Conversion rates improved from 2.3 to 3.7.

Logistical complexities prolonged the average time from declaration of brain death until the start of donor organ retrieval (4–9.2 h); at the same time, costs per donation increased significantly. However, outcomes have been worth the efforts. Offering surplus organs abroad within Scandiatransplant markedly increased transplant rates, improved ICU doctors’ motivation to identify donors, and enhanced skills for multiorgan donor management. Estonian transplant coordinators acquired invaluable experience in coordinating international procurements and transplant surgeons had an excellent opportunity to work with the experienced Scandinavian teams. Our local teams obtained additional knowledge in evaluating donor organ viability and organ retrieval techniques.

This gradually growing collaboration with Scandiatransplant aimed to establish mutual contacts and trust between individual transplant professionals, also enhanced learning from the practices of experienced centers, while setting goals for the future.

As a result, laparoscopic living donor nephrectomies have been started in January 2015 and a national program for simultaneous pancreas-kidney transplantations have been initiated in March 2015. In parallel, a cooperation with Helsinki University Hospital in Finland has been established to perform heart transplants for Estonian patients.

The next important breakthrough came in May 2017, when the Scandiatransplant council of representatives formally accepted Tartu University Hospital as an associate member of Scandiatransplant. Subsequently, rules and regulations of Scandiatransplant have been implemented, local working processes and logistics have been revised, database reprogrammed, user training conducted, and waiting list data harmonized to mention some important changes. Everything went smoothly, and Tartu University Hospital started day-to-day operations within Scandiatransplant in October 2017.

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ONE YEAR OF COOPERATION WITH SCANDIATRANSPLANT

In 2018 we had 25 deceased organ donors pmp and 3 living kidney donors pmp. Altogether 122 donor organs were procured and transplanted, 53.3% in Estonia and 46.7% in other Scandiatransplant centers. Around 18% of Estonian patients transplanted in Tartu received organs from other Scandiatransplant centers.5

Estonian patients have access to all organ transplants, either locally for kidney, pancreas, liver, and lung transplants or via the collaboration with Scandiatransplant (mainly heart and pediatric liver). About 76 organ transplantations (57.6 per million) were performed for Estonian recipients in 2018, including 72 in Tartu and 4 in Helsinki

Altogether 1.341 organ transplantations have been performed in Estonia from 1968 to 2018 (Table 1).

TABLE 1

TABLE 1

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OPPORTUNITIES AND CHALLENGES

Organ donation and transplantation in Estonia has significantly improved in recent years. There is a well-functioning network of donor hospitals and multiple organ procurements are performed in most deceased donors. Although the comprehensive cooperation between Scandiatransplant and Tartu is still in its early phase, it has evolved rapidly and successfully.

Undoubtedly, there are problems and challenges behind such a successful development. Because of the relatively small volume of services, it is quite difficult to retain staff competence and ensure expert availability at any time. The awareness of the general population for organ donation remains limited and requires improvement. Donor registration is voluntary in Estonia and <1% of the population have registered as donors. Moreover, the potential for living donation remains underutilized. Future goals are the implementation of national programs for paired kidney exchange and donation after circulatory death.

Overall, transplantation is well established in a small country such as Estonia. The engagement and support by local professionals and competent Authorities have been the pillar for the success of organ transplantation in Estonia.

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REFERENCES

2. Regio websiteMap of Estonia.Available at www.regio.ee. Accessed March 13, 2019
    3. Statistics Estonia websiteAvailable at https://www.stat.ee/en. Accessed March 13, 2019
      4. Estonian Society of Tissue and Organ Transplantation websiteAvailable at http://elundidoonorlus.ee/doonorlus. Accessed February 9, 2019
      5. Scandiatransplant websiteScandiatransplant figures.Available at www.scandiatransplant.org/data. Accessed February 9, 2019
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