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.
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).
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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2. Regio websiteMap of Estonia.Available at www.regio.ee
. Accessed March 13, 2019