Organ Transplantation in Sweden (2016)

EARLY DAYS OF TRANSPLANTATION IN SWEDEN Sweden is a small country in the northern part of Europe with a population close to 10 million people. The tradition of organ transplantation in Sweden dates back to the late 1950s and early to mid-1960s based on collaborative efforts with, at that time, Peter Bent Brigham Hospital, Harvard Medical School by the late transplant pioneer, Professor Lars-Erik Gelin from Gothenburg. Lars-Erik Gelin had been a postdoctoral fellow with Francis D. Moore in the late 1950s and had developed close ties with Joseph E. Murray. In subsequent years, both Stockholm and Gothenburg sent young surgeons to Thomas Starzl who had just started liver transplants in Denver, CO. This international network has had a great impact on organ transplantation in Sweden and the rest of Scandinavia. Lars-Erik Gelin was not only a pioneer in organ transplantation, he was also instrumental in establishing the International Surgical Group after World War II. This group of highly recognized surgeons is limited to 60 active and 60 retired members holding meetings throughout the world that promote science and peace. Infrastructure and Organ Allocation Sweden is 1 of 5 member countries constituting Scandiatransplant, the organ procurement organization of Scandinavia. Finland, Norway, Denmark, and Iceland are additional members representing a population of 25.8 million. Priorities of Scandiatransplant include the procurement and allocation of organs for transplantation with an emphasis on allocating kidneys to highly sensitized recipients, in addition to providing liver, heart, lung, small bowel/multivisceral, or pancreas recipients with organs. In contrast to allocation priorities in Eurotransplant or United Network for Organ Sharing, organs are allocated locally first, unless there is a high urgency request within Scandiatransplant. Organs can also be offered to allocation organizations outside Scandiatransplant. Organs will neither be offered to individual hospitals or institutions nor directly to recipients outside of Scandinavia. Directed donation is allowed within the concept of living donor procedures but not for organs from deceased or nondirected donors. It has been our policy not to identify live donors because this may encourage organ trading. Scandiatransplant is owned by participating hospitals (centers) and not by the government of participating countries. Sweden has 4 centers performing kidney transplantations (Gothenburg, Stockholm, Uppsala, and Malmö); livers are performed in Gothenburg and Stockholm, heart and lung transplantations in Gothenburg and Lund, whereas pancreas transplants are performed in Gothenburg, Uppsala, and Stockholm. Small bowel and multivisceral transplants are only performed in Gothenburg. This center is also certified as a European Union of Medical Specialists/European Board of Surgery educational center. Data Systems and Overall Transplant Volume All centers performing organ transplants are public academic institutions, and there are no private transplant programs in Scandinavia. Although there is no legal restriction for private renal transplant centers in Scandinavia, European Union regulations have effectively prevented private transplant units. It is mandatory to register all donors and recipients in the Scandiatransplant registry. Basic follow-up data are submitted to Scandiatransplant in addition to national and international registers. Of note, the submission of some but not all data is mandatory. By 2015, more than 14 000 kidney transplants had been performed in Sweden with almost 30% of this number being live donor kidney procedures (Figures 1A and B). There has been no reported donor mortality from any of the centers to date. At present, live donor nephrectomies are almost exclusively performed by minimally invasive methods—either hand-assisted retroperitoneally or through a total laparoscopic approach.FIGURE 1: A, Kidney transplants per year in Sweden. B, Total number of kidney transplants in Sweden. LD, living donor; DD, deceased donor.More that 600 pancreas transplants had been performed by 2015 of which the majority had been simultaneous kidney/pancreas transplants (Figures 2A and B). Interestingly, pancreas transplants had an initial peak during the late 1980s and early 1990s. Numbers remained low in the subsequent 15 years, and of interest, since 2007 numbers have again increased significantly. Approximately 40 pancreas transplants are currently performed per year.FIGURE 2: A, Pancreas transplants per year in Sweden. B, Total number of pancreas transplants in Sweden.Liver transplantation has been performed since the mid-1980s in Sweden with more than 3000 procedures registered in Scandiatransplant (Nordic Transplant Liver Register) and European Liver Transplant Register by 2015 (Figures 3A and B). Heart and lung transplants are performed in Gothenburg and Lund, and more than 1000 hearts and 900 lungs were transplanted by the end of 2015. Annual rates of heart and lung transplants presently exceed a volume of 60 per year, per organ (Figures 4A and B and 5A and B). Professor Stig Steen has pioneered the preservation of lungs with the so-called Steen solution. This approach has been particularly successful to recondition marginal lungs and critically contributed to an increasing volume of lung transplants since 2009. Sweden has been one of the pioneering countries for small bowel and multivisceral transplantation since 1991. More than 30 small bowel and multivisceral transplants have been performed by 2015, currently with an annual rate of 2 to 3 procedures per year (Figure 6). In Scandinavia, those procedures are offered in Gothenburg and also most recently in Helsinki.FIGURE 3: A, Liver transplants per year in Sweden. B, Total number of liver transplants in Sweden.FIGURE 4: A, Heart transplants per year in Sweden. B, Total number of heart transplants in Sweden.FIGURE 5: A, Lung transplants per year in Sweden. B, Total number of lung transplants in Sweden.FIGURE 6: Total number of bowel transplants in Sweden.Living and Deceased Donation Rates Organ donation is based on presumed consent in Sweden; a register for organ donation has been established by the Swedish Board of Health. Organ donation rates in Sweden are on the lower side compared to other European or North American countries with 15 to 16/million pp reflected by 150 to 160 donors/year. Donor rates in Norway and Finland are higher with 20+ donors/million pp. Organ coordinators employed by transplant centers are responsible for the organization of local procurement. Before the introduction of brain death criteria, organs had also been procured from donors after cardiac death. Currently, legal modifications are being considered that may allow the utilization of donors after cardiac death in parallel to brain-dead donors. Barriers to Living/Deceased Donation Living donor renal transplants have traditionally contributed substantially to the overall kidney transplant volume in Sweden, ranging from 25% to 50% of procedures performed. Currently, approximately 40% of all kidneys transplanted in Sweden come from live donors, including nondirected donors and close friends. Live donor liver transplants have been a critical component of the pediatric and adult liver programs in Gothenburg since the mid-1990s, linked to close collaborations with transplant surgeons in Hamburg, Germany (Christoph Broelsch and Xavier Rogiers). Living donor procedures are supported and considered as safe by the general public in Sweden with no donor mortality in either the pediatric or adult liver live donor programs. Achievements and Challenges During the mid and late 1960s, Sweden became one of first countries performing kidney transplants pioneered by the late Professor Lars-Erik Gelin, who also established the center in Gothenburg as one of the largest kidney transplant programs in the world. The late Professor Carl-Gustaf Groth from Stockholm was another key leader in the field. Groth promoted pancreas transplantation in Europe while establishing liver and islet cell transplantation in Sweden. The center in Gothenburg has not only been instrumental in establishing split-liver and live donor liver transplantation in Scandinavia for almost 20 years, but also in initiating one of the first small bowel and multivisceral programs in Europe. Most recently, Gotheburg witnessed the first baby born to a patient transplanted with a uterus as part of the world's largest uterus transplant program. With many successes in the field of transplantation, Sweden is battling low deceased donor rates that have not increased despite strenuous efforts. Regulation and Oversight New European directives for organs and tissues in addition to working hour restrictions will directly impact infrastructure, clinical care, and the overall attraction to our field. It is expected that government regulations in Sweden will result into a consolidation of transplant centers in Sweden with transplant activities in only few centers of the country. Keeping a high educational standard is as much a Swedish problem as it is in many other countries. Strained support of healthcare in addition to restrictions of industry support requires a readjustment of educational efforts. Outcomes are monitored in national registers, with open comparisons of quality variables, including graft and patient survival, 30-day mortality, number of transplants/million pp. The National Board of Health audits outcomes on a regular basis. All centers actively pursue the use of marginal donors to increase the pool of available organs.