Overview of Scandiatransplant Activities and Purpose

Scandiatransplant is the organ exchange organization for Denmark, Finland, Iceland, Norway, Sweden, and Estonia, serving a population of about 29.1 million. Its purpose is to facilitate organ exchange transparently and ethically among its member hospitals. The organization covers various transplantations, maintains waiting lists, ensures traceability, operates registries, and promotes research in the field. Additionally, it awards grants for innovative research projects. The office is located at Aarhus University Hospital, Denmark.

• Scandiatransplant
• Organ Exchange
• Transplantation Activities
• Organ Donation
• Research Grants

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2. Slideshow 2021 Scandiatransplant activities Slide presentation of Scandiatransplant activities Presentation, purpose, awards and office Slide 3 Organ procurement and transplantation activities in Scandiatransplant Slide 8 Kidney Transplantation Slide 14 Liver Transplantation Slide 26 Thoracic Transplantation Slide 30 Pancreas and Islet Transplantation Slide 41

3. Scandiatransplant Scandiatransplant is the organ exchange organization for the countries Denmark, Finland, Iceland, Norway, Sweden and Estonia. It covers a population of about 29,1 million inhabitants. It is owned by the eleven hospitals performing organ transplantation in these countries. The office is located at Aarhus University Hospital, Denmark.

4. Purpose of Scandiatransplant to serve as a common organ exchange organisation and allocation resource for its member hospitals including kidney, liver, heart, lung, pancreas, pancreatic islet, liver cells, composite graft, intestinal and multivisceral transplantation. This is done transparently, using ethical principles and in full compliance with the national legislation of the members countries, to maintain and operate a common waiting list for transplantation, to ensure complete traceability from organ donors to patients, to maintain and operate follow-up registries of transplanted patients, to maintain and operate follow-up registries of living donors, to serve as a collaborative platform through specialized working groups and advisory groups in order to facilitate best practice recommendations and policies optimizing retrieval, allocation and transplantation of organs, and to form a collaborative network for the member hospitals to promote research and development related to organ donation, allocation and transplantation.

5. Reykjavik Oslo Gothen- burg Uppsala Stock- holm Sk ne Copen- hagen Odense Aarhus Helsinki Tartu Council of Representatives NKG NLTG Chair Board SHLG N TG NTCG Medical Director Scandiatransplant office STTG NTC INF Scandiatransplant IT system YASWA

6. Awarded Grants in 2021 Reseach Grants Travel Grants Principal investigator: Lilia Martinez de la Maza "Bile composition and its regulatory pathways as predictors of liver function in liver transplantation". Supported with 150.000 DKK. From Sk ne: Caroline Stolt, was granted 22.000 DKK From Aarhus: Lene Ugilt Pagter Ludvigsen, was granted 21.000 DKK Principal investigator: Bente Jespersen "EVITA study - Epstein-Barr Virus Infection monitoring in renal transplant recipients. Early identification of increased risk of infection and cancer for individualised immunosuppression". Supported with 201.000 DKK.

7. Scandiatransplant Office Activities 2021 Customize the IT-system to the user s wishes and optimizing security and functionality of the system. Incorporating more deceased donor functionalities and variables in the IT-system, so that people involved in the donation process are continuously updated with relevant information and documentation is securely stored electronically. Educate users and comply with demands from users, owners, researchers and the public. Arrange and participate in meetings for groups, committees, board and council of representatives, almost all online this year. Take care of finance and personnel.

8. 2021 Organ procurement and transplantation activities in Scandiatransplant

9. Scandiatransplant 2021 539 Utilized deceased donors (18,53 PMP) Organ transplants performed 1253 kidneys (304 were kidneys from living donors) 397 livers (3 were livers from living donors ) 135 hearts 123 lungs 54 pancreas (47 as combined kidney-pancreas) 3 pancreatic islet 2 intestine 2539 patients on waiting list at the end of 2021

10. Patients entered on waiting list during 2021 (2020 figures) Kidney Liver Heart Lung Pancreas Kidney + Pancreas 61 (75) Liver + Kidney 21 (16) TOTAL 1228 (1427) 422 (465) 159 (149) 170 (158) 5 (10) 2066 (2300)

11. Utilized deceased donors PMP 40 1993-99 2000-09 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 35 Number of deceased donors 30 25 20 15 10 5 0 Denmark Finland Norway Sweden Iceland Estonia

12. Yearly flow on the waiting list 3000 2500 Number of patients Entered during the year 2000 Transplanted recipients during the year 1500 On waiting list at end of year 1000 500 0 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021

13. Deceased donor organ exchange between centers in 2021 35% 30% 25% 20% 15% 10% 5% 0% Kidney Liver Heart Lung Notes: Only organs not used for combined transplantations are included Organs exchanged due to local/national agreements are not included

14. Kidney Transplantation

15. Kidney Transplantation 1989 2021 1400 1200 Number of transplants 1000 800 600 400 200 0 1989 2019 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2021 Deceased donors Living donors

16. Kidney exchange rate in % between centers 1969 - 2021 80 70 60 50 40 30 20 10 0 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021

17. Kidney Transplantation activity 2021 by centre 300 Number of transplants 250 200 Living donor Deceased Donor 150 100 50 0

18. Kidney Transplantation PMP 2021 60 50 40 PMP Living donor 30 Deceased donor 20 10 0 Finland Sweden Norway Denmark Iceland Estonia

19. Kidney Transplantation 2021 100% 90% 80% 70% 60% Living donor 50% 40% Deceased donor 30% 20% 10% 0%

20. Number of patients on the kidney waiting list at the end of the year 1995 - 2021 2500 2000 Number of patients 1500 1000 500 0 2005 1995 1997 1999 2001 2003 2007 2009 2011 2013 2015 2017 2019 2021

21. Average months on kidney waiting list at end of year (including patients active and on hold) 1999-2004 40 2005-2009 35 2010 30 Number of months 2011 2012 25 2013 20 2014 2015 15 2016 10 2017 2018 5 2019 0 2020 Finland Sweden Norway Denmark Estonia 2021

22. Average months on kidney waiting list by immunisation status at end year 50 2002-2007 2008 45 2009 40 2010 Number of months 35 2011 30 2012 2013 25 2014 20 2015 15 2016 10 2017 2018 5 2019 0 2020 High immunized Immunized Prev. immunized Non immunized 2021

23. Deceased donor kidney transplants 1994 - 2021 400 1994-99 2000-04 350 2005-09 Number of transplants 2010 300 2011 250 2012 2013 200 2014 150 2015 2016 100 2017 2018 50 2019 0 2020 Denmark Finland Norway Sweden Figures included from Estonia year 2017 starts from October 1st 201 Estonia 2021

24. Living donor kidney transplants 1994 - 2021 200 1994-99 180 2000-04 2005-09 160 Number of transplants 2010 140 2011 2012 120 2013 100 2014 80 2015 2016 60 2017 40 2018 20 2019 2020 0 2021 Denmark Finland Norway Sweden Iceland Estonia

25. Kidney exchange obligations Patient with STAMP-status that are ABO compatible with donor and where all donor HLA-A, -B, -C -DRB1, -DRB3/4/5, DQA1, -DQB1, -DPA1 -DPB1 antigens are either shared with the recipient or are among those defined as acceptable. Highly immunized (PRA 80%) patients who are HLA-A, -B, -DRB1 compatible with donor. Immunized patients (PRA 10% but below 80%) who are HLA-A, -B, -DRB1 compatible with donor. If organ donor is <50 years of age, at least one kidney is offered to recipient <16 years of age (counted from time of registration) if there is HLA-DRB1 compatibilitty and in addition not more than 2 HLA-A, B mismatches. Patients who are HLA-A, -B, -DRB1 compatible with donor unless the proposed recipient is > 30 years older than the donor. 1. 2. 3. 4. 5. Priority 1: Donors are matched ABO-compatible Priority 2-5: Donors are matched ABO-identical, with the exception of donors of blood group A, which also can be exchanged to recipients of blood group AB.

26. Liver Transplantation

27. Liver Transplantation 1989 - 2021 450 18 400 16 350 14 300 12 250 10 200 8 150 6 100 4 50 2 0 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Number (columns) PMP (line)

28. Liver Transplantation 1994-2021 250 1994-99 2000-04 2005-09 200 Number of transplants 2010 2011 2012 150 2013 2014 100 2015 2016 2017 50 2018 2019 2020 0 2021 Denmark Finland Norway Sweden Figures included from Estonia year 2017 starts from October 1st 20 Estonia

29. Exchange criteria Liver Exchange obligation to highly urgent patients: acute liver failure acute liver re-transplantation highly urgent patients that needs to be transplanted within 72 hours Exchange obligation to pediatric (<18 years at entry on liver waiting list) and visceral recipients if donor liver fulfils split criteria Return (pay back) liver to donor centre Rota system for spare livers

30. Thoracic Transplantation

31. Thoracic transplantation 2021 70 60 Number of transplants 50 40 Heart 30 20 Lung 10 0 Denmark Finland Norway Sweden Estonia

32. Heart Transplantation 1989 - 2021 180 7.0 160 6.0 140 5.0 120 4.0 100 80 3.0 60 2.0 40 1.0 20 0 0.0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Number PMP

33. Heart transplantation 2021 70 60 Number of transplants 50 40 30 20 10 0 Denmark Finland Norway Sweden

34. Heart Transplantation 1994 - 2021 80 1994-99 2000-04 70 2005-09 Number of transplants 2010 60 2011 2012 50 2013 40 2014 2015 30 2016 2017 20 2018 2019 10 2020 0 2021 Denmark Finland Norway Sweden

35. Number of patients on the heart waiting list at the end of the year 1989 - 2021 140 120 Number of patients 100 80 60 40 20 0 1993 1989 1991 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021

36. Exchange criteria Heart Exchange obligation to highly urgent patients on waiting list: Patient on short-term assist devices (ECMO, centrifugal pump). Patient on para corporeal or implantable blood pump with device failure or uncontrollable device infection. Patients below 16 years on inotropic support for more than 12 months support on implantable LVAS. Rota system for exchange of hearts between countries.

37. Lung transplantation 1990 - 2021 including heart-lung 160 140 Number of transplants 120 100 80 60 40 20 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020

38. Lung Transplantation 1994 - 2021 80 1994-99 2000-04 70 2005-09 Number of transplants 2010 60 2011 50 2012 2013 40 2014 2015 30 2016 20 2017 2018 10 2019 2020 0 2021 Denmark Finland Norway Figures included from Estonia year 2017 starts from October 1st 201 Sweden Estonia

39. Number of patients on the Lung waiting list at the end of the year 1990 2021 160 140 Number of patients 120 100 80 60 40 20 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020

40. Exchange criteria Lung Exchange obligation to highly urgent patients on waiting list Priority 0: Patient on extra-corporeal circulatory support (ECMO, Novalung or other device) or ventilatory support*. Priority 1: Patient with a rapid progression of organ failure with poor prognosis in a short time defined by the responsible centre*. *max. three patients per centre per year (Tartu one per year). Rota system for exchange of lungs between countries.

41. Pancreas and Islet Transplantation

42. Exchange recommendations Pancreas If there is no suitable recipient in own centre, the pancreas (and kidney if SPK) is recommended to be offered to AB0 compatible recipients in other centres. The centre at the highest position on the rota list accepting the pancreas will receive it and be put last. Shipment of a kidney is only performed if no other kidney exchange obligation with higher priority (as defined by Scandiatransplant) exists. The receiving centre has the responsibility for the pancreas procurement. The receiving centre has to pay back, as soon as possible, with an AB0 identical kidney of a quality acceptable to the recipient centre. There is no mandatory payback for the pancreas.

43. Pancreas Transplantation 1988 2021 100 3.5 90 3.0 80 2.5 70 60 2.0 50 1.5 40 30 1.0 20 0.5 10 0 0.0 1992 2006 2020 1988 1989 1990 1991 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2021 Number PMP

44. Islet Transplantation 1997-2021 25 1 0.9 20 0.8 0.7 15 0.6 0.5 10 0.4 0.3 5 0.2 0.1 0 0 2000 2017 1997 1998 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2018 2019 2020 2021 Number PMP

45. Thank you