How Spain became the world leader in organ transplants

Spain has been the world leader in organ donation for the last 25 years and in 2016 it broke its own record for the number of transplants carried out. But how has Spain done it?

How Spain became the world leader in organ transplants
Spain continues to lead the way in organ donations. Photo: AFP

A total of 4,818 organ transplants were carried out in Spain during 2016, beating the record of 4,769 from the year before, according to data published by  the National Transplant Organization (ONT)..

Of these, 2,994 were kidney, 1,159 were liver, 281 were hearts, 307 were lungs, 73 were pancreas and four were intestines.

It means that Spain saw 43.4 individual donors per million people (pmp) in 2016, an increase from 39.7 pmp in 2015 and 36 pmp in 2014, “much higher” than the EU average (19.6) and the US average (26.6) according to stats published by Spain’s Health Ministry.

Spain has maintained its gold standard in organ donation despite deep austerity cuts which saw public spending on health slashed during the economic crisis years.

According to a paper published in January’s American Journal of Transplantation, Spain is a model from which other countries have a lot to learn.

The creation in 1989 of the ONT by the Health Ministry meant that one body has been responsible for overseeing and coordinating donation and transplant policies across the regions and more than doubled the number of organ donations within a decade of its creation.

The Spanish model also relies on the designation of appropriate professionals (mostly intensive care doctors) to ensure donations are quick to happen when a patient dies in conditions that allow organ donation.

A nurse prepares a patient for a renal transplantation at La Paz hospital in Madrid.  Photo: Pierre-Philippe Marcou / AFP

Professionals supported in their work by ONT and regional coordination offices are also trained to identify donation opportunities outside of intensive care units, in emergency departments and hospital wards.

While some nations cap the age at which donors qualify, Spain considers organ donation from those over the age of 65 years – and in fact ten percent of organ donors in Spain are over 80 years-old.

Furthermore, Spain considers donation after circulatory death, in which circulation, heartbeat, and breathing have stopped (as opposed to brain death, in which all the functions of the brain have stopped), even in the setting when death follows a sudden cardiac arrest in the street.

Lead author Rafael Matesanz, MD, PhD, who is the director of ONT, highlighted that “good organization in the process of deceased donation and continuous adaptations of the system to changes are always the basis of successful results in organ donation”.

Most importantly Spain operates an “opt-out” system in which all citizens are automatically registered for organ donation unless they choose to state otherwise, a measure that was adopted in France on January 1st.

The most important success is that the system has made organ donation be routinely considered when a patient dies, regardless of the circumstances of death,” said ONT's Beatriz Domínguez-Gil, MD, PhD, co-author of the article highlighting the Spanish Model's impact.

The European Union has highlighted the lack of organs for transplant and the increasing number of patients on waiting lists worldwide.

Its figures claim that in 2014, 86,000 people were waiting for organ donations in EU states, Norway and Turkey, and 16 people were dying every day while waiting for a transplant.

In Spain the number of those on the waiting list was reduced to 5,477 in 2016 from 5,673.





How Spain became the world leader in organ transplants

Juan Benito Druet has just learned that his life may be about to change.

How Spain became the world leader in organ transplants
Photo: Pierre-Philippe Marcou / AFP

In the next few hours he will receive a healthy kidney thanks to a pioneering system that has made Spain the world leader in organ transplants for the past 25 years.

“We don't know what will happen. but you have to take a chance,” said Druet, 63, a reserved and moustachioed boilermaker, as he lays in his bed at Madrid's La Paz hospital.

Hospital staff try to reassure him by telling him organ transplants are carried out every day in Spain.

A nurse prepares patient Juan Benito Druet for a renal transplantation at La Paz hospital in Madrid.  Photo: Pierre-Philippe Marcou / AFP

Doctors performed 4,818 transplants last year, including 2,994 kidney transplants, according to the health ministry's National Transplant Organisation (ONT).

That means there were 43.4 organ donors per million inhabitants last year, a world record, up from 40.2 donors in 2015.  

By comparison in the United States there were just 28.2 donors per million inhabitants in 2015, 28.1 in France and 10.9 in Germany, according to the Council of Europe.

“It is even better than if we had won the jackpot in the lottery,” says Druet's wife Jeronima, 60, as she sits close to him along with the couple's two adult children.

Now she dreams of going on a cruise with her husband, something impossible as long as he needed to be hooked to a 15-kilo (33-pound) kidney dialysis machine every night to filter his blood.

'Transplant lives'

The transplant operation lasts four and half hours.  

Surgeons make a 15-centimetre (six-inch) incision in Druet's abdomen to transplant a healthy kidney extracted the night before from a woman who died.    

After a transplant patients “start to regain weight, their health improves. It is as if we transplant lives,” the founder of the ONT, Rafael Matesanz, tells AFP.

Founder and Director of the Spanish National Transplant Organisation (ONT), Rafael Matesanz Photo: Pierre-Philippe Marcou / AFP

Matesanz oversaw the implementation of a centralised and well-oiled organ donation and transplant system which has been replicated in Portugal and Croatia and inspired others across Europe.

Each hospital has a transplant coordinator, usually a doctor or nurse who specialises in intensive care, charged with identifying patients at risk of a heart attack or brain death.

In both situations kidneys, livers, lungs, pancreas and sometimes even the heart can still work and can be transplanted.  

Organ donations are quickly reported to the ONT which searches for the best match from its organ waiting list.    

If the patient is far away, a cooler with the organ is sent by plane inside the cockpit with the pilot.

The operation is free under Spain's public health system, anonymous and available only to residents of the country to avoid organ trafficking.


“What makes the difference is the organisation of the system. This network, this centralisation, is the key,” says Marie-Charlotte Bouesseau of the World Health Organisation's department of ethics.

Worldwide only about 10 percent of all patients who need a transplant receive a donated organ, she adds.

“That means that 90 percent will die while they are on a waiting list,” she explains.

In Spain only four to six percent of patients died in 2016 while they were on a waiting list for a vital organ – a liver, heart or lung.  

Ramon Garcia Castillo, 85, a former TV technician, spent 13 months on dialysis before he received a kidney transplant in 2010.    

He would previously trek to a hospital three times a week to be hooked up to a machine for three-and-a-half hours.  

The kidney transplant “gave me my life back”, says Castillo, who now just needs to take pills to ensure his body does not reject the donated kidney.

'Empathy and respect'

The other secret to the success of the Spanish system is training and communication, explains Matesanz.

Since it was set up in 1989, the ONT has trained over 18,000 transplant coordinators who break the news of a person's death and then gently convince their loved ones to agree to donate their organs.  

Spanish law presumes consent for organs to be removed on their death unless they had previously made clear that they were against donation.  

But loved ones are systematically consulted.    

“You have to have a lot of empathy, sensitivity, respect,” says Belen Estebanez, the transplant coordinator at Madrid's La Paz hospital.  

The work of a transport coordinator was depicted in Spanish director Pedro Almodovar's 1999 Oscar-winning movie “All About My Mother”. The director consulted with the ONT to prepare the movie.

“If they have a lot of doubts we ask them what the person was like, if they were generous…from there we get them to reflect on an organ donation,” adds Damiana Gurria, another transplant coordinator.

“It comforts many families to know that the organs of their loved ones will live on inside someone else, that people will be thankful for the rest of their lives.”

Castillo said he drinks two litres of water each day and follows a balanced diet since he received his new kidney.  

“I have to take care of it, especially since it was given to me. I have to be thankful.”

By Adrien Vicente / AFP