Closing the gap: standardising organ donation and transplantation success in Europe

European Donation Day, taking place on 5 October 2024, is an opportune time to acknowledge the remarkable progress being made in organ donation and transplantation in Europe and to discuss how to accelerate further achievements. Here, Dr Chloë Ballesté Delpierre, elected member of the European Society for Organ Transplantation Council (ESOT), shares her thoughts.

Organ transplantation is one of modern medicine’s most significant milestones, providing life-saving treatments to countless individuals. However, significant disparities persist in access to these procedures, leaving many without the care they need.

The number of patients receiving transplants in Europe varies widely, from 114.8 per million in Spain to just 7.6 in Bulgaria in 2019 – a stark disparity.¹ As technological advancements and innovations like bio-artificial organs continue to transform patient care, they also underscore the challenge of preventing these inequities from widening.²

The 2023 Global Convergence in Transplantation Summit marked a significant step toward addressing such disparities, highlighting the critical need to standardise practices and ensure equitable access for all.³

Leveraging successes to overcome challenges

Successful programmes in Spain, Portugal, Italy, Croatia and the UK provide valuable lessons for developing a blueprint for best practice throughout Europe. The deceased organ donor rate can also be used to evaluate successful practice, measured per million of population (pmp) in 2023.⁴

Spain’s programme with 49.38 deceased donors pmp, is regarded as a global benchmark.⁴ The country excels due to its robust three-tiered governance structure: specialised doctors in organ donation, a comprehensive reimbursement strategy and strong media collaboration.⁵

This structure, covering national strategy, regional coordination and hospital-level donor management, is key to its success and Spain’s commitment to innovation, including donation after circulatory death and expanded donor criteria, further strengthens its leadership in this space.⁵

Portugal with 37.13 deceased donors pmp is catching up with Spain and emerging as a global leader in organ donation.⁴ Of note is how Portugal capitalised on its close geographical, governmental and cultural ties with Spain to foster collaboration and knowledge exchange, which significantly strengthened its own organ donation and transplantation system.⁶ Other key strategies include a focus on tertiary prevention, reforms in dialysis governance and sustained financial commitment.⁶

Italy, with 29.39 deceased donors pmp,⁴ has developed a robust organ donation system coordinated by the National Transplant Network, with legal frameworks, cultural integration of altruistic donation and a national training strategy that has increased donation rates.⁷

Similarly, Croatia has built an efficient national transplantation network, with strong central governance, collaboration and resource-efficient management that ensures sustained excellence in organ donation practices.⁸ In Croatia, Spain, Portugal and Italy, intensive care doctors are also actively involved in organ donation.^5-8

In the UK, organ donation and transplantation have seen significant progress, with 1,510 deceased donors (22.35 pmp) and 938 living donors in 2023/24, enabling 4,651 transplants – a 6% increase in deceased donors and a 3% rise in transplants from the previous year.⁹

The UK’s success stems from its integration of research with clinical practice, donor coordinators and impactful public awareness campaigns. These efforts are supported by robust funding structures and significant investments in infrastructure and technology.⁹

On the other end of the spectrum, Greece lags behind its European counterparts with 8.45 deceased donors pmp⁴ and an urgent need for systemic reform. The Onassis Foundation recommends establishing an independent national transplant organisation with strong governmental backing, implementing a ‘soft opt-out’ consent policy, integrating donor specialists in hospitals and focusing on public trust and education.¹⁰

Based on the success of Spain, Portugal and the UK, key priorities for Greece include expanding infrastructure, standardising the organ donation process, improving reimbursement systems and emphasising patient-centred care.¹⁰ A dedicated task force is advised to oversee these complex reforms.

Collective efforts for organ donation

To effectively build on the successful programmes described in this article, other countries must adapt these best practices to their unique cultural, legal and healthcare contexts.¹¹

A flexible and aligned approach that balances local needs with European standards is required, along with collective efforts to close the gaps in organ donation and transplantation.

A recently developed 16-domain conceptual framework offers a comprehensive guide for developing and evaluating national programmes, focusing on responsiveness, efficiency and equity.¹²

This framework promotes a standardised approach that considers the diverse realities across jurisdictions, ensuring that all patients, regardless of their location or socio-economic status, benefit from the latest advancements in transplantation technology. This serves as a strong example, but additional initiatives across Europe are required to standardise clinical practices and ensure equitable access to transplantation.

ESOT is actively collaborating with the World Health Organization, among other stakeholders, on this matter, with a strong dedication to continuing the efforts to bridge the gap in Europe.

By working together, we can create a more equitable system, extending the benefits of organ transplantation to every corner of Europe and addressing disparities that hinder progress.

References

1. Dominguez-Gil, B. (2020). International figures on donation and transplantation 2019. Newsletter Transplant, 25, 51–53.
2. Ambagtsheer, F., Annema, C., Forsythe, J., Jansen, N., & Paredes-Zapata, D. (2024). Ethical and legal aspects of organ donation and transplantation. Transplant International, 37. https://doi.org/10.3389/ti.2024.13011.
3. Pullen, L. C. (2024). Creating an international standard: Global convergence in transplantation. American Journal of Transplantation, 24(2), 151–153.
4. IRODaT (2023). International Registry in Organ Donation and Transplantation [accessed September 2024].
5. Streit, S., Johnston-Webber, C., Mah, J., Prionas, A., Wharton, G., Casanova, D., Mossialos, E., & Papalois, V. (2023). Ten Lessons From the Spanish Model of Organ Donation and Transplantation. Transplant International, 36. https://doi.org/10.3389/ti.2023.11009.
6. Streit, S., Johnston-Webber, C., Mah, J., Prionas, A., Wharton, G., Paulino, J., Franca, A., Mossialos, E., & Papalois, V. (2023). Lessons from the Portuguese solid organ donation and transplantation system: Achieving success despite challenging conditions. Transplant International, 36. https://doi.org/10.3389/ti.2023.11008.
7. Mah, J., Johnston-Webber, C., Prionas, A., Romagnoli, J., Streit, S., Wharton, G., Mossialos, E., & Papalois, V. (2023). How to Structure a Successful Organ Donation and Transplantation System in Eight (Not So Easy) Steps: An Italian Case Study. Transplant international : official journal of the European Society for Organ Transplantation, 36, 11010. https://doi.org/10.3389/ti.2023.11010.
8. Mah, J., Johnston-Webber, C., Prionas, A., Bušić, M., Streit, S., Wharton, G., Mossialos, E., & Papalois, V. (2023). Organ Donation in Croatia: The Importance of a National Champion, a Comprehensive Plan, and International Collaborations. Transplant International: Official journal of the European Society for Organ Transplantation, 36, 11011. https://doi.org/10.3389/ti.2023.11011.
9. NHS Blood and Transplant. (2024). Organ donation and transplantation activity report 2023/24 [accessed September 2024].
10. Johnston-Webber, C., Prionas, A., Wharton, G., Streit, S., Mah, J., Boletis, I., Mossialos, E., & Papalois, V. (2023). The national organ donation and transplantation program in Greece: Gap analysis and recommendations for change. Transplant International, 36. https://doi.org/10.3389/ti.2023.11013.
11. Berney, T., Ulasi, I. I., Balleste, C., Martins, P. N., Bellini, M. I., Valantine, H. A., & Potena, L. (2022). Editorial: Equity in Transplantation: A Commitment for Progress in Troubled Times. Transplant International, 35, 10781. https://doi.org/10.3389/ti.2022.10781.
12. Johnston-Webber, C., Mah, J., Streit, S., Prionas, A., Wharton, G., Mossialos, E., & Papalois, V. (2023). A conceptual framework for evaluating national organ donation and transplantation programs. Transplant International, 36, 11006. https://doi.org/10.3389/ti.2023.11006.