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International Examples of Transplant Success

The US transplant rate is 50% higher than Canada’s at 34 kidney transplants per million. A key part of their success is the United Network for Organ Sharing (UNOS), which is the private, non-profit organization that manages the nation’s organ transplant system under contract with the federal government.

Case Studies: USA


  • The United Network for Organ Sharing (UNOS) is a non-profit organization that administers the Organ Procurement and Transplantation Network (OPTN) in the United States established in 1984(1)
  • The OPTN is a “private, not-for-profit entity with an expertise in organ procurement and transplantation”. It is contracted to UNOS. In other words, UNOS is the contractor that administers UNOS has held the OPTN contract since 1986 and is the first and only OPTN contractor
  • UNOS and OPTN are not the same OPTN will exist as an entity of the Health Resources and Services Administration (HRSA).
  • More details on the organizational structure can be found at:
  • The Scientific Registry of Transplant Recipients (SRTR) is a separate organization which maintains a database of comprehensive information on all solid organ transplantation in the US (2)
  • The USA has an explicit “opt-in” system


  • USA has one of the highest deceased organ donation (5th) in the world (Link: INTERNATIONAL REGISTRY IN ORGAN DONATION AND TRANSPLANTATION)
  • Some researchers argue that a big difference between the USA and Spain’s deceased organ donation rate is that Spain uses older donors(3)
  • One study found that state policies such as first-person consent laws, donor registries, public education, paid leave and tax incentives was not significantly associated with donation rates or number of transplant. They did note that the establishment of revenue polciies, in which individuals contribute to a protected state fund to promote organ donation activities was associated with a small (5.3%) increase in the absolute number of transplants. (4)

The United States experience in the past year:

Four important initiatives that contributed to the increase in organ donors in the USA according to Wynn and Alexander (2011)(1)

  • OPTN policies to encourage the use of kidneys from expanded criteria donors
  • Breakthrough collaboratives sponsored by the Division of Transplantation of the Health Resources and Services Administration of the federal Department of Health and Human Services (federal organizations)
    • Shafer et al. suggests that the US Organ Donation Breakthorugh Collaborative (est 2003) led an increase of total US organ donors by 22.5%(5)
  • Use of organs from donors after cardiac death
  • State donor registries


  1. Wynn JJ, Alexander CE. Increasing organ donation and transplantation: the U.S. experience over the past decade. Transplant International 2011; 24: 324–332.
  2. Leppke S, Leighton T, Zaun D et al. Scientific Registry of Transplant Recipients: Collecting, analyzing, and reporting data on transplantation in the United States. Transplantation Reviews 2013; 27: 50–56.
  3. Chang GJ, Mahanty HD, Ascher NL, Roberts JP. Expanding the donor pool: can the Spanish model work in the United States? American Journal of Transplantation: Official Journal of the American Society of Transplantation and the American Society of Transplant Surgeons 2003; 3: 1259–1263.
  4. Chatterjee P, Venkataramani AS, Vijayan A, Wellen JR, Martin EG. The Effect of State Policies on Organ Donation and Transplantation in the United States. JAMA Internal Medicine 2015; 175: 1323–1329.
  5. Shafer TJ, Wagner D, Chessare J et al. US organ donation breakthrough collaborative increases organ donation. Critical care nursing quarterly 2008; 31: 190–210.

Spain has the highest deceased organ donation rate per million population in the world. Spain’s National Transplant Organization (ONT) is a national network of specialists that of coordinates donation, recovery, preservation, distribution, exchange, and transplantation of organs and tissues throughout the whole Spanish Health Care System.

Case Studies: Spain


Spain has the highest deceased organ donation rate per million population in the world.(1,2) In 2016, Spain broke their own record with over 40 donors pmp.(2) Many researchers attribute this success to the “Spanish Model” of organ donation which is an integrated approach to improve organ donation.(1,2) In 1989, the National Transplant Organization (ONT) and a national network of trained and motivated hospital physicians responsible for organ donation was created.(3) This technical organization is solely responsible for the coordination of organ donation and transplantation policies across all regions in Spain. Although Spain has a presumed consent system, in practice, the next-of-kin is always approached and can make the final decision regarding organ donation.(4)

Main Elements of the Spanish Model:

There are several key elements of the Spanish Model as described by Matesanz et al. (2).

  • There are three levels that work together: national (ONT), regional (17 regional coordinators) and hospital. The national and regional levels work together to support any technical or political processes related to organ donation and transplantation. At the hospital level of coordination, a network of official procurement hospitals help develop the deceased donation process.
  • The appointment of a transplant coordinator at each procurement hospital
    • This individual is a medical doctor (usually a critical care physician) with a part-time role dedicated to deceased organ donation
    • Facilitate early identification and referral of potential donors
    • Hired and report to the medical director of the hospital
    • The part-time role enables them to fulfil their duties even at hospitals with very low deceased organ donor potential
  • The ONT is a supportive agency
  • The Quality Assurance Program in the Deceased Donation Process is a tool that helps monitor deceased organ donor potential, evaluative hospital performance and targets key areas for improvement.
  • Hospitals are reimbursed for donation activities

Replication of Spanish Model in other countries:

The Spanish Model has been successfully adapted to other jurisdictions with differing results.(5) For example, Tuscany doubled its organ donation rate to 26.9 donors per million population in just one year by adopting the Spanish model for organ donation.(6) In addition, Croatia and Portugal have adopted aspects of the Spanish Model and consequently increased their deceased donor rate per million by 37% and 54%, respectively.(5)

Other Information

Spain has compiled a list of best practices for organ donation here:


  1. Matesanz R, Marazuela R, Domínguez-Gil B, Coll E, Mahillo B, de la Rosa G. The 40 Donors Per Million Population Plan: An Action Plan for Improvement of Organ Donation and Transplantation in Spain. Transplantation Proceedings 2009; 41: 3453–3456.
  2. Matesanz R, Domínguez-Gil B, Coll E, Mahíllo B, Marazuela R. How Spain Reached 40 Deceased Organ Donors per Million Population. American Journal of Transplantation 2017; 17: 1447–1454.
  3. Matesanz R, Miranda B. A decade of continuous improvement in cadaveric organ donation: the Spanish model. Journal of Nephrology 2002; 15: 22–28.
  4. Rosenblum AM, Horvat LD, Siminoff LA, Prakash V, Beitel J, Garg AX. The authority of next-of-kin in explicit and presumed consent systems for deceased organ donation: an analysis of 54 nations. Nephrology, dialysis, transplantation: official publication of the European Dialysis and Transplant Association – European Renal Association 2012; 27: 2533–2546.
  5. Matesanz R, Domínguez-Gil B, Coll E, de la Rosa G, Marazuela R. Spanish experience as a leading country: what kind of measures were taken? Transplant International 2011; 24: 333–343.
  6. Simini B. Tuscany doubles organ-donation rates by following Spanish example. The Lancet 2000; 355: 476.

Relevant News Articles:

Badcock, J. (2015, February 11). How Spain Became the World Leader in Organ Donations. Newsweek. Retrieved from

Turnbull, B. (2013, September 30). What Spain can teach us about the gift of life. The Toronto Star. Retrieved from