With cadaveric organ donation rates decreasing across much of the world, the success of the Spanish Organ Donor Service is truly remarkable. In 1998, greater than 31.5 donors/million population were identified, an increase greater than 8% from the preceding year. In contrast, the situation elsewhere seems bleak, and in the United Kingdom, like most of Europe, the number of solid-organ donors has decreased each year, from 896 in 1990 to 732 in 1998, a reduction of nearly 18%.
In the United Kingdom in 1990, a total of 1,875 kidney transplantations were performed against a national waiting list of 3,849 patients. By 1999, transplantation activity from cadavers had decreased to 1,476 transplants, whereas the waiting list had reached 6,045 patients. The current UK cadaveric donor rate of 13.5/million population in 1998 is unacceptable if this decline is to be reversed. In only 1 area does the United Kingdom match Spain, and that is the percentage of donors that are multiorgan. In the United Kingdom, 83.2% of all donors yield multiple organs, and in Spain, the rate is 84.5%. In 1998, a total of 24.3 cadaveric kidney transplantations were performed per million population in the United Kingdom compared with 49.8 in Spain, 30.2 in France, and 22.8 in Germany. In that same year, 11 liver transplantations per million population were performed compared with 22.7 in Spain, 11.5 in France, and 8.7 in Germany.
Clearly, the problems of organ donation extend across much of Europe as well.
A careful study of the experience in Spain is needed to see what lessons can be learned and which might apply to other countries. However, such comparisons are not easy because a number of issues may be involved, and differences in religious, cultural, and health care arrangements may influence events. Furthermore, changes in the population demographics, with families getting much smaller and people living much longer, may also have an impact.
The country's infrastructure may also have an important role. Within the United Kingdom, there has been a significant reduction in road traffic-accident (RTA) deaths over the last decade. However, the donor numbers resulting from RTA deaths have decreased more sharply than the overall death rate from RTAs. In 1991, for every 1,000 RTA deaths, 40.7 deaths provided a donor, whereas by 1998, this had decreased to 30.1. Concurrently, the proportion of donor organs that come from RTAs has decreased from 27% of all organ donation in 1991 to 14% in 1998. This reduction has been accompanied by an apparent reduction of nearly 3% to 6% in cerebrovascular accident deaths reported over the same time span. However, the patients who die of cerebrovascular accidents represent an increasingly important proportion of solid-organ donors, increasing from 50% of all donors in 1990 to greater than 70% in 1999. It is interesting that during this time, the specialist inten-