In 2010, when the 63rd World Health Assembly of the World Health Organization adopted a resolution (WHA 63.22) urging member states to put in place measures to maximize organ donation from deceased donors and protect living donors, Spain had already started implementing changes that would make it the world leader in the field of organ, tissue and cell donation and transplantation.
“The key to the success of our model lies in the reforms of the management system and in the organizational approach to the process”, explained Beatriz Domínguez-Gil, MD, PhD, director general of the National Transplantation Organization (Organización Nacional de Trasplantes, ONT), an agency of the Spanish Ministry of Health created in 1989 to lead the reorganization of the country’s donation and transplant system.
The creation of the ONT was a step in the process, said Domínguez-Gil. Ten years earlier, in 1979, the Spanish transplantation law had been enacted, guaranteeing universal coverage through a public health system and providing for a policy of “presumed consent” for organ donation. Presumed consent is a legal framework under which citizens must register their names in a national “waiver” registry, failing which consent to organ donation is presumed.
But she points out that the transplant law isn’t what really made the difference.
Rather, it was the agreement reached by the 17 autonomous regions of Spain to implement what is now known as the “Spanish model of organ donation and transplantation”.
The country has grown from 14 donors per million inhabitants before the ONT was established to 49 donors per million inhabitants in 2019. While other regions of the world, such as Santa Catarina and Paraná in Brazil, have almost reached these rates, Spain continues to be the world leader in organ donation.
A number of Latin American countries have since learned from Spain, sending doctors there to undergo procedures. Others could still benefit, as could nations around the world.
One of the keys to collaboration with Latin America has been the creation of the Ibero-American Donation and Transplantation Network / Council (RCIDT), of which Domínguez-Gil is president.
How did Spain do it?
Originally, the Spanish system was based on managing a very complex deceased donation process. “To carry out the process successfully requires a system of trained professionals who can identify cases, make a diagnosis of brain death, conduct family interviews and ensure that organs are properly preserved,” underlined Domínguez-Gil. .
ONT invests 1 million euros per year in the continuing education of professionals who participate directly or indirectly in this process, she said.
“In Spain, we have a reimbursement system adapted to the characteristics of the donation and transplant program. This system guarantees the coverage of expenses related to human and material resources necessary for the development of these activities, ”she noted.
In hospitals capable of performing transplants, the units have specific coordinators, almost all of them intensive care physicians. Through the quality assurance program in the post-death donation process, the ONT performs an audit of all deaths that have occurred in intensive care units (CCUs), identifying who is eligible to be a donor and collecting indicators at the level national.
Another important aspect is engagement with the public, said Domínguez-Gil. “We do this through the media. We are always available for interviews to answer questions and educate people about organ donation and transplantation.”
Share Spain‘s Experiences with Latin America
In partnership with the Pan American Health Organization (PAHO), ONT and RCIDT have developed courses and training programs to share experiences from Spain, as well as those from other regions of the world that have adapted the Spanish model.
By ONTs Master Alianza Program, professionals from Latin America and other regions spend 2 months in Spain to participate in training sessions and, under the direction of a senior transplant coordinator, experience the day-to-day operations of a local hospital. What they learn will then be incorporated into return home practices.
Created in 2005, the mission of the RCIDT is to encourage national systems to organize, regulate and train professionals in the field of organ, tissue and cell donation and transplantation.
“Thanks to the RCIDT, Spain and Latin America have been able to collaborate in the development of legislation, the structuring of coordination systems in these countries and the 100% increase in donation activity in the region, ”said Domínguez-Gil.
“The effects of adapting the Spanish model to Brazil translated into a very positive experience in Santa Catarina,” confirmed the coordinator of the state transplant center, Joel de Andrade, MD, who participated in the Máster program. Alianza 2008 and now runs RCIDT and OPS courses.
Even during the COVID-19 pandemic, two states in Brazil were able to maintain a high level of donation and transplantation. At the end of 2020, Paraná had the best rate in the country – 41.5 donors per million inhabitants – followed by Santa Catarina with 39.4 donors per million inhabitants. In recent years, the two states have taken turns claiming the top spot.
Minimum baseline health care needed to maximize organ donation
José Luis Bustos, MD, is the Vice President of the Single Ablation and Implantation Coordinator at the Argentine National Central Institute (INCUCAI), the agency responsible for the regulation, coordination and supervision of organ, tissue and cell donation and transplantation activities in the country.
He believes that for some Latin American countries, such as Paraguay, the Dominican Republic and Bolivia, the shortcomings in terms of the number of donors reflect shortcomings in other areas: hospital structure, human resources, even political policies. “There are a number of factors,” Bustos said.
He recalled that the organization of the health system including monitoring, training of professionals and communication are the basic pillars necessary to ensure the proper functioning of the donation process and transplantation.
The states parties to the Southern Common Market Agreement (MERCOSUR) have also created the Donation and transplant register (DONASUR), a tool to record their donation and transplantation activities. Over the years, the register has grown to include 17 countries in the region. “By describing the relationship between donations and transplants, DONASUR made the system transparent,” Bustos said.
Bustos partnered with PAHO to create an online course to share best practices and increase the number of donations and transplants in the region. Composed of modules and addressing all the pillars of the process, the course is planned over 5 years, starting in early 2022. The first stage is aimed at health managers and decision-makers.
Where does Spain go from here?
Having established a successful model that others can replicate, Spain is now taking the next step – one with three lines of action. The first is organ transplantation in the elderly population – donors and recipients alike – called “old for old”.
“Over 50% of our donors are 60 years of age or older; 28% are over 70 and 5% are over 80. These are individuals who die of stroke. We are making progress and obtaining good results in organ transplants between the elderly. These types of transplants are frequent in Europe, given the aging of the population; However, we still don’t see them very often in Latin America, ”explained Domínguez-Gil.
The second line of action is the development of techniques for donation after circulatory death. After cardiac arrest, the blood stops flowing and the organs deteriorate rapidly, so they cannot be transplanted; however, in Spain there has been an increase in this type of donor thanks to the use of extracorporeal membrane oxygenation (ECMO) machines to preserve the organs inside the body before their removal, as well as machines ex vivo to preserve the organ after it has been removed.
“These techniques allow us to keep the organs viable and to assess them before they reach the recipient,” said Domínguez-Gil, who also represents Spain to the competent authorities of the European Commission for transplantation. organs, tissues and cells, and is a member of the WHO Transplantation Working Group.
The third line of action is to introduce more places for donations. They mainly occur in intensive care units, but the goal is also to integrate emergency rooms (ER).
“We have set up a collaborative effort so that the transplant coordinator is informed if there is an end-of-life patient or a deceased patient in an emergency room,” said Domínguez-Gil.
It is essential that emergency physicians participate in continuing education so that they can acquire knowledge about the protocols and documents required as well as the skills to assess the results. Recording these measurements will facilitate the development of a set of recommendations for organ donation and transplantation that can be replicated in other countries.
This story originally appeared on Portuguese Medscape.
Spanish experience as a leading country: what measures have been taken? Available here. Accessed December 8, 2021.
Red / Consejo Iberoamericano of Donación Trasplante there – RDCIT. Available here. Accessed December 8, 2021.
Donation after circulatory death and its expansion in Spain. Available here. Accessed December 8, 2021.
Summary of Spanish recommendations on intensive care to facilitate organ donation. Available at here. Accessed December 8, 2021.
About Master Alianza. Available here. Accessed December 8, 2021.
[The challenge of keeping up organ donations and transplantations during the pandemic.] Available here.
Registro Mercosur de Donación y Trasplante – DONASUR. Available here. Accessed December 8, 2021.