01 · Introduction

Introduction.

Solid organ transplantation has, over the last four decades, moved from experimental therapy to standard of care for end-stage organ failure. Despite this maturation, global supply meets only a fraction of estimated need: in 2023, transplant volumes covered no more than ~10% of patients on national waiting lists [1]. The Global Observatory on Donation and Transplantation (GODT), maintained jointly by the World Health Organization and the Organización Nacional de Trasplantes (ONT), is the principal international registry of donation and transplantation activity [1]. The Council of Europe's Newsletter Transplant (edited by ONT and published annually by EDQM) provides an independent and overlapping data source [2]. National-level activity is reported by NHSBT in the United Kingdom [3], OPTN/UNOS in the United States [4], IRODaT internationally [5], ONT in Spain [6], and equivalent national bodies in other reporting countries [7–11].

This article summarizes the 2023 reporting cycle, places it in the context of consent-system and circulatory-death donation literature, and identifies the structural drivers of the year's changes.

02 · Methods

Methods.

Data sources

Country-level deceased-donor rates and donor counts were drawn from Newsletter Transplant [2] (the EDQM/Council of Europe publication that compiles validated 2023 data) and the GODT 2023 Global Report [1]. Where the two sources differed, GODT figures were used as the international canonical source. National-level UK data are from the NHSBT 2023/24 Activity Report [3]; United States data from the OPTN/SRTR 2023 Annual Data Report on deceased organ donation [4]. IRODaT 2023 [5] supplied an estimate for Iran (which did not contribute to the Newsletter Transplant cohort). Population denominators were taken from UN DESA, World Population Prospects [12].

Inclusion

All countries with confirmed 2023 deceased-donor figures in either GODT 2023 or the Newsletter Transplant cohort were included. Reporting cycles vary; activity is reported as the 2023 calendar-year volume except for the UK, where the NHSBT 2023/24 fiscal year (April 2023 onwards) is used [3].

Variables and limitations

Variables. Deceased donors per million population (pmp), DCD share of deceased donation, total transplant volume by organ, year-on-year change versus 2022. Limitations. Provisional figures appearing in GODT 2023 may differ slightly from later national-registry releases. Iran's 2023 estimate carries the IRODaT footnote [5] and is not directly comparable to the validated Newsletter Transplant cohort.

03 · Results

Results.

3.1 Global activity

Total transplant activity in 2023 reached 172,397 procedures across 93 Member States, an increase of 9.5% on 2022 and the highest figure on record at the time of the report [1]. Deceased donor numbers reached 45,861 (DBD 34,466, 75%; DCD 11,395, 25%) [1]. Of the 11,395 DCD donors, controlled DCD (Maastricht type III) accounted for approximately 93% (n ≈ 10,562) [1, 24]. The five-organ distribution (kidney, liver, heart, lung, pancreas) is summarized below.

Figure 1. Worldwide transplant volumes by organ, 2023; total 172,397 transplants. Source: [1].

3.2 National deceased-donor rates

Spain reported 49.4 pmp (2,346 donors) [2, 6], retaining global leadership for the third decade. The United States reported 48.0 pmp (16,335 donors) [4, 7] and the largest absolute DCD cohort (5,895 donors). Other high-rate systems (≥ 30 pmp) included Portugal (36.8) [2], Belgium (32.7) [2], and Slovenia (30.5) [2]. Mid-rate systems (10–30 pmp) covered most reporting Western, Northern, and Eastern European nations as well as Australia (19.4) [8] and Canada (21.3). Low-rate systems (< 10 pmp) included South Korea (9.3) [30] and Colombia (7.4) [2].

Figure 2. Deceased donor rate (pmp), top reporting countries 2023. Sources: [1, 2, 3–11].

3.3 DCD by Maastricht type

Of the 11,395 DCD donors reported globally, controlled DCD (Maastricht type III) accounted for approximately 93% (n ≈ 10,562) [1, 24]. National-level breakdowns where reported in the GODT national tables are summarized in Table 1. Spain remains the only national program routinely transplanting all five solid organ types from DCD donors, including hearts, via thoracoabdominal normothermic regional perfusion [22]. Type V donors — donation following medical assistance in dying — were reported by Australia, Belgium, Canada, the Netherlands, and Spain [1, 22].

Table 1. DCD donors by Maastricht type, selected countries 2023. Source: [1].

3.4 Waiting lists and unmet need

Across all reporting countries, transplant volumes met no more than ~10% of estimated global need.

04 · Discussion

Discussion.

4.1 Consent framework versus coordinator infrastructure

Comparative analysis across the reporting cohort indicates that the legal consent framework (opt-in vs opt-out) is a weaker predictor of donation rate than the strength of hospital-embedded coordinator infrastructure and family-consent culture [13, 14, 15, 17]. Spain (49.4 pmp) and the United Kingdom (22.3 pmp) both operate under soft opt-out [2, 3]; the gap between them is attributable to the 1989 introduction of the ONT hospital-coordinator model, not to consent law. England's adoption of soft opt-out in May 2020 has not produced sustained gains; NHSBT 2023/24 reported family consent at 61% overall (DBD 68.1%, DCD 55.3%), down from 67–68% in the pre-pandemic period [3, 38]. Germany, at 11.6 pmp under opt-in, reports a bedside consent rate of approximately 72% when the deceased has documented their wishes [36], while only 44% of the public has documented any decision and 36% have made no decision at all [37] — its performance gap is identification and infrastructure rather than culture. Recent trial-based work has reinforced this finding: opt-out defaults alone do not increase donation in laboratory or registry settings when removed from the broader coordinator system [20].

4.2 The structural rise of donation after circulatory death

DCD now accounts for more than one in four deceased donors worldwide [1, 21]. This shift has clinical, organisational, and ethical implications. Clinically, controlled DCD requires explicit auto-resuscitation criteria (informed by a systematic review of post-arrest no-touch periods [26]) and either direct procurement-perfusion or normothermic regional perfusion to mitigate warm-ischemic injury [22, 28]. Organisationally, DCD demands ICU-embedded protocols and dedicated retrieval pathways [21, 23, 25]. Ethically, the practice has been the subject of sustained policy work — particularly around the dead-donor rule and the standardisation of cardio-circulatory death determination [24, 27]. The Maastricht classification system [24] remains the operating standard. Country-level adoption is uneven: high-volume DCD activity is concentrated in Western Europe, North America, and Australia, with Asian programs building from a low base [29, 30, 31].

4.3 Persisting global inequity

The 2023 cycle reaffirms a strong gradient between high-income, infrastructure-rich systems and the rest of the world. Iran (≈ 12.6 pmp) [5] led the Middle East but reported through IRODaT rather than the validated cohort. African deceased-donor activity remained marginal (South Africa 1.3 pmp; Tunisia 0.8; Morocco 0.4) [32, 33]. Outside high-income systems, the principal constraints are infrastructural — ICU capacity, brain-death legislation, organ-procurement organization — rather than the consent default [32, 33]. The Council of Europe Guide to the Quality and Safety of Organs for Transplantation (9th edition) [34] and the Istanbul Declaration on Organ Trafficking and Transplant Tourism (2018 edition) [35] provide the standing international frameworks for safe and ethical practice.

4.4 Limitations

Three principal limitations apply. First, GODT figures are provisional at the time of cycle close and may be revised in the subsequent GODT release [1]. Second, country-level data are reported on different cycles (the UK reports on a fiscal year starting in April [3]; most other countries on the calendar year). Third, family-consent and refusal rates are not consistently published across registries; comparative claims about culture-versus-default rest on the subset of countries that publish refusal data.

05 · Conclusion

Conclusion.

The 2023 reporting cycle confirms continued global growth in transplant activity (+9.5% on 2022), Spain's continued leadership at the country level, and a structural shift toward circulatory-death donation. The strongest predictors of high national donation rates remain coordinator infrastructure and family-consent culture rather than the legal consent framework. Sustained gains in subsequent reporting cycles will depend on continued investment in DCD pathway capacity, ICU coordinator training, and the closure of long-standing infrastructural gaps in low- and middle-income reporting countries.

06 · References

References.

local PDF on file in the WOD biblio  ·  web link only