01 · Introduction

Introduction.

The 2024 reporting cycle is the third consecutive year of global growth in transplant activity and the first in which donation after circulatory death (DCD) contributed nearly three in ten deceased donors worldwide [1, 2].

Data are drawn from the GODT 2024 global report [2], the EDQM Newsletter Transplant 2025 [3], NHSBT [4], ONT [5], OPTN/UNOS [6], and national bodies [7–10]. The composition of growth — DCD up 17%, DBD down 2% — extends a multi-year shift that is now structural rather than provisional.

This article summarizes the cycle, examines regional and national patterns, and argues that the data reinforce a finding now visible across multiple reporting cycles: legal change without infrastructural reinforcement does not deliver outcomes. Three threads carry the argument — the regional distribution of high-performance systems, the United Kingdom as a natural experiment in soft opt-out, and family-consent data as the proximate variable [14].

02 · Global activity

Global activity and top performers.

Total transplant activity rose to 173,727 in 2024, up from 172,397 in 2023 [2]. Activity was reported by 92 Member States, of which 91 performed transplants (Luxembourg reported only donation activity). Deceased donor numbers reached 47,180, an increase of approximately 3%, driven entirely by DCD growth.

Of the 13,366 DCD donors reported globally, controlled DCD (Maastricht type III) accounted for 94% (n = 12,485); Type II (uncontrolled) for 1%; Type IV (cardiac arrest after brain-death declaration) for 4%; and Type V (DCD following medical assistance in dying) for 1% [20].

Top-performing systems

Table 1. Top-performing systems by deceased-donor rate 2024, with DCD share where reported. Sources: [3, 5, 6, 10].

Spain's 53.9 pmp is the highest deceased-donor rate ever submitted to GODT, exceeding its 2023 figure of 49.4 [5]. The United States held second place by rate and led globally by absolute volume (16,989 donors) [6]. The Netherlands continued to operate the most DCD-led major program in the world: 247 of its 373 deceased donors (66.2%) were DCD [2]. Spain reported 1,316 DCD donors and remains the only national program transplanting all five solid organ types from DCD donors, including hearts [11].

03 · Regional patterns

Where the system held — and where it bent.

3.1 Western Europe

Western Europe remained the most productive region for deceased donation. Spain set a national record at 53.9 pmp; DCD now accounts for roughly half of Spanish donors. Portugal held at 36.7 pmp. Belgium reported 32.6 pmp, with a DCD share approaching 50%.

The Netherlands reported 21.1 pmp at the world-leading 66.2% DCD share. The United Kingdom, at 20.4 pmp, diverged from the rest of the region. Germany remained the lowest-performing major Western European program at 11.4 pmp — a function of low registration rather than low family consent [13].

3.2 Northern Europe, Eastern Europe, and the Americas

Nordic systems remained stable, with low objection rates (typically under 6%) underpinning the soft-opt-out frameworks. Lithuania emerged as a standout performer at 24.8 pmp, attributed to strengthened hospital coordination and public awareness.

Eastern Europe's leaders — Croatia (30.3 pmp), Czech Republic (34.3 pmp), Belarus (near 25 pmp) — continued to perform under hard opt-out frameworks. Poland rose to 16.6 pmp; Bulgaria remained well below its nominal opt-out potential, reinforcing the finding that the legal default alone does not translate into higher donation rates [17].

In the Americas, the United States (49.7 pmp / 16,989 donors) remains globally dominant by volume; US DCD reached 7,283 donors in 2024 [6]. Canada reported 23.1 pmp. Latin America showed mixed performance — Argentina 17.5, Brazil 17.3 (functioning as opt-in despite the nominal opt-out law), Uruguay 19.7, Chile 10.8.

3.3 Asia-Pacific, Middle East, and Africa

Japan remained an outlier — DCD pathways predominate culturally even at low overall donation rates. South Korea reported 7.7 pmp following the formalization of controlled DCD in 2022. Australia reported 19.7 pmp at 36.4% DCD share (192 of 527 donors); New Zealand 13.2 pmp. Both Australia and New Zealand operate ONT-patterned coordinator models [10].

The Middle East continued to operate under Islamic scholarly endorsements of brain death. The UAE reported 11.6 pmp, Kuwait 11.2, Israel 10.4, Qatar 8.1; no country in the region had a functioning DCD program. Africa remained constrained by infrastructural and legislative barriers: South Africa 1.5 pmp, Tunisia 0.7 pmp; Nigeria and Kenya reported zero deceased donors [27].

04 · The UK natural experiment

The United Kingdom — divergence in detail.

The NHSBT Activity Report 2024/25, covering April 2024 through March 2025, recorded a 7% fall in deceased donors: DBD donors fell 12% to 676; DCD donors fell 2% to 727 [4]. Total transplants declined 2%. The transplant waiting list reached 8,096 patients at 31 March 2025 — the highest figure on record and an 8% increase year-on-year.

Family consent (or authorization) held static at 59% overall — deemed-consent group at 48%, expressed-consent group at 87% [4]. The system also showed pockets of growth: living-donor kidney transplants rose 6% to 964, now 29% of the kidney program; lung transplants rose 8% to 151 (inclusive of the heart-lung block; NHSBT’s lung-only subtotals sum to ~149), the highest UK total since 2019/20.

The UK divergence is not attributable to consent law. England's soft opt-out framework, in place since May 2020, has not produced sustained gains. Consent rates fell from a pre-2020 peak around 67% to 59–61% by 2023/24 and have not recovered [15]. The pattern is consistent with the wider literature on opt-out defaults [19] and with the conclusion that legislative reform delivers only when paired with investment in coordinator capacity, family-approach training, and intensive-care pathway design [14].

05 · Family consent

Family consent — the real variable.

Across reporting countries, family-consent rate continues to track more closely with donation activity than the legal consent default. Spain reports approximately 85% (refusal ≈ 15%); Belgium approximately 83%; Sweden approximately 78%; Germany approximately 75% — alongside donor-registry registration of only approximately 36%, where the gap is identification, not culture [5, 13]. The United Kingdom's 59% sits well below the European top tier.

• Spain ≈ 85%
• Belgium ≈ 83%
• Sweden ≈ 78%
• Germany ≈ 75% (registry ≈ 36%)
• United Kingdom 59% (deemed 48%, expressed 87%)

High-refusal countries — Bangladesh, Oman, Kazakhstan, Türkiye, Tunisia, Switzerland, Malaysia — operate under widely different consent frameworks, suggesting that culture, trust, and approach quality dominate the legal-default question. In Spain, ICU-embedded coordinator models engage families earlier and produce a refusal rate roughly half that of the UK [14].

The Council of Europe regional total for waiting list and waiting-list deaths followed the same proportional pattern reported across recent cycles: kidney disease accounted for 85.5% of all waiting-list patients and 63% of all deaths on the waiting list [3].

06 · Conclusion

Conclusion.

The 2024 cycle reaffirms Spain's continued leadership, a structural shift toward circulatory-death donation, and the now-familiar finding that legal change without infrastructural reinforcement does not deliver outcomes.

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 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 [27, 28].

07 · References

References.

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