01 · Introduction

Introduction.

The 2025 reporting cycle is the first in which a major national transplant authority has explicitly attributed year-on-year donation decline, in part, to online misinformation [14]. It is also the year in which the country-level league table that has organized the field for two decades began to show wider divergence.

France, Italy, Australia, Belgium and the United States all reported national records [2–5, 12]. Spain, the United Kingdom and the Netherlands either dipped or flattened. The patterns sit alongside a sustained structural shift: DCD now drives essentially all year-on-year deceased-donor growth in the systems that have built the pathway [17].

This article argues that the divergence between record-setting systems and plateauing systems is best explained by three forces acting at once: a plateau ceiling defined by how often families say yes in mature systems [20]; a new misinformation channel producing measurable registry behavior change in at least one major system [14]; and DCD continuing to do the heavy lifting where the pathway has been built [17]. Each force is introduced below and synthesized in the conclusion.

02 · National records

Five national highs.

Table 1. National records reported in 2025. Sources: [1–6, 12].

France's 6,148 transplants exceeded the prior national high (6,120 in 2017) by a small margin [2, 3]. Of 3,188 potential brain-death donors identified (+0.6%), 1,590 were procured (+3%). Italy's 30.2 pmp is the country's best year ever; DCD now accounts for nearly 20% of national activity [4]. Australia's 8 million total donor registrations represent approximately 35% of the eligible population, against survey support for donation of roughly 80% [5, 6].

The United States' 49,064 transplants — the fifth consecutive record — masked a kidney-program dip. Kidney transplants totalled 27,573 (21,052 deceased + 6,521 living), 102 fewer kidneys than 2024: the first dip in over a decade. The record total was reached despite, not because of, the deceased-donor count, which contracted year-on-year [12]. DCD continues to grow as a share of US deceased donation [17].

03 · Divergences

Where the curve bent.

3.1 United Kingdom, Spain, Italy

The United Kingdom extended its multi-year contraction. Deceased donors fell 7% year-on-year (DBD −12% to 676; DCD −2% to 727); total transplants fell 2%. The waiting list reached a record 8,096 patients at 31 March 2025 (+8% YoY). Family consent held static at 59% overall — deemed-consent 48%, expressed-consent 87% [7].

Spain's organ-transplant total slipped to approximately 6,300 in 2025, down from the 2024 record of 6,464 [1]. Spain remains the world leader by deceased-donor rate (approximately 51 pmp; approximately 2,547 deceased donors), with DCD volume at approximately 56% share. The 2025 contraction is the first slight dip since pandemic recovery.

Italy registered an opposition-to-donation rate at electronic-ID issuance of 40.1% in 2025 — up from 36.3% in 2024 [4]. The erosion is concentrated among younger respondents, and it sits against the country's otherwise record-setting year.

3.2 The United States — de-registrations and the trust question

UNOS identified a deceased-donor decline as the year's most significant signal [12]. Donate Life America documented sharp spikes in donor-registry removals: a 700% spike in one week mid-year; state-level removal rates of 297–1,052% year-on-year in Florida; more than 5,000 removals in California following national reporting on donation practices [14, 27].

AOPO and Donate Life America have made the strongest attribution to online misinformation; UNOS itself has been more measured, calling for the cause to be better understood [14, 27]. Social-media circulation of these reports — focused on premature death declaration, allocation concerns, and donor incentives — coincided with measurable registry behavior change [28, 29].

The reporting coincided with a broader HHS / HRSA review of organ-procurement practices, with HRSA directing the OPTN to adopt clearer policies on donor eligibility and on the boundary between continued resuscitation and procurement preparation. The most concrete regulatory outcome in 2025 was the September announcement of intent to decertify the University of Miami’s Life Alliance Organ Recovery Agency — the first mid-contract decertification of an OPO on record. Beyond that single action, individual case judgments have remained unfinished, and several of the cases featured in the published investigations have been contested by the OPOs involved. Distinguishing protocol failures from clinical ambiguity in donation after circulatory death is genuinely difficult, and the broader claim of systemic ethical failure has been pushed back on both within the transplant field and by the state donor registries that responded to the reporting [27].

3.3 Australia — the consent-rate constraint

Australian donor numbers reached a record but family-consent rates held flat at 53%, well below the 2018 historic peak of 60% [5]. The Authority estimates that closing the gap to 60% would have produced approximately 200 additional transplants in 2025 alone. The national target is 25 dpmp; consent rate is the binding constraint.

04 · Three forces

Plateau, misinformation, and the DCD engine.

Read together, the 2025 records and divergences point to three forces acting at once.

4.1 The plateau hypothesis

Spain's small dip, the UK's continued contraction, and near-flatness across several mature European programs suggest that systems with fully built coordinator infrastructure are approaching a ceiling defined by how often families say yes [20]. Spain's approximately 85% family-consent rate is already exceptional; further gains will require either cultural shift or expansion of the donor pool — DCD, Type V, paired exchange.

4.2 The misinformation channel

This is the first cycle-level signal that online information environments can move registry-level behavior at scale. The channel sits outside the infrastructural variables that have explained between-country variation for the last two decades [14]. It is the analytical novelty of the 2025 cycle.

4.3 The DCD engine

France's 2025 growth was driven primarily by continued expansion of DCD-MIII procurement; Italy's record came alongside its DCD-center expansion [17]. Where DCD pathways have not been built, donation activity remained essentially flat. Type V (DCD after assisted dying) continued to be reported by Belgium, the Netherlands, and Canada [9]; Spain has not adopted the Type V pathway, and the UK, France, Australia, and the United States currently do not permit it.

05 · Conclusion

Conclusion.

The 2025 cycle is the first in which the long-running pattern of generalized growth has fractured into record-setting systems on one side and plateauing or contracting systems on the other.

The thesis of this article is that the divergence is best explained by three forces acting at once: a plateau ceiling defined by family-consent behavior in mature systems, a new misinformation channel that moves registry behavior at scale, and the continued role of DCD as the structural engine of year-on-year growth where the pathway has been built.

The practical implications for subsequent cycles are direct. Investment in family-approach training and public communication will matter at least as much as additional coordinator headcount in mature systems; the closure of long-standing DCD pathway gaps will continue to drive growth elsewhere [17]. The GODT 2025 global dataset, expected around December 2026, will allow these claims to be tested against the validated cohort [15, 19].

06 · References

References.

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