Logistics that saves lives: Spain, world leader in organ transplants for 32 years

Spain has remained the world leader in organ transplants for 32 consecutive years. It is a benchmark in this surgical procedure.

Professionals like Rebeca Bajo, a nurse in the coordination area of Spain’s National Transplant Organization, work against the clock every day to retrieve organs, find recipients, and deliver the organs before their blood flow diminishes. The reward is huge: in 2023, organs belonging to deceased individuals provided 5,863 new chances for life.

• What has made the Spanish organ transplant system the world leader in its field for 32 years?

  Some believe it’s because Spaniards are more altruistic, but it’s actually due to a confluence of factors. The first is our country’s legislation, which states that everyone is a donor unless they’ve explicitly opted out. The second is our public healthcare system. Working in a network at the national, regional, and hospital levels ensures that we operate very efficiently. Having coordinators in transplant hospitals is also key. Lastly, there are no financial transactions involved. This lends the process a great deal of credibility, which is fundamental. People trust that if they ever need a transplant, they’ll have the same opportunities to receive one as anyone else. There are countries where organ trafficking and private transplants exist, and if you have money, you can afford to live, but if you don’t, you can’t. In Spain, access to transplants is the same for all citizens.

  

  Rebeca Bajo, Nurse, Coordination Area, National Transplant Organization (Spain)

• Qualified donors must have passed away in a hospital. How do you organize extractions and donations?

  It all begins with a call from a hospital coordinator. We communicate by phone and share documentation through secure platforms to assess which organs we consider suitable for donation. We do this based on two complementary criteria. On the one hand, we consider clinical criteria. In Spain, if there’s a person who’s in urgent need and more critically ill than others, we prioritize that individual. Then we have the geographical criteria. These consider ischemic time, meaning the time an organ can survive from extraction to implantation. We have a window of a matter of hours to decide where the organ can be transplanted, and this varies depending on its type.

  Ideally, as little time as possible should elapse because that will make the transplant much more successful. We expand the search radius from the donor’s hospital. We start by looking for a recipient in the same city, then province, autonomous community, and region until we find the right match. Next, we determine which hospital to offer the organs to. However, the first hospital we contact doesn’t always have a suitable recipient. Sometimes the organs may not be appropriate due to size or blood type. Moreover, they have to be compatible with the recipient’s weight and height. When everything aligns, we focus on preparing the logistics processes.

  It’s always a race against time: every time you start the process with a new donor, it feels like you’re already late

• How do you carry out this logistics race for survival?

  We arrange air and road transportation based on the distance. If the transplant is within the same autonomous community, the organ is transported by ambulance. If it’s outside, we use private vehicles. This varies depending on the organ. A liver could endure up to three hours of travel by road, but if the transit time exceeds that, it has to be flown. The heart and lungs, however, need to arrive within a shorter time frame.

  

  Companies such as Iberia, Air Europa, Vueling, and Air Nostrum transport organs free of charge
  Photo credit: Vueling

  For long distances, which we cover by plane, we work with a series of private air taxis in cities such as Madrid, Barcelona, Vitoria, A Coruña, and Seville. We act as intermediaries, and the charge goes to the hospital performing the transplant. But these aircraft may not always be available. This has happened to us, in fact, during some major events and in the summer, when they’re booked for tourism purposes. Fortunately, we also have collaboration agreements with airlines such as Iberia, Air Europa, Vueling, and Air Nostrum, which transport the organs free of charge. For example, if we need to send a kidney from Galicia to Barcelona, we check whether there’s a commercial flight scheduled and make a request. Even in the case of a plane set to depart within an hour, it’s no problem. We receive the OK within two minutes, the coolers are boarded, and they’re placed in the cabin, safeguarded by the crew.

  The last mode of transportation we use, albeit more sporadically, is the train. We do this in the context of paired kidney exchanges. In collaboration with Renfe, Spain’s national railway company, a person transports the cooler from one city to another.

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  Maintaining communication is vital in an operation like this.

  We communicate constantly with coordinators, airports, and private companies. We share documentation through secure platforms in a formal, regulated manner, but we always call to make sure they’re aware of our arrival. At the ONT, we can make up to 300 calls for a single operation. Sometimes airports are under construction, while others close at a certain time; but they remain open if we request it.

  Our phone never goes unanswered, and we can have several calls on hold. We also have other emergency lines for contingencies and a direct line with the airports. We work the same way with private companies; they’re committed to having a terminal available 24 hours a day, and we always receive responses immediately.

• Do organs sometimes lose their viability during these transfers?

  Few, although it can happen under certain circumstances. Occasionally, there are issues with the weather. Private jets are very small, and if there’s a storm, they might not be able to take off or land. These situations complicate our day-to-day a bit more, although we always look for other ways to ensure that the organ isn’t lost and can still be transplanted.

• Could technology help make this mission more efficient in the future?

  Artificial intelligence (AI) is very popular for document preparation and decision-making. That would be ideal because oftentimes our huge dilemma is: will this organ we’re evaluating be suitable or not? If there were a secret formula that could tell us who would benefit the most… We select recipients based on many criteria, but it would be helpful to have more certainty in terms of their blood type, pathology, age, and the size of the organ.  Many variables can make an organ more compatible with one person over another, and while human intuition and perception will always be part of the final decision, it would be great if AI algorithms could assist us in making these choices. That’s what we would ask of technological advancements and the world of AI.

  People trust that if they ever need a transplant, they’ll have the same opportunities to receive one as anyone else. In Spain, access is the same for all citizens

  It’s always a race against time: every time you start the process with a new donor, it feels like you’re already late. You’re always trying to beat the clock. New technologies — such as sharing documents in the cloud and using smartphones — make our work easier. They enable us to be more agile in decision-making and logistics planning. This difference in time can mean life or death. Everything matters, and in the 10 years I’ve been with ONT, we’ve seen many changes.

• Spain is also involved in international transplants. Under what circumstances are they performed abroad?

  There are typically three scenarios. We might have a donor but no eligible recipients in the country. This could occur, for instance, if the donor’s blood type is AB, which is quite rare in our population. If we have an AB heart for donation but no local recipient, we look beyond our borders. Initially, we turn to Portugal, which has a direct collaboration agreement with Spain. If there’s no candidate there either, we expand our search to Europe using a platform. If the heart is accepted, we coordinate the extraction and transportation of the teams. We take into account distances to ensure that ischemic times are feasible.

  

  Another scenario could involve a pediatric donation. Luckily, the infant mortality rate is very low in our country. Moreover, there are very few children on the waiting list, so we offer these organs to the rest of Europe. Finally, we engage in international kidney paired exchanges, similar to those we coordinate among Spain’s autonomous communities.

• How did you manage medical emergencies during the Covid-19 pandemic, when hospitals were under such great strain?

  It was extremely challenging because Covid saturated the intensive care units (ICUs), which are precisely where our donors are located. They ran out of beds, and resources had to be found from wherever possible. In addition, many people were dying from Covid, which made transplants contraindicated. The number of donors plummeted. While there were still some available due to life circumstances such as brain injuries, there were no traffic accidents because driving was restricted.

  The most challenging aspect was performing transplants. Transplant recipients will become immunosuppressed and need to remain in a safe room. But many hospitals informed us that they didn’t have Covid-free ICUs to safely accommodate the patient. At the ONT, we prioritized emergencies and did everything possible to assist the most severely ill individuals. If a hospital said they couldn’t perform the transplant, we called every day to see if their conditions had improved and they could proceed with it.

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  You’re constantly looking for new ways to obtain viable organs. What projects is the ONT currently involved in?

  Older citizens represent a new donor pool. Clinical studies have shown that their organs are suitable for donation, so efforts are made to match the donor’s age with that of the recipient. Life expectancy is increasing, so it seems appropriate that people can also donate for a longer time. The heart can be more restrictive, but, for example, the lungs were the standout organ for transplants in Spain last year, largely due to these advances. The oldest donor was 92 years old.

• In addition to performing major logistics feats, you show great empathy. How do you address the emotions of bereaved families at such a critical moment in another patient’s life?

  Hospital coordinators are medical professionals or nurses who work in critical care units. There’s always an interview in which we inquire about what the deceased person would have wanted since very few people draw up a living will; they generally communicate their wishes to their loved ones. Many are aware and know what their family member would have wanted. Others say they’d never discussed it. Nevertheless, this conversation always takes place at the hardest moment for the family, right after their loved one has passed away. And it has to happen then because we can’t afford to wait.

  The coordination team establishes a supportive relationship with the families to help them through their grief. Many have told us afterwards that knowing their loved one was an organ donor and gave the gift of life to others was a great source of solace.

• What would you say to people who are considering becoming donors? Are there any limitations?

  No, none, and we don’t rule anything out beforehand because there are also older individuals who need them. For me, organ donation is the greatest act of human kindness. To think that someone’s death could give life to other people brings me great peace. Also, not everyone meets the conditions to be a donor. One of the requirements is to have died in a hospital, and there will be people who would have liked to donate, but their manner of death didn’t allow for it. I’ve been working in the organization for 10 years, and I feel fortunate. My daily work moves me deeply. It’s very closely tied to death, but it’s also very beautiful; it makes you appreciate life every day.

100 people coordinate to make every transplant happen

One of the pillars of the Spanish model is its mass organization, based on three levels. An average of 100 professionals take part in every donation and transplant process.

• National coordination. This involves the National Transplant Organization, (ONT), which evaluates the organs, distributes them, and manages their logistics operations. Up to 16 nurses work 24-hour shifts to handle calls.
• Regional coordination. Each of the 17 autonomous communities — which manage their own public health services — has an office dedicated to organ donation, acting as the base in its region.
• Hospital coordination. Each Spanish hospital with a donation program has a team composed of medical and nursing personnel. There are a total of 185 such teams