European approach to increasing organ donation: European Union donor card, presumed consent, and other innovations


  • Juan C. Garcia-Valdecasas

    Corresponding author
    1. Department of Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
    • Department of Surgery, Hospital Clinic of Barcelona, University of Barcelona, Villarroel 170, Barcelona, Spain 08036
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    • Telephone: 011-34-93-227-5718; FAX: 011-34-93-227-5589

  • Potential conflict of interest: Nothing to report.


Key Points

1. Liver transplantation has become the standard of care for terminal liver disease.

2. Unfortunately, liver transplantation has become the victim of its own success because the number of available donors is not meeting the growing demand for organs. Liver Transpl, 2012. © 2012 AASLD.

There are several possible approaches to increasing organ donation.

First, reduce the need for transplantation. Hepatitis C virus–related cirrhosis is today one of the main indications, and although it seems that effective treatments will be available in the near future, there is still a need for transplantation, mainly because of hepatitis C virus–related complications such as cirrhosis and hepatocellular carcinoma. Therefore, a reduction in the number of indications is not feasible for now.

Second, make more organs available for transplantation. In this era of organ shortages, the Spanish model of organ donation is based on organizational measures that have resulted in a substantial increase in the number of organ donations.1 Most European countries have adopted presumed consent legislation, according to which no explicit consent is required for a person to become a potential donor. However, in most European countries, the family is still consulted to complete the process.2 It is clear that so-called classic measures such as promotional campaigns, donor cards, and facilitated donation drives are not effective unless they are used in a specific, coordinated way.3 The Spanish model, which is now successfully used in many parts of the world, including Europe (Italy, Croatia, and France), is based on transplant coordinators with a special profile (mainly intensivists) who have been specially trained and work inside a hospital. Good Practice Guidelines in the Process of Organ Donation4 was recently published with the aim of helping the coordination network improve its results. These guidelines have proved to be effective and have further increased the number of donations by 15%. These guidelines have been translated into English, French, German, and Italian.5

Third, apply special procedures or transplant techniques to make the best use of available donor organs. These include not only surgical techniques (eg, the split liver technique) that have proved to be effective (especially in the pediatric population) but also the retrieval of organs from donors after cardiocirculatory death. At present, using organs from these donors (and especially donors who fall within category 2 or 3 under the Maastricht criteria) is a way of significantly increasing the number of donations (Table 1).6 Organs from category 3 donors (in the intensive care unit awaiting cardiac arrest), which are the most commonly used worldwide, and organs from category 2 donors (unsuccessful resuscitation), with which there is less experience, are important sources that will need to be increased in the future. As for category 2 donors, our group has established a procedure that allows us to obtain organs in addition to kidneys (eg, livers) in a good enough condition to be useful.7–9 The procedure consists of placing the patient in normothermic extracorporeal membrane oxygenation at 37°C once the individual has been declared dead. By doing so, we have been able to obtain as many as 34 liver grafts over the last few years with a 74% probability of survival at 5 years. This procedure is now being implemented in other cities and countries such as the United Kingdom and France.

Table 1. Maastricht Classification for Donors After Cardiac Death
1UncontrolledDeath on arrivalRare
2UncontrolledUnsuccessful cardiopulmonary resuscitationVery frequent
3ControlledRemoval of ventilationLess frequent
  Awaiting cardiac arrest 
4ControlledBrain death followed by cardiac arrestRare

Fourth, use living donor liver transplantation. The use of living donor liver grafts in the setting of very active deceased organ donation (eg, Europe) suggests that this type of donation does not provide an effective way of expanding the donor pool, at least with respect to liver transplantation. At present, living donor liver transplantation represents less than 5% of all transplants performed in Europe. The surgical risk factors for the donors reduce the chances of this being a significant source of donations. Its applicability is low, and 2 European studies have suggested that only 15% to 20% of all patients with a potential donor end up receiving a graft from a living donor.10–11

In conclusion, ways to increase organ donation in Europe should include actions such as the early referral of possible donors to transplant coordinator teams, a benchmarking project to identify critical success factors for donation after brain death, new methods to approaching families and providing care, and the development of additional training courses aimed at specific groups of professionals. Organs from donors after cardiocirculatory death constitute a unique source that could significantly increase organ donation, and the number of these donors could be increased by the use of normothermic extracorporeal membrane oxygenation during organ retrieval. Other alternatives (eg, living donor transplantation, split liver transplantation, and domino liver transplantation) may provide good results but affect transplantation activity only marginally.