International issues in transplantation. Setting the scene and flagging the most urgent and controversial issues

Organ transplantation is the primary technique for treatment of end-stage organ failure and has benefited more than one million persons world wide. A number of patients have survived for well over 25 years and survival rates at 5 years can be 70% or higher for many organ transplant programs. However, currently more than 40,000 patients are waiting for a kidney, and in western Europe mortality rates for patients waiting for a heart, liver, or lung range from 15 to 30%. The potential need for transplants is even greater and this imbalance between supply and demand creates technical and ethical problems including the risk of organ trafficking. Consequently the number of available organs must be increased. In some cases the organ shortage reflects a true lack of donors, but more often it results from the failure to turn potential into actual donors. The transplant commission of the Council of Europe has just approved a document recommending that member states ensure that all potential donors are identified and as many as possible converted to actual donors. Even with the highest organ donation rate, the indications for organ and tissue transplantation will continue to increase, perpetuating the gap between supply and demand. Organ transplantation, whether living or cadaveric, might be supplemented or replaced by the use of artificial organs, although problems such as power supply, thrombosis, infection, and biocompatibility pose obstacles to long-term function. The use of animals as an alternative source is considered, but so many problems still remain unresolved that xenotransplantation cannot be put forth as a solution at this time. This paper reviews these issues and, citing the Spanish experience, offers strategies to improve the organ donation rate.