Optimizing Cadaveric Organ Procurement
The need to face the increasing gap between the supply and the demand of transplants has led to the development of a permanent network of trained medical staff responsible for the organ donation and removal process in all centers accredited for that process. In Spain, this activity received a specific budget, like any other medical activity in hospitals, and the responsible staff became accountable for performance. This system dramatically increased the number of potential donors referred, not only young donors with trauma, but also elderly donors dying from stroke. The effect was that the donation rate increased by more than 100% in 10 years (from 14 to 34 donors per million population). Consequently, so did all the transplant figures. In some areas, such as Catalonia, it has been demonstrated that sustained kidney transplant activity of over 60 procedures per million population can maintain or slightly decrease the waiting list, despite increasing incidence and prevalence of end-stage renal failure. Quality monitoring of the donation and retrieval process shows that there are still opportunities for improvement if all potential donors are referred and all technical problems are overcome. Living donation and nonheart beating organ retrieval should also be promoted.

The success of organ transplantation has led to an big increase in the number of patients admitted to the waiting lists in recent years. However, organ donor rates, and hence transplantation probabilities, have remained unchanged or slightly increased. Despite all the advantages of organ transplantation, many patients cannot benefit from such therapy. The improvement in the number of available organs for transplantation is a permanent challenge for health-care organizations all around the world. Indications for transplantation have risen much more than the number of grafts. This gap is much higher in the USA than in the European countries ( Table 1 and Table 2 ).

In Spain, kidney transplant activity was very low in the late seventies, with only 8 renal transplants per million population (pmp) per year. In 1979, transplant law was enacted to improve transplant activity. In addition to the new legal framework, in some areas the responsible health-care units designed a full approach to an integrated treatment for end-stage renal patients. This approach represented a very useful tool to regulate transplant activity, ensuring patients access to the waiting list. This was the case in Catalonia, when in 1982 the Chronic Renal Failure Care Program was created. This program worked with advisory groups, involving doctors and health care managers, formulating common criteria for the care of end-stage renal failure patients. The Kidney Patients' Catalan Registry, which is a mandatory registry for all renal units, was created. At the same time, a public education program in the field of organ donation and transplantation was promoted. Following all these measures, kidney transplant activity increased dramatically during the eighties, and liver and heart transplant programs were started.

During the late seventies, most European and North American countries developed organ exchange organizations, with the aim of creating a system for waiting list management, allocation of organs and data registry analysis. This approach was followed in some areas, such as Catalonia and the Basque Country, but not in other Spanish regions. After a maximum organ donation level of 16 donors pmp in 1986, donation and transplantation figures decreased by more than 20% during 1987 and were maintained at these low levels during 1988 and 1989. This led to exponential growth of the kidney waiting list. As a consequence, a complaint was lodged with the kidney patients' associations, and the Ombudsman intervened. This, together with the increasing complexity of heart and liver transplant procedures, waiting list management and other organizational problems, led the Health Ministry to set up the National Transplant Organization (ONT) at the end of 1989, with the main commitment to increase organ donation and transplantation rates.