Expanding the organ donor pool: the Spanish Model.

2. Matesanz R, Miranda B, Felipe C: Organ procurement in Spain: Expanding the organ donor The impact of transplant coordination. Clin Transplant 8:281–286, 1994 3. Matesanz R, Miranda B, Felipe C, Naya T: Continuous improvepool: The Spanish Model ment in organ donation. Transplantation 61:1119–1121, 1996 4. International figures on organ donation and transplantation—1999, in Transplant Newsletter, Council of Europe 5:18–19, 2000 To the Editor: We read with interest the discussions of Dr. Hou regarding the best ways to improve organ donations [1]. As usually happens in this field, most strategies are cited to imply that they did not achieve signifiBone mass evolution after renal cant improvements. Rather surprising, the Spanish experience is not even considered, despite the fact that Spain transplantation is the only large country (40 million citizens) in the world with a sustained and progressive increase of cadaveric To the Editor: Now that tailoring immunosuppression organ donation rates during the last decade. Since the National Transplant Organization was estabis possible, efforts have concentrated on the prevention lished in 1989, together with a national network of inof post-transplant complications, including bone deminhospital, specifically trained, part-time, dedicated, and eralization. In this context, the recent study by Westeel et strongly motivated physicians in charge of organ proal suggests that cyclosporine-steroid immunosuppression curement [2], Spain has increased its organ donations may prevent post-transplant osteopenia [1]. from 14 to 33.6 organ donors per million people in 1999, Unfortunately, this conclusion is not convincing. It rests a 142% increase [3]. This organ donor rate is by far the only upon data collected between 3 and 24 months posthighest in the world (the United States has 21.8 per transplantation. When the first post-transplant months million people, Canada has 13.8, and the mean of the are included, all published studies agree that cyclosporineother European countries is 14.3), which has also resteroid–based immunosuppression is consistently associsulted in the highest transplant rates of cadaveric kidney, ated with bone loss [2, 3]. We have confirmed this concluliver, heart, and lungs [4]. There was no change in legislasion in 44 unselected graft recipients (Fig. 1). tion during this period and, as in most European counThe bone loss between 3 and 24 months post-transtries, permission from the family is always obtained beplantation that can be anticipated from the results of fore donation. previous studies averages 1.5% [2, 3]. The results of The number of renal transplants rose from 1039 in Westeel et al that were collected during this interval are 1989 to 2023 ten years later, 99% cadaveric (50.6 per thus of borderline significance when the precision error million people versus 29.9 in the United States), a sigof the methods used to evaluate bone mass is considered nificant and sustained increase that, at least in our opin(0.4 and 6 2 to 4% for the dual energy x-ray absorptiion, deserves a reference in reviews from authors of ometry and the quantitative computed tomography [4], possible methods to expand the donor pool. The “Spanrespectively). ish Model” results from the efforts of many to overcome Finally, these authors’ conclusions are limited by paobstacles such as untrained or under trained staff, untient selection, specifically excluding osteopenic postidentified donors, and the reluctance to approach grieving family members. menopausal women. Indeed, the independent effect on bone mass when the normal ovarian cycle is resumed in Rafael Matesanz and Blanca Miranda pre-menopausal women, as well as the prescription of Madrid, Spain potential osteogenic drugs (such as statins or thiazides) Correspondence to Rafael Matesanz, M.D., Nephrology Service, and the increased mobilization associated with successful Hospital Ramon y Cajal, Ctra de Colmenar Km 9, 100, 28034, Madrid, renal transplantation, is not considered. Spain. The clinician concerned with the fate of the patient E-mail: [email protected]