What does it mean to be placed on a transplant waiting list?

Being placed on a waiting list for an organ transplant involves many things, but above all, it represents a veritable roller coaster of feelings, hopes, fears, doubts, and questions for the patient and their family. These questions require considerable time and effort to be clarified by the responsible team , both medical and nursing. The truth is, given the intensity of the moment, this doesn't always produce good results . The patient's life is at stake, and that's a big deal.

It is therefore interesting to consider what these waiting lists really mean and what can be expected from the inclusion of a patient on them. From the outset, it must be said that they have nothing to do with the endless and ever-growing medical, surgical, and examination lists that characterize our national health system . While these lists are always a matter of an imbalance between supply and demand that can only be resolved by adding more resources and better management to the system, in the case of transplants, there is a fundamental limiting factor: the number of organs available. It matters little that we deploy more and better surgeons to perform transplants if organ donation doesn't work , and a good number of countries that have neglected this crucial aspect and find themselves unable to develop a good transplant system know this well.

Obviously, a country's donation rates will decisively determine the likelihood of its patients ultimately receiving the desired transplant. To better understand what it means for Spain to have led the world in organ donation rates for 33 years , it's enough to say that of an estimated global demand of approximately 2 million transplants annually according to the WHO, just over 170,000 were performed in 2023, which means a probability of receiving the necessary organ of less than 10%.

On the contrary, for many years now this figure in Spain has been between 90% and 95% , and it doesn't reach 100% because some patients' condition when they reach the waiting list can be so serious that they die on the waiting list or are left clinically unable to receive a transplant. Patients who enter the waiting list in Spain can be assured, based on data, that their chances of receiving a transplant are maximum and certainly higher than in any other country, which is no small feat.

From these figures, it could be deduced, and it is often taken for granted when discussing the subject, that the more transplants are made, the shorter the waiting list will be , and that it could even disappear. Although it may seem paradoxical , this is not at all the case. In fact, in countries with little transplant activity, the waiting list is also very short, which does not mean that the patients and the needs do not exist, but simply that it is a possibilist concept and that it would make no sense to include thousands of patients on the list when only a few dozen are expected to receive it.

As more and more organs become available for transplant , doctors increase the number of indications to match demand with supply, treating older, more complicated, or worse-looking patients who, years ago, were not considered transplant candidates . To summarize, since the creation of the ONT in 1989, transplant activity in Spain has increased from 1,315 to 6,464, a fivefold increase.

Those more than 5,000 additional patients each year that we transplant today probably already existed back then , corrected for population growth, but they couldn't be considered because we didn't have enough organs, the necessary equipment, or the medical and surgical procedures to, for example, transplant patients over 70-80 years old, as we do now. While in the 1970s , a 50-year-old patient was considered the age limit for a kidney transplant, today many patients over 80 are being accepted .

This relativity of the criteria for inclusion on the list, which varies greatly over time and with technical advances, makes it impossible to reduce the number of patients waiting below certain limits and, of course, to "disappear the waiting list" because new patients will take the place of those who leave it because they have already received a transplant, thus continuing the chain . It must always be kept in mind that the concept of transplantation is to replace a diseased organ that has reached its terminal stage and for which there is no other medical or surgical solution other than replacing the part. This means that the theoretical need for hearts, lungs , and other organs could grow exponentially to thousands more patients if the organ supply were unlimited and the results achieved supported it, as is often the case. The total need will never decrease.

A very illustrative example of all the above has occurred in recent years following the fortunate discovery and systematic application of anti-C virus drugs. Traditionally, this virus was the leading cause of liver transplant indications in Spain (not so in other countries with a lower incidence), so that around a third of the patients on the list were C virus+, and in some hospitals this figure even exceeded 50%.

However, widespread treatment since 2014 has completely reversed the situation , plummeting these percentages (from 32% to 7%) and reducing the waiting list by the end of the year to less than half that number (from 751 in 2014 to 330 in 2023). Since the number of livers eligible for transplant and, consequently, the number of procedures has continued to increase (from 1,068 to 1,262 over the same period ), what has happened has been a shift towards other indications while also producing a welcome reduction in waiting times and mortality on the waiting list.

The emerging cause of liver transplantation has become fatty liver, caused by poor diet and excessive alcohol consumption, a veritable pandemic at the present time. At the same time, transplants have begun to be performed in selected patients with colorectal cancer and liver metastases, a condition that was previously considered a contraindication, but which has now been shown to be viable after careful analysis involving the entire Spanish transplant community. Thirty-four such transplants have already been performed with good results.

As can be seen, the waiting list is a flexible concept that changes over time , adapting to circumstances and technological improvements to achieve a common goal: that everyone who could benefit from an organ transplant ultimately receives one under the best conditions and in the shortest possible time.