Changing Brain Death Donation Dynamics in Spain: A National Overview of Neurocritical Care and Organ Donation Trends.

BACKGROUND: Donation after brain death (DBD) has declined in Spain despite sustained transplantation activity and marked growth in donation after circulatory death (DCD). We examined whether this transition was driven by controlled or uncontrolled DCD and contextualized it alongside national trends in neurocritical care and organ utilization. METHODS: We conducted a descriptive ecological analysis of aggregated national data from the Spanish National Transplant Organization, healthcare registries, and epidemiological sources for 2015-2024. Annual DBD, controlled DCD (cDCD), uncontrolled DCD (uDCD), donation-potential indicators, mechanical thrombectomy, decompressive craniectomy, and organ recovery and utilization were examined. RESULTS: Actual DBD decreased from 1537 (33.0 per million population [pmp]) to 1246 donors (25.6 pmp). cDCD increased from 211 (4.5 pmp) to 1294 donors (26.6 pmp), whereas uDCD decreased from 103 (2.2 pmp) to 22 donors (0.5 pmp); thus, cDCD accounted for 98.3% of DCD activity in 2024. Donation-potential indicators fell during the COVID-19 pandemic and partially recovered thereafter. Mechanical thrombectomy increased from 2160 to 8762 procedures and decompressive craniectomy from 456 to 729. In 2024, DBD donors generated more recovered and implanted organs per donor than Maastricht category III cDCD donors (3.6 vs. 3.1 and 2.8 vs. 2.3, respectively). CONCLUSIONS: Spain's DCD expansion was almost entirely driven by controlled donation, while uDCD declined. These findings demonstrate a reconfiguration of deceased-donation pathways but do not establish patient-level substitution between DBD and cDCD. Linked individual-level studies are required to determine the contributions of neurocritical care, end-of-life decisions, and perfusion technologies.