Global inequities in organ transplantation, 2008-2023: trends, unmet need, and policy implications.

Background: Solid organ transplantation is the definitive treatment for end-stage organ failure, yet access is highly inequitable worldwide. Comparable long-term evidence across organs, regions, and development settings remains limited. Methods: Data from the WHO Global Observatory on Donation and Transplantation (GODT) for six solid organs (2008-2023) were analyzed. Per-million population (PMP) rates and the estimated annual percentage change (EAPC) were calculated; disparities by Human Development Index (HDI), WHO regions, and Global Burden of Disease 2021 (GBD 2021) regions were quantified using the slope index of inequality (SII) and concentration index (CI); and transplant capacity gap was estimated by comparing observed volumes with PMP benchmarks from very-high-HDI countries. Findings: Global transplants rose 76% (101,990-179,091); PMP increased 15.1 → 23.1 (EAPC 2.5%). Kidney transplantation accounted for 65% of all solid organ transplants in 2023, representing the largest share of global activity; lung transplantation showed the fastest relative growth. Two procedures declined globally-pancreas-only transplantation and small-bowel transplantation. Absolute volumes were highest in the USA, China, and India, but PMP ranged from >120 (Spain, USA) to <5 in most low-HDI countries. Growth accrued mainly in very-high-HDI settings, with minimal contribution from low-HDI regions. Japan showed persistently low rates despite very-high-HDI status, whereas Mongolia achieved the world's highest EAPC despite low HDI. Inequality widened by SII (55.9 → 73.9), while CI fell modestly (0.61 → 0.53). Benchmarking indicated the largest transplant capacity gap for kidney (>200,000 procedures), then liver (>80,000) and heart (>30,000); coverage remained <10% in most low-HDI countries. Interpretation: Global activity increased substantially but gains concentrated in very-high-HDI countries, and inequities persist. Outlier trajectories highlight sociocultural and policy factors beyond economic development. Large benchmark-based gaps-especially for kidney, liver, and heart-remain across low- and middle-HDI settings. Strategic investment in policy, infrastructure, and integration of transplantation within universal health coverage is essential to advance equitable access. Funding: The Integrated Fund4150102990-58803-0/Prof. Dr. Z.K. Chen; The Fund of Guangzhou Key Laboratory of Organ Transplantation2025A03J4036.