The Spanish transplantation model as a benchmark: clinical, societal, and economic impact of liver transplants in Spain (1984-2024).

Spain leads the world in organ donation, and the 40th anniversary of its first liver transplant was recently commemorated. Our aim was to evaluate the evolution of the Liver Transplantation (LT) program in Spain over its four decades (1984-2024), examining clinical outcomes and societal economic benefits within a mature transplantation framework. Standardized national data from the Organización Nacional de Trasplantes and the Sociedad Española de Trasplante Hepático were used to reconstruct recipient cohorts by age group. Patient survival was estimated using Kaplan-Meier analysis. An economic evaluation from a societal perspective integrated surgical costs, long-term immunosuppressive therapy, and productivity gains associated with recipients' participation in the labour market. LT activity increased steadily during the initial expansion of the program and has stabilised at approximately 1,200 procedures per year over the past two decades. Both donor and recipient populations have aged; there are currently more patients over 60 years of age than two decades ago. Survival improved throughout the study period, extending life expectancy despite variations related to underlying disease. From an economic perspective, annual surgical costs remained below €60 million, increasing to €70-90 million when long-term immunosuppressive therapy was included. The economic contribution of surviving recipients to the labour market increased steadily, exceeding €75 million in 2024 and resulting in a positive balance since the early 2010s. Adult recipients generated net economic benefits, whereas paediatric recipients showed delayed but progressively increasing contributions as they entered the workforce. LT in Spain has produced sustained improvements in expected survival while generating substantial societal value, demonstrating that LT is both an effective clinical intervention and a valuable public health investment. The Spanish liver transplantation system may serve as a benchmark for evaluating the sustainability and societal impact of liver transplant programs in other healthcare systems.