Although the lists include around 2,000 patients waiting for a new organ, the number of consents for donation and transplantation, which are given annually in Serbia, is far from sufficient to reduce the waiting lists. Those on the lists wait for the “most important call,” day in day out, often losing hope. A person who has experienced brain death, by donating their organs, in a way continues to live in the body of the person who receives the transplant. However, in Serbia, the story of organ transplantation and donation is still accompanied by stigma.

Eleven years of diagnosis, six and a half years spent on the waiting list and dialysis, three calls, and one successful transplant. This is the shortest way to describe the life of Ivana Pantelić since 2013. In July 2024, she started living freely again, as she says. She no longer depends on the machine that cleans her blood and replaces her kidney function, because, thanks to the consent of the family of a deceased person, she received a new kidney. “I kept expecting and losing hope that I would get the organ. Sometimes I thought it would happen, but then there were moments when I would completely fall apart, give up on everything, and think that nothing would come of the transplant, yet optimism was stronger. I held on until I got the kidney,” says this Belgrade woman 10 months after her transplant, in an interview for the Vreme. Her life completely changed when one morning, while she was on dialysis, the doctor called and told her that they had found a donor and that she was the best candidate for the transplant. “She told me that the transplant should take place that day and that I should come in. She explained that I was the most suitable candidate. I didn’t stop my dialysis; I went there after that. Around midnight, I knew I was chosen, that I had passed all the tests, that everything had matched, and I entered the operating room at one o'clock in the morning,” Ivana recalls that day, which she remembers perfectly, and which changed her life.

It was the third call from the hospital for a potential transplant. The previous two times, she was not fully compatible with the donor’s organs. But the third call was successful. “The first time, there was another girl besides me who matched, and it was tight to decide who would get it, but she had a slightly better match and received the kidney. The second time, I was told I was the best candidate, but something would have been wrong if I had received that kidney, because the doctors said I would need several more surgeries afterwards, so it just wouldn’t have been the right choice,” explains Pantelić.

URGENCY AND COMPATIBILITY

Around 2,000 people are currently on waiting lists for organ transplants. The majority – about one thousand, are waiting for a new cornea, and around 600 are waiting for a new kidney. The remaining patients are waiting for a new heart or liver. Whether or when any of them will receive an organ depends on many factors.

For a transplant to be performed, there must be compatibility between various factors of the immune systems of both the donor and the recipient, as only in such cases can the transplant be successful and lead to the recipient’s recovery. In addition to this immunological compatibility, other factors are considered, including the severity of the disease in the person waiting for the organ, the time spent on the waiting list, concurrent illnesses, as well as the urgency and degree of threat to the potential recipient. “You can be at the top of the list, but if you have a cold, you can’t get the organ,” says Dr Saša Knežević, an anaesthesiologist and one of the transplant coordinators at the University Clinical Centre of Serbia, adding that the organs are truly given to the most critically ill patients. “There are lists, typing, and urgency. As rule, the organ is given to the most urgent patients and those who are compatible. Everything must be aligned – from blood type to antigen typing. For kidney patients, this is the most difficult. Likewise, anthropometric measurements are important. What does this mean? If we have a large donor and a small recipient, we cannot perform the transplant. Or if the donor weighs 50 kilograms and the recipient weighs 100, we cannot perform the transplant because the organs will not be suitable. However, anthropometric measures can be disregarded in cases of extreme urgency. A lot of things must align for the transplantation to be successful and medically sound. If you do something wrong, when the patient leaves the hospital, it can destroy many lives,” explains Dr Knežević.

Ivana Pantelić was not compatible with potential donors twice, but, as she says, she hoped for a third call. “It’s difficult when you don’t know when the call might come. It could happen at any time of the day. The first time I was called in the middle of the night, the second time between two and three in the afternoon, and the third time it was in the morning. You never know when they will call you, you just have to be ready and not lose hope. But even when you lose hope, when the call comes – the hope is there again,” says Ivana Pantelić with visible enthusiasm, as dialysis and everything related to living with dialysis is now behind her.

Organ transplantation is the only therapeutic option when there is a permanent loss of function in certain organs. As a method of treatment, for patients who need it, transplantation represents the only chance for healing. Ivana’s kidneys had failed, so the transplant completely changed her life. “You can live on dialysis, but it’s a completely different lifestyle. You can travel, work, exercise, but there are many dietary restrictions. The worst part is the limited amount of liquid you can consume. That’s extremely hard. I could never fully adjust to that lifestyle. I managed to cope, but it was terribly difficult. If you’re traveling, you must find dialysis there, schedule it, cancel it here… for me, that was a hassle,” Ivana says as she finishes a glass of water – something she couldn’t even imagine just a few months ago. Water was what she missed the most during her long six and a half years on dialysis. “After the transplant, life returns to normal. Of course, the people who have received the organ must pay attention to certain things, but it’s still a normal life where you get freedom. Freedom is exactly what I felt the most. I no longer have the obligation to go to dialysis, I can function normally. I am still in the recovery phase, which will last for about one year if everything goes well, but this is a completely different life, a new life. In fact, I got my normal life back.”

WHO CAN(NOT) BE AN ORGAN DONOR?

According to legal procedures, in Serbia, all citizens are potential organ donors if they experience brain death, unless they have explicitly stated to their physician that they do not wish to be organ donors and are registered in the non-donor registry. There are some exclusionary factors, such as individuals treated for malignant diseases, HIV, hepatitis, and other viral infections, who cannot be donors. If these factors are ruled out and a person experiences brain death, they are considered a potential organ donor. At that point, a medical team is involved to confirm the brain death.

Brain death is the permanent and irreversible loss of brain function, and it is caused by the cessation of blood circulation in the brain. A team of doctors follows strictly defined medical procedures to confirm the diagnostic processes that verify the interruption of blood flow to the brain, and that the brain cells are irreparably damaged. “Brain death is an irreversible process of brain and brainstem damage. It is a process after which the person can no longer function. For a short time, they can be kept alive on machines with the help of doctors, usually anaesthesiologists in our country, and medications. This maintenance serves to preserve organ perfusion and condition, to potentially extend life for someone else, if the family of the deceased agrees,” explains Dr Knežević, adding that in case of brain death, the patient's condition cannot improve, and further treatment is no longer effective. “The brain is damaged to such a degree and since all the centres that control metabolic processes and all bodily functions are located in it, the person cannot live, cannot wake up, cannot function normally,” Dr Knežević clarifies.

Brain death is never proven in situations where the cause leading to brain damage is unknown. “There is,” continues Dr Knežević, “a situation where we cannot prove brain death, even though clinically we know the patient is brain dead. In such cases, their organs cannot be donated. Everybody and every organism reacts differently when the brain stops functioning, and sometimes, even with all our skills, medications, and machines, we cannot stabilise the body and complete the procedure. This is not very often, but once every few months we have a patient whose organs would be suitable for donation, but we cannot complete the procedure.”

Once brain death is confirmed and it is determined that the organs could potentially be transplanted, the family or closest relatives are informed, and they make the final decision. “The procedure is difficult because when the family loses their loved one, they are not prepared for this tragedy, and it is a huge and unpleasant surprise for them. However, they must find the strength to decide, in those moments, whether they want to give consent for organ donation. We do not have much time to wait. This is one of the problems in the transplantation process because you cannot let people think for days and evaluate whether this is good for them and for the deceased. We explain to them what led to the brain death, how it happened, and what organs can be donated. We ask them if they agree to save someone’s life with this gesture, to, in a way, extend the lives of their loved ones, and extend life to the organ recipient,” explains Dr Knežević.

If the deceased patient had a spouse, consent is sought from them. If there is no spouse, consent is sought from parents, children, or closest relatives. If there are no family members, consent can be given by the ethical committee and a panel of doctors, says Dr Knežević. He adds that there have been no such cases in Serbia so far. Once consent is obtained, the organs are surgically removed from the body, and then the body of the deceased is reconstructed. The organs can be preserved in special machines that maintain their function. There is also the so-called cold preservation of organs on ice, explains Dr Knežević. In this process, every minute is crucial, as with the passage of time, the quality of the organs deteriorates.

While she was waiting, many thoughts crossed Ivana’s mind. “I had moments of despair when I realised that I had to wait for someone to pass away so that I could be well, and it’s very hard to come to terms with that. Yet again, that organ prolongs life, it helps someone. That thought was hard for me to accept. I wondered if it’s horrible that I am looking forward to something like that, because it means someone’s demise. Unfortunately, someone’s demise can prolong the lives of several people. In fact, it can completely change the quality of several lives,” says Ivana Pantelić.

LOW NUMBER OF DONORS IN SERBIA

Statistics conducted around the world indicate that the chances of someone needing an organ are much higher than of being a potential organ donor, explains Dr Knežević. The situation is similar in Serbia, he says. “There are more and more patients on the waiting lists who need organs, and fewer and fewer quality donors. Unfortunately, even when we find suitable organs, in many cases we face a lack of understanding from the family, who refuse to give consent due to various kinds of prejudice, customs, and local cultures. The biggest uncertainty stems from insufficient information. I believe it’s not a lack of humanity, nor is it selfishness, as one might quickly assume, but rather a lack of information and deep-rooted prejudice,” says Dr Knežević, adding that the situation is completely different for those in need of an organ. “The emergency centre, the tragedies we witness, and the experiences we have with patients have taught me that no one is immune to illness, to misfortune, that it can happen to anyone, at any time. We never know who will need an organ and when, and we must always think about how we would feel if we or someone close to us needed an organ. How would we react? Would we want someone to burn, bury, or discard the body, or would we want them to donate organs and extend someone’s life, to give back dignity to someone’s life, and return them to their family after 5, 10, 15, 20 years, or more?” Dr Knežević reminds us.

The rarity of families giving consent is also reflected in the statistics on the number of transplantations annually performed in Serbia. In 2024, Ivana Pantelić was one of the 17 patients who received a kidney transplant in Serbia. According to data from the Ministry of Health, during 2024, there were a total of nine cadaveric donors in healthcare institutions for organ donation (transplantation centres), and 44 cadaveric organ transplants were carried out – 17 kidneys, seven hearts, six livers, and 14 corneas.

In addition to cadaveric, or deceased-donor transplants, living-donor transplants are also performed in Serbia. In 2024, 27 organs were transplanted from living donors. “These are the closest relatives, and if the matches align, they can donate paired organs like one kidney, or parts of unpaired organs, such as a portion of the liver. This is a very risky process because it jeopardises the donor, and you cannot be completely sure whether the recipient will successfully accept the organ,” explains Dr Knežević. Living donors can also donate organs to individuals who are not related to them, provided it’s medically confirmed that there is an adequate match. In case of living-donor transplants, parts of the liver, one of two kidneys, one of two lung lobes, blood, bone marrow, and bones can be transplanted.

The data on the number of transplants in Serbia in recent years are not favourable, but the statistics for the first three and a half months of 2025 are relatively good, as almost two-thirds of last year’s total number of transplants have already been performed. From January 1 to April 15, 2025, seven families gave consent for organ donation, while nine families refused consent. According to the Ministry of Health, from the beginning of 2025 to mid-April, 31 patients received organs. There were five heart and liver transplants each, nine kidney transplants, and 12 corneal transplants. Looking at the statistics of the past 10 years, Dr Knežević notes that the highest number of transplants occurred in 2017 and 2018. “At that time,” continues Dr Knežević, “we had around 100 solid organ transplants annually, and we had more than 30 donors. Essentially, three donors a month for around seven million residents. That was our peak. The optimal average we are aiming for is 10 donors per million residents, or 70 annually, and then we could enter an organ exchange system, and our patients could receive organs more efficiently and safely.” Dr Knežević points out that Serbia has the necessary medical staff and equipment, but there is a shortage of organs. “With the current number of transplants, we are not part of any organ exchange system with Europe,” he explains.

The most renowned community is Eurotransplant, but Serbia is not a member. Before joining the Eurotransplant community, the Republic of Serbia must meet the prerequisites for organ donation and transplantation, but primarily, it must increase the number of actual donors, according to the website of the Ministry of Health. It is also noted that member countries of Eurotransplant must meet transparent and objective criteria. “By joining Eurotransplant, our country would reduce the high mortality rate on waiting lists, decrease the waiting time for transplants, especially for kidney transplants. From the moment we join Eurotransplant, potential organ recipients will belong to the universal waiting list of this organization, which gives priority to life-threatening patients. Children are at the top of the list, and there are higher chances that highly sensitised patients will receive a transplant due to the larger number of donors,” according to the website of the Ministry of Health.

Although Serbia is not a member of Eurotransplant, it has several intergovernmental agreements on organ transplantation. “The most complex surgeries that our healthcare system does not perform are carried out abroad. The most frequent destinations are Italy and England. These include paediatric liver transplants or lung transplants. We bear in mind that we owe all these organs long-term and that once we establish our transplantation system, we should move towards organ exchange when, at some point, we have an excess of organs. This is in our interest because all our patients, who are in urgent need, can receive an organ faster from abroad,” concludes Dr Knežević.

The text was created in collaboration with the Hemofarm Foundation.