More than 29 countries have membership of the Middle East Society for Organ Transplantation (MESOT), and collectively these countries have a population > 600 million. These include all Arab countries, Iran, Turkey, Pakistan, and countries of central Asia. There are common features of organ transplantation in the Middle East countries that include inadequate preventive medicine, uneven health infrastructure, poor awareness in the medical community and public at large of the importance of the organ donation and transplantation, and poor government support of organ transplantation. In addition, there is lack of team spirit among transplant physicians, lack of planning for organ procurement and transplant centers, and lack of effective health insurance. Patients seek commercial transplantation most of the time. The number of patients on waiting lists for organ transplantation increases with time, and the gap is growing between supply and demand of organs in the MESOT countries. Living organ donation is the most widely practiced type of donation in the Middle East and includes kidney and partial liver. Cadaveric organ donation has great potential in the Middle East Nevertheless, this source is still not used properly because of the continued debate in the medical community about the concept of brain death and inadequate awareness of the public of the importance of organ donation and transplantation in many countries in this region. There are 3 dominant and distinctive models for practice: the Saudi, Iranian, and Pakistani models. The Saudi model includes a national organ procurement center as a governmental agency to supervise organ donation and transplantation. The Iranian model consists of renal graft donation from living people. The Pakistani model is a funding model for management of end-stage organ failure in developing countries. Organ donation and transplantation are hampered with obstacles in MESOT countries. Solutions need continuous work on many fronts. Local experiences can be implemented into new improved models that can help overcome current obstacles.