Organ donation after circulatory death: current status and future potential

Abstract

The continuing shortage of deceased donor organs for transplantation, and the limited number of potential donors after brain death, has led to a resurgence of interest in donation after circulatory death (DCD). The processes of warm and cold ischemia threaten the viability of DCD organs, but these can be minimized by well-organized DCD pathways and new techniques of in-situ organ preservation and ex-situ resuscitation and repair post-explantation. Transplantation survival after DCD is comparable to donation after brain death despite higher rates of primary non-function and delayed graft function. Countries with successfully implemented DCD programs have achieved this primarily through the establishment of national ethical, professional and legal frameworks to address both public and professional concerns with all aspects of the DCD pathway. There remains a worldwide shortage in organ availability, and it seems unlikely that expanding standard DCD programs in isolation will be sufficient to address this. It is therefore likely that reliance on extended criteria donors will increase, with the attendant imperative to minimize ischemic injury to candidate organs. Normothermic regional perfusion and ex-situ perfusion techniques allow enhanced preservation, assessment, resuscitation and/or repair of damaged organs as a way of improving overall organ quality and preventing the unnecessary discarding of DCD organs. This review will outline exemplar controlled and uncontrolled DCD pathways, highlighting practical and logistical considerations that minimize warm and cold ischemia times while addressing potential ethical concerns. Future perspectives will also be discussed. Take home message Donation after circulatory death (DCD) is an effective means of expanding the potential donor pool, and has comparable transplantation survival to donation after brain death despite higher rates of primary nonfunction and delayed graft function. Countries with successfully implemented DCD programs have achieved this primarily through the establishment of national ethical, professional and legal frameworks to address both public and professional concerns with all aspects of the DCD pathway.

Donation after circulatory death today: an updated overview of the European landscape

“…Legislative obstacles and ethical concerns constitute the main barriers for the development of new DCD programs . Overcoming such obstacles requires exchanging views and practices between countries and building consensus on aspects such as the determination of death by circulatory criteria . Indeed, immediately after finalizing the present work, we were informed that the DCD program in Norway had been temporarily halted due to ethical and juridical concerns regarding the practice that required national scrutiny and agreement.…”

“…DCD is only practiced in a minority of jurisdictions. Activity levels vary, with some countries primarily focusing on uDCD, while cDCD is predominant in others . The regulatory frameworks and the procedures applied are heterogeneous, as are the reported outcomes with the transplantation of DCD donor organs.…”

Facilitators and Barriers in the Organ Donation Process: A Qualitative Study among Nurse Transplant Coordinators

“…Finally, NTCs are facing a paradigm shift. Concurrently, in the field of donation and transplantation, there are new fields in clinical practice where nursing must be present, such as controlled asystole donation with perfusion in situ and the appearance of preservation programs in normothermia and hypothermia [40]. Moreover, the donor's profile has changed.…”

The Neurology of Death and the Dying Brain: A Pictorial Essay

“…The most obvious arena where this expertise is needed concerns the determination of brain death in a potential organ donor (1). In addition, donation after circulatory death (DCD) is increasingly practiced when brain-injured patients are deemed unlikely to enter brain death before withdrawal of life-sustaining therapy (2). In these cases, neurologists are typically consulted to confirm that meaningful recovery of brain function is futile, which requires proficiency in neuro-prognostication (3,4).…”