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Donation after circulatory death (DCD) donors are a unique group of patients who do not fulfil the conventional classification of brain death but in whom further resuscitation or treatment is considered futile. Once cardiac arrest and the cessation of circulation has been confirmed, either due to unsuccessful resuscitation or planned withdrawal of treatment they can proceed to organ donation. Donation is performed by rapidly preserving and cooling the organs followed by surgical removal.

Purpose of Review Allocation of deceased donor kidneys for transplantation has evolved since the first utilitarian approach in 1989. This review looks at how the schemes have evolved over the ensuing three decades. Recent Findings Four kidney offering schemes have been used in the last 30 years. Successive schemes have evolved from offering only one donor kidney for a nationally prioritised patient to offering both kidneys, from addressing only kidneys from donors after brain death (DBD) to offering kidneys from both DBD and circulatory death donors (DCD) and from prioritising purely on the basis of zero class 2 and minimising class 1 mismatches to a more relaxed approach for older donors and more difficult to match patients while introducing the concept of longevity matching. Summary UK kidney offering schemes have evolved through a series of evidence-based analyses to try to optimally address the principles of utility and fairness in kidney offering.

Although biliary complications are likely the most acknowledged and studied morbid complication associated with the use of donation after circulatory death (DCD) grafts, the scope of the issues with DCD livers extends beyond the bile duct to include post-reperfusion syndrome, overall graft dysfunction (both primary non-function and early allograft dysfunction), renal dysfunction (acute kidney injury and end-stage renal disease), and vascular complications (microthrombi, hepatic artery stenosis, hepatic artery thrombosis). This chapter covers the current incidence rates of these non-biliary complications in liver grafts from DCD donors in several large-center studies, both in isolation and in comparison to donation after brain death (DBD) liver grafts. Additionally, it briefly describes new modeling systems to better assess these complications and potential modalities to mitigate some of these issues.

The imbalance between injury, repair, regeneration, and maintenance of normal function that occurs during liver transplantation (LT) is more pronounced in recipients of donation after circulatory death (DCD) than in donation after brain death. As a way to balance this risk, careful selection of the adequate recipient is essential. Recipients with significant metabolic needs and/or poor functional reserve, such as those with advanced liver disease (extremely high MELD), fulminant hepatic failure, cardiopulmonary dysfunction, hemodynamic instability, or fulminant hepatic failure, should, in general, be avoided when using DCD livers. For the same reasons, DCD livers should be also avoided in patients with potential complex liver transplant operations where prolonged ischemia times, excessive bleeding, or other potential operative complications could create additional metabolic stress and/or ischemic injury to the allograft compromising its functional and regenerative processes. We describe our method of patient selection based on surgical complexity. Likewise, we review the published scoring systems which try to match the best potential candidates for DCD livers and avoid futile transplants. We also review the use of DCD livers in specific recipient populations such as those who are in need of simultaneous liver-kidney transplant, those with renal dysfunction, with primary sclerosing cholangitis, and with hepatocarcinoma, and in older recipients.

Since the advent of liver transplantation, optimal anesthesia care is necessary for positive perioperative outcomes. In the context of liver transplantation using grafts from donation after circulatory death (DCD) donors, the anesthesiologist must understand the pathophysiology of these grafts and their predisposition to an increased incidence of intraoperative events such as post-reperfusion syndrome, which can affect both short- and long-term outcomes. Although there is minimal research in this area, it generally supports that DCD grafts result in a higher incidence of intraoperative instability. Anesthesiologists should be aware of these implications and prepare accordingly for these cases, with considerations for advanced monitoring and alternative therapies for vasoplegia and cardiopulmonary collapse.

Dynamic preservation strategies are a promising option to improve graft quality and to extend preservation time for either logistic or treatment reasons. In contrast to normothermic oxygenated perfusion, which is based on physiologic conditions, thereby aiming to simulate the human body, hypothermic oxygenated liver perfusion appears un-physiologic and induces a unique, mitochondrial response for its protective effect. Both ex vivo perfusion techniques can be used for viability assessment, which will open the door for an increased liver utilization in the future.

Donation after circulatory death (DCD) provides the option of organ donation for patients who are not brain-dead, but for whom ventilator support will be removed for the purpose of death. With over 112,000 people waiting for a life-saving transplant, it is crucial that organ procurement organizations determine opportunities for the greatest potential for growth. For many, it is DCD donation. It is possible for DCD donors to donate the liver, kidneys, pancreas, lungs, and even the heart, but the most common organs recovered and transplanted from this donor population remain the liver and kidneys.

Uncontrolled donation after circulatory death (uDCD) donors suffer sudden and unanticipated cardiac arrest, typically outside the hospital setting. After advanced cardiopulmonary resuscitation has been attempted and determined to be unsuccessful, uDCD may be considered. At present, all programs recovering and transplanting uDCD livers rely on postmortem normothermic regional perfusion (NRP) to restore the flow of oxygenated blood following declaration of death. In this chapter, we discuss different aspects related to liver transplantation uDCD donors, including logistical and ethical issues surrounding the uDCD process, the use of NRP, graft and recipient selection criteria, perioperative recipient management, and post-transplantation outcomes that have been reported to date. We aim to demonstrate that, while uDCD is complex and the yield of livers for transplantation remains relatively low, it is nonetheless a viable alternative to more standard forms of liver donation and one that may be able to be expanded in the coming years through advances in both donor maintenance and ex situ organ preservation.

The use of donation after circulatory death (DCD) grafts is associated with the occurrence of ischemic-type biliary lesions (ITBL) and results in high morbidity and graft loss. It has been postulated that vascular stasis during cardio-circulatory arrest leads to microvascular thrombus formation and that the viability of DCD livers may be improved through the application of fibrinolytic therapy.

Despite recent outcome improvement, liver transplantation from donation after circulatory death (DCD) donors remains a challenge. Multiple donor, graft and procurement factors not only contribute to the results after transplantation but also impact on the selection process and the decision to utilize or decline such livers, which potentially transmit a high risk for severe complications including primary graft non-function or ischemic cholangiopathy. Although the transplant community has gained significant experience in this field, the majority of risk factors is still inconsistently reported with various acceptance criteria and thresholds, when to accept a DCD donor liver, which also depends on national and centre guidelines and the surgeons’ experience. Throughout the past 10 years, we have developed an increasing awareness of the cumulative risk and how to best combine donor and recipient parameters, which encouraged the community to adapt the allocation process and to match certain DCD livers with presumed higher risk with healthier recipients, as, for example, with candidates with liver tumours. In this chapter, we highlight currently considered donor and graft risk factors and how they contribute to outcomes after transplantation. Additionally, we also describe the impact of donor surgery and current prediction models which may influence the DCD liver selection process and how we may expect new developments and preservation technology to impact on our decisions in the future.

The donor operation in donation after circulatory death (DCD) donors presents unique challenges to the donor hospital staff, organ procurement organization staff, and transplant center team that expose all parties including the liver transplant recipient to challenging risk. Herein, we provide an approach to ensure clear communication, collaborative coordination, and faithful representation of the gift of liver donation in the setting of DCD liver transplantation. In this chapter, we describe the pre-operating room discussion, a detailed description of the modified super-rapid technique as per the Mayo Clinic Florida Protocol, and the critical organ and donation appraisal prior to liver acceptance.

Normothermic machine perfusion (NMP) involves perfusing organs ex vivo with normothermic oxygenated blood–based solutions that recreate the physiological environment, thereby tending to decrease the detrimental effects seen with standard cold storage (SCS). Several different NMP platforms exist that are in various stages of development. NMP has the potential to restore normal metabolic physiology, recondition marginal livers, and allow for the assessment of graft viability. The use of NMP for donation after circulatory death (DCD) liver grafts has been of particular interest, given the additional period of damaging warm ischemia these grafts are exposed to compared to donation after brain death (DBD) liver grafts. The present chapter describes the rationale for NMP, as well as providing a summary of pre-clinical and clinical studies that have investigated its application. The various platforms for NMP that have been utilized are also described.

Determination of death and provision of organ transplantation can result in controversy for the pediatric provider caring for a critically ill or injured child. Despite accepted legal definitions for death and guidelines for neurologic and circulatory determination of death, there remains an evolving and, at times, contentious dialogue among medical experts and the community. We provide the historical context and summarization of several legal and clinical aspects to define death and discussion of potential ethical controversies regarding death by neurologic and circulatory criteria. We highlight conflicts and controversies raised by both family and healthcare team members that are becoming increasingly prevalent in our practice of critical care medicine. We offer insight and proposed solutions into matters of autonomy, maleficence, non-beneficence, and the respectful, dignified care of the sick and dying child and their family.

Donation after circulatory death (DCD) is a relatively new topic in pediatric ethics. This chapter explores the ethical dimensions of controlled DCD, first examining the distinction between donation following brain death and donation following controlled circulatory death. While uncontrolled donation following circulatory death increases, a detailed consideration of the unique issues in that setting is beyond the scope of this chapter. We describe the background of and challenges to the dead donor rule, including debate over whether it comprises the appropriate ethical or legal basis for organ donation. With respect to donation in pediatrics, we examine the DCD process from the standpoint of multiple stakeholders, including parents/family members, clinicians, and organ procurement organizations. Finally, we explore the role of national and organizational regulations and guidelines in systematically addressing ethical issues with DCD practices. This discussion gives special attention to parental involvement and consent. Lastly, we consider the role for DCD protocols as additional mechanisms to manage the many ethical issues that arise with pediatric DCD.

During Shakespeare’s time in the late sixteenth and early seventeenth century, not breathing and the absence of blood circulation were universal criteria to declare someone dead. For almost two centuries, doctors have been using the stethoscope to diagnose death. In the twentieth century, the discovery of cardiopulmonary resuscitation, defibrillation, and pharmacologic therapies to counteract heart arrest changed the definition; cardiac arrest could be established as a clinical death, giving rise to the possibility of post-arrest resuscitation. For almost 50 years, doctors have thus been diagnosing death by applying neurological criteria. We discuss in this chapter the changing concepts for brain death from the sixteenth century to the Harvard criteria and to the Declaration of Sidney. The irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe is acknowledged globally as death. Different legal definitions of death have evolved in different countries over time. In Europe, the United States, and almost worldwide, the following two types of donation after death are commonly employed: (a) donation after brain death (DBD) and (b) donation after circulatory death (DCD).

Complexities and misunderstanding related to the determination of death continue to evolve in response to remarkable technological advances in the ability to support, replace or transplant failing organs. This paper reviews the principles of management of life-threatening critical illness and the corresponding biological aspects of life, death and organ donation which are both informed and complicated by these technological and scientific achievements. Clarity in lexicon should be established, including movement toward functional definitions and away from anatomically based terms such as cardiac and brain death that erroneously imply death of the organ. Medicine is evolving towards a single unified determination of death, based on the cessation of brain function subsequent to catastrophic brain injury or circulatory arrest. In the presence of clear cause and in the absence of reversible or confounding conditions, the cessation of clinical functions of the brain that will not resume is determined by the absence of capacity for consciousness, centrally mediated motor responses, brainstem reflexes and capacity to breathe.

From a medical perspective, organ donation from newborn infants is fraught with difficulty: the diagnosis of brain death is difficult to make in this age group and, by current definition, exceedingly rare. In addition, severely brain-injured newborns often retain sufficient respiratory ability to maintain circulation long past the time when organs may be suitable for donation after circulatory death (DCD) following the withdrawal of life-sustaining treatment. The issue of donor suitability in terms of organ size and the frequent absence of a clear diagnosis compound the complexity. These medical issues lead to ethical challenges for caregivers and the families of newborn infants when the potential for organ donation is raised. In this chapter, we will address the issues relating to the diagnosis of brain death in the newborn; with regard to DCD we will discuss the timing of death and how the dying and grieving process for families and the team may be altered by the prospect of donation. While organ donation may salvage some good for the family and broader society, caution is required not only for practical and medical reasons but also in view of the ethical uncertainty inherent in the concept of the newborn as an organ donor.

In the 1990s, the ever-increasing demand for organs led Spain, and later also France as well as other European countries, to authorise uncontrolled donation after circulatory death (uDCD). More recently, NYC developed its own uDCD protocol.