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Transplanting kidneys small for recipient’s size results in inferior graft function. Body surface area (BSA) is related to kidney size. We used the BSA index (BSAi) (Donor BSA/Recipient BSA) to assess whether the renal graft size is sufficient for the recipient. We included 26,223 adult single kidney transplants (01/01/2007–31/12/2019) from the UK Transplant Registry. We divided renal transplants into groups: BSAi ≤ 0.75, 0.75 1.25. We compared delayed graft function rates, primary non-function rates and graft survival among them. (Reference category: BSAi ≤ 0.75). Cases with BSAi ≤ 0.75 had the highest delayed graft function rates in living-donor renal transplants (11.1%) (0.75 1.25: OR = 0.32, 95% CI = 0.13–0.77, p = 0.011) and in renal transplants from donors after brain death (26.2%) (0.75 1.25: OR = 0.65, 95% CI = 0.47–0.9, p = 0.01). There were no significant differences in renal transplants from donors after circulatory death regarding delayed graft function rates (~ 40% in all groups). Graft survival was similar among BSAi groups in renal transplants from living donors and donors after brain death. Renal transplants from donors after circulatory death with BSAi ≤ 0.75 had the shortest graft survival (0.75 1.25: HR = 0.45, 95% CI = 0.31–0.66, p

PURPOSE: There is increasing clinical utilization of hearts from the donation after circulatory death (DCD) pathway with the aim of expanding the donor pool and mitigating the ever-present discrepancy between the inadequate availability of good quality donor hearts and the rising number of patients with end-stage heart failure. METHODS: This article reviews the rationale, practice, logistical factors, and 5-year experience of DCD heart transplantation at St Vincent’s Hospital, Sydney. FINDINGS: Between July 2014 and July 2019, 69 DCD donor retrievals were undertaken resulting in 49 hearts being instrumented on an ex situ normothermic cardiac perfusion device. Seventeen (35%) of these hearts were declined and the remaining 32 (65%) were used for orthotopic DCD heart transplantation. At 5 years of follow-up, the 1-, 3-, and 5-year survival was 96%, 94%, and 94% for DCD hearts compared with 89%, 83%, and 82% respectively for donation after brain death (DBD) hearts (n.s). The immediate post-implant requirement for temporary extra-corporeal membrane oxygenation (ECMO) support for delayed graft function was 31% with no difference in rejection rates when compared with the contemporaneous cohort of patients transplanted with standard criteria DBD hearts. SUMMARY: DCD heart transplantation has become routine and incorporated into standard clinical practice by a handful of pioneering clinical transplant centres. The Australian experience demonstrates that excellent medium-term outcomes are achievable from the use of DCD hearts. These outcomes are consistent across the other centres and consequently favour a more rapid and wider uptake of heart transplantation using DCD donor hearts, which would otherwise be discarded.

Biliary strictures are a common complication of donation after circulatory death (DCD) liver transplantation (LT) and require multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures. Three classification systems, based on cholangiograms, have been proposed for categorizing post-LT biliary strictures. We examined the interobserver agreement for each of the three classifications. DCD LT recipients from 2012 through March 2017 undergoing ERCP for biliary strictures were included in the study. Initial cholangiograms delineating the entire biliary tree prior to endoscopic intervention were selected. One representative cholangiogram was selected from each ERCP. Five interventional endoscopists independently viewed each anonymized cholangiogram and classified the post-LT stricture according to each of the three classification systems. The Ling classification proposes four types of post-LT strictures based on their location. The Lee classification proposes four classes based on location and number of intrahepatic strictures. The binary system classifies strictures into anastomotic or non-anastomotic types. The Krippendorff’s alpha reliability estimate was used to grade the strength of agreement as “poor,” “fair,” “moderate,” “good,” or “excellent” for values between 0–0.20, 0.21–0.4, 0.41–0.6, 0.61–0.08, and 0.81–1, respectively. One hundred DCD LT recipients (age 57.07 ± 8.8 years; 71 males) were initially evaluated. Of these, 49 patients who underwent 206 ERCP procedures for biliary strictures were included in the analysis. One hundred thirty-nine cholangiograms were selected and subsequently classified by five endoscopists. Interobserver agreement for post-LT biliary strictures was 0.354 for Ling classification (fair agreement), 0.405 for Lee classification (fair agreement), and 0.421 for the binary classification (moderate agreement). The binary classification provided the least amount of detail regarding the location and number of biliary strictures. The currently available classification systems for assessing post-LT biliary strictures have sub-optimal interobserver agreement. A better-designed classification system is needed for categorizing post-LT biliary strictures.

To assess the impact of introducing a devastating brain injury (DBI) pathway on patient outcome, intensive care unit (ICU) resources, and organ donation practice in the first 3 years of implementation in a regional neurosciences ICU in the South West of England. Patients with DBI admitted to our ICU between 2015 and 2018 were identified from our ICU database and their outcomes compared to those of non-DBI patients. Data were also obtained from the national potential donor audit to compare organ donation metrics before and after the introduction of the DBI pathway. Organ donation metrics in DBI patients and non-DBI patients were compared once the pathway had been implemented. We admitted 85 DBI patients (1.3% of all admissions), with a significantly shorter median length of ICU stay than in non-DBI patients, 1.14 versus 2.93 days (p

DCD is expanding, and with this expansion, there are emerging ethical issues involved in approaching the parents of a child for DCD. This paper will address those issues. The ethical issue that has received the most focus recently regarding pediatric DCD is the duration of the waiting period, after death declaration but prior to organ recovery, to ensure lack of autoresuscitation. A growing body of literature exists investigating autoresuscitation, thus providing a little more insight into the process of death determination. Pediatric DCD involves both the organ donor and the donor family. Informed consent for organ donation is obtained using the best interest model in pediatrics. Full disclosure of the process of DCD is essential to equip parents to make the best decision for their child. Additionally, the clinician must be prepared to explain the process to the families and honestly answer questions they might have about the process of their child’s death and organ recovery.

The basic question concerning the compatibility of donation after circulatory death (DCD) protocols with the dead donor rule is whether such protocols can guarantee that the loss of relevant biological functions is truly irreversible. Which functions are the relevant ones? I argue that the answer to this question can be derived neither from a proper understanding of the meaning of the term “death” nor from a proper understanding of the nature of death as a biological phenomenon. The concept of death can be made fully determinate only by stipulation. I propose to focus on the irreversible loss of the capacity for consciousness and the capacity for spontaneous breathing. Having accepted that proposal, the meaning of “irreversibility” need not be twisted in order to claim that DCD protocols can guarantee that the loss of these functions is irreversible. And this guarantee does not mean that reversing that loss is either conceptually impossible or known to be impossible with absolute certainty.

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. It is unlikely that expanding standard DCD programs will, in isolation, be sufficient to address the worldwide shortage of donor organs for transplantation. 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.

Kidney injury during donation after circulatory determination of death (DCDD) includes warm ischemic (WI) injury from around the time of asystole, and cold ischemic (CI) injury during cold preservation. We have previously shown that Matrix Metalloproteinases (MMPs) are involved in CI injury and that Doxycycline (Doxy), an antibiotic and known MMP inhibitor, protects the transplant kidney during CI. The purpose of our study was to determine if Doxy given before asystole can also prevent injury during WI. A rat model of DCDD was used, including Control, Preemptive Doxy (45 mg/kg iv), and Preemptive and Perfusion (100 microM) Doxy groups. Thirty minutes after asystole, both kidneys were removed. The left kidney was perfused at 4 °C for 22 h, whereas the right was used to establish the degree of warm ischemic injury prior to cold preservation. MMP-2 in the perfusate was significantly reduced in both treatment groups [Control 43.7 ± 7.2 arbitrary units, versus Preemptive Doxy group 23.2 ± 5.5 (p = 0.03), and ‘Preemptive and Perfusion’ group 18.0 ± 5.6 (p = 0.02)]. Reductions in NGAL, LDH, and MMP-9 were also seen. Electron microscopy showed a marked reduction in mitochondrial injury scores in the treatment groups. Pre-arrest Doxy was associated with a reduction in injury markers and morphologic changes. Doxy may be a simple and safe means of protecting transplant kidneys from both WI and CI.

Background Controlled donation after circulatory death (cDCD) has emerged as one of the main strategies for increasing the organ donor pool. Because of the ischemic injury that follows the withdrawal of life-sustaining therapies, hearts from cDCD donors have not been considered for transplantation until recently. The ex-situ perfusion of hearts directly procured from cDCD donors has been used to allow the continuous perfusion of the organ and the assessment of myocardial viability prior to transplantation. Based on our experience with abdominal normothermic regional perfusion in cDCD, we designed a protocol to recover and validate hearts from cDCD donors using thoraco-abdominal normothermic regional perfusion without the utilization of an ex-situ device. Case presentation We describe the first case of a cDCD heart transplant performed with this approach in Spain. The donor was a 43-year-old asthmatic female diagnosed with severe hypoxic encephalopathy. She was considered a potential cDCD donor and a suitable candidate for multiorgan procurement including the heart via thoraco-abdominal normothermic regional perfusion. The heart recipient was a 60-year-old male diagnosed with amyloid cardiomyopathy. Cold ischemia time was 55 min. The surgery was uneventful. Conclusions This case report, the first of its kind in Spain, supports the feasibility of evaluating and successfully transplanting cDCD hearts without the need for ex-situ perfusion based on the use of thoraco-abdominal normothermic regional perfusion opening the way for multiorgan donation in cDCD.

Early interstitial fibrosis (IF) correlates with long-term renal graft dysfunction, highlighting the need for accurate quantification of IF. However, the currently used Banff classification exhibits some limitations. The aim of our study was to precisely describe the progression of IF after renal transplantation using a new morphometric image analysis method relying of Sirius Red staining. The morphometric analysis we developed showed high inter-observer and intra-observer reproducibility, with ICC [95% IC] of respectively 0.75 [0.67–0.81] (n = 151) and 0.88 [0.72–0.95] (n = 21). We used this method to assess IF (mIF) during the first year after the kidney transplantation from 66 uncontrolled donors after circulatory death (uDCD). Both mIF and interstitial fibrosis (ci) according to the Banff classification significantly increased the first three months after transplantation. From M3 to M12, mIF significantly increased whereas Banff classification failed to highlight increase of ci. Moreover, mIF at M12 (p = 0.005) correlated with mean time to graft function recovery and was significantly associated with increase of creatininemia at M12 and at last follow-up. To conclude, the new morphometric image analysis method we developed, using a routine and cheap staining, may provide valuable tool to assess IF and thus to evaluate new sources of grafts.

In the current era of liver transplantation (LT), there is a large discrepancy between waiting list demand and organ donor availability. Increased utilization of donation after circulatory death (DCD) donors continues to expand the donor pool and improve access; however, concerns regarding recipient outcomes have limited wider adoption of these donor livers. This review will describe the current evidence regarding recipient outcomes and strategies that may help to optimize them. Historical outcomes of DCD LT are somewhat inferior to the DBD LT, yet new emerging evidence suggests that this outcome disparity may only be marginal at most; however, ischemic cholangiopathy remains a concern. Ideal donor selection criteria and optimizing recipient operative times appear to mitigate some of this risk. Extracorporeal membrane oxygenation (ECMO), hypothermic machine perfusion (HMP), and normothermic machine perfusion (NMP) are promising strategies to further improve graft resilience and performance. Cardiac death donors continue to expand the donor pool but may carry an increased risk of biliary complications. Graft reconditioning techniques, donor selection, and recipient optimization appear to mitigate this risk; however, these strategies need further investigation before generalized adoption.

Dr. O.P. Yadava, CEO and Chief Cardiac Surgeon, National Heart Institute, New Delhi, India, and Editor-in-Chief, Indian Journal of Thoracic and Cardiovascular Surgery, in conversation with Dr. Vivek Rao, Chief of Cardiovascular Surgery, Peter Munk Cardiac Centre, University of Toronto, discusses donation after circulatory death, role of pulsatility in mechanical circulatory support (MCS) and current status of MCS versus heart transplant as a destination therapy. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s12055-020-01044-6) contains supplementary material, which is available to authorized users.

Dr. O.P. Yadava, CEO and Chief Cardiac Surgeon, National Heart Institute, New Delhi, India, and Editor-in-Chief, Indian Journal of Thoracic and Cardiovascular Surgery, in a conversation with Dr. Catherine Dushyant Sudarshan, discusses the state of donation after circulatory death for cardiac transplant and how it can address the donor shortages. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s12055-020-01043-7) contains supplementary material, which is available to authorized users.

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them.

Donation after circulatory death (DCD) has contributed significantly to kidney, lung and liver transplant activities over the last decade. With an ever increasing demand for cardiac transplantation and worsening shortages of donor hearts, there has been growing interests in transplanting hearts from DCD donors. This was initially made possible by co-locating the donor and recipient to ensure the shortest possible ischaemic time for the DCD heart. More recently, reconditioning and distant procurement of arrested DCD hearts has been achieved by using machine perfusion. Early outcomes have been very encouraging, and experience to date suggests that DCD donors can contribute significantly to the number of donor hearts available for transplantation. There are variations in the legal and ethical frameworks between countries with regard to DCD organ donation and transplant teams must work within their respective local guidelines. We review the current status of clinical DCD heart transplantation and appraise the merits of the various approaches.

Human heart transplantation started more than half a century ago. The Royal Papworth Hospital, in Cambridgeshire, United Kingdom, where this procedure has been performed for more than four decades, has pioneered the resurgence of Donor Circulatory Death (DCD) heart transplantation, acknowledging the fact that the first transplant performed by Dr. Christian Barnard was from a DCD donor. The history of this procedure, the work carried out towards establishing a robust and successful DCD heart transplant program and the outcomes of the first fifty DCD heart transplants are described and discussed.

Organ donation after circulatory death (DCD) has experienced a revival worldwide over the past 20 years, and is now widely practiced for kidney transplantation. Some previous concerns about these organs such as the high incidence of delayed graft function have been alleviated through evidence from adult studies. There are now a number of large adult cohorts reporting favorable 5-year outcomes for DCD kidney transplants, comparable to kidneys donated after brain death (DBD). This has resulted in a marked increase in the use of DCD kidneys for adult recipients in some countries and an increase in the overall number of kidney transplants. In contrast, the uptake of DCD kidneys for pediatric recipients is still low and concerns still exist over the longer-term outcomes of DCD organs. In view of the data from adult practice and the poor outcomes for children who stay on dialysis, DCD kidney transplantation should be offered as an option for children on the kidney transplant waiting list.

Introduction and Methods: This report summarizes the results of the first phase in the development of international guidelines for death determination, focusing on the biology of death and the dying process, developed by an invitational forum of international content experts and representatives of a number of professional societies. Results and Conclusions: Precise terminology was developed in order to improve clarity in death discussion and debate. Critical events in the physiological sequences leading to cessation of neurological and/or circulatory function were constructed. It was agreed that death determination is primarily clinical and recommendations for preconditions, confounding factors, minimum clinical standards and additional testing were made. A single operational definition of human death was developed: 'the permanent loss of capacity for consciousness and all brainstem functions, as a consequence of permanent cessation of circulation or catastrophic brain injury'. In order to complete the project, in the next phase, a broader group of international stakeholders will develop clinical practice guidelines, based on comprehensive reviews and grading of the existing evidence. © 2014 Springer-Verlag Berlin Heidelberg and ESICM.

Background In the Netherlands, consent from relatives is obligatory for post mortal donation. This study explored the perspectives of relatives regarding the request for consent for donation in cases without donor registration. Methods A content analysis of narratives of 24 bereaved relatives (14 in-depth interviews and one letter) of unregistered, eligible, brain-dead donors was performed. Results Relatives of unregistered, brain-dead patients usually refuse consent for donation, even if they harbour pro-donation attitudes themselves, or knew that the deceased favoured organ donation. Half of those who refused consent for donation mentioned afterwards that it could have been an option. The decision not to consent to donation is attributed to contextual factors, such as feeling overwhelmed by the notification of death immediately followed by the request; not being accustomed to speaking about death; inadequate support from other relatives or healthcare professionals, and lengthy procedures. Conclusion Healthcare professionals could provide better support to relatives prior to donation requests, address their informational needs and adapt their message to individual circumstances. It is anticipated that the number of consenting families could be enlarged by examining the experience of decoupling and offering the possibility of consent for donation after circulatory death if families refuse consent for donation after brain-death. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0120-6) contains supplementary material, which is available to authorized users.

This study examined health professionals' (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)-controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios-BD, uncontrolled DCD and controlled DCD-were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors' loss of circulatory function could be reversed, and raises questions about >death> as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs' discomfort must be further identified and addressed., This study was supported in part by the French Agence de la Biome´decine and by an unrestricted grant from the Musculoskeletal Transplant Foundation. We thank Carissa Ve´liz, Sam Shemie, Howard Doyle and Linda Wright for their thoughtful comments and suggestions on previous versions of this paper

Donation after circulatory death (DCD) is a promising solution to the critical shortage of donor graft tissue. Maintaining organ viability after donation until transplantation is essential for optimal graft function and survival. To date, static cold storage is the most widely used form of preservation in clinical practice. However, ischemic damage present in DCD grafts jeopardizes organ viability during cold storage, and whether static cold storage is the most effective method to prevent deterioration of organ quality in the increasing numbers of organs from DCD is unknown. Here we describe the historical background of DCD liver grafts and a new preservation method for experimental and clinical transplantation. To prevent ischemia-reperfusion injury in DCD liver grafts, a hypothermic machine perfusion (HMP) technique has recently been developed and may be superior to static cold preservation. We present evidence supporting the need for improving liver perfusion performance and discuss how doing so will benefit liver transplantation recipients.

Background Kidneys from donors after cardiac or circulatory death are exposed to extended periods of both warm ischemia and intra-arterial cooling before organ recovery. Marshall’s hypertonic citrate (HOC) and Bretschneider’s histidine-tryptophan-ketoglutarate (HTK) preservation solutions are cheap, low viscosity preservation solutions used clinically for organ flushing. The aim of the present study was to evaluate the effects of these two solutions both on parameters used in clinical practice to assess organ viability prior to transplantation and histological evidence of ischemic injury after reperfusion. Methods Rodent kidneys were exposed to post-mortem warm ischemia, extended intra-arterial cooling (IAC) (up to 2 h) with preservation solution and reperfusion with either Krebs-Hensleit or whole blood in a transplant model. Control kidneys were either reperfused directly after retrieval or stored in 0.9% saline. Biochemical, immunological and histological parameters were assessed using glutathione-S-transferase (GST) enzymatic assays, polymerase chain reaction and mitochondrial electron microscopy respectively. Vascular function was assessed by supplementing the Krebs-Hensleit perfusion solution with phenylephrine to stimulate smooth muscle contraction followed by acetylcholine to trigger endothelial dependent relaxation. Results When compared with kidneys reperfused directly post mortem, 2 h of IAC significantly reduced smooth muscle contractile function, endothelial function and upregulated vascular cellular adhesion molecule type 1 (VCAM-1) independent of the preservation solution. However, GST release, vascular resistance, weight gain and histological mitochondrial injury were dependent on the preservation solution used. Conclusions We conclude that initial machine perfusion viability tests, including ischemic vascular resistance and GST, are dependent on the perfusion solution used during in situ cooling. HTK-perfused kidneys will be heavier, have higher GST readings and yet reduced mitochondrial ischemic injury when compared with HOC-perfused kidneys. Clinicians should be aware of this when deciding which kidneys to transplant or discard.

Transplantation: Prolonged cold ischaemic time reduces graft survival in kidneys from controlled-circulatory-death donors

Introduction: Organ donation after circulatory death (DCD) has become an accepted strategy to reduce the shortage of organs for transplantation in many European countries. The use and number of DCD donors varies between countries. The purpose of this study was to evaluate the available protocols for DCD in Europe. Methods: We contacted national transplant societies and responsible transplant co-ordinators in the countries that perform DCD to obtain DCD protocols. We compared information on the protocols and additional data including: inclusion and exclusion criteria for donation, legislation, determination of death and preservation methods. Results: In ten European countries DCD is performed, eight of which describe the methods in protocols. There are large differences in used DCD categories, legislation and the way death is determined. Protocols differ in the detail in which DCD procedures are described and the way methods are supported by additional consensus statements and ethical frameworks. Conclusions: Although DCD is an established strategy to enlarge the donor pool and to contribute to the reduction of the waiting list for transplantation, its potential has not been fully utilized yet. To further promote DCD transplantation, it is important to share expertise and obtain consensus, so that this can be translated into more uniform and solid protocols supported by the competent authorities, transplant and intensive care professionals, which may eventually result in a further promotion of DCD transplantation in Europe.

Introduction: We studied whether the choice of timing of discussing organ donation for the first time with the relatives of a patient with catastrophic brain injury in The Netherlands has changed over time and explored its possible consequences. Second, we investigated how thorough the process of brain death determination was over time by studying the number of medical specialists involved. And we studied the possible influence of the Donor Register on the consent rate. Methods: We performed a retrospective chart review of all effectuated brain dead organ donors between 1987 and 2009 in one Dutch university hospital with a large neurosurgical serving area. Results: A total of 271 medical charts were collected, of which 228 brain dead patients were included. In the first period, organ donation was discussed for the first time after brain death determination (87%). In 13% of the cases, the issue of organ donation was raised before the first EEG. After 1998, we observed a shift in this practice. Discussing organ donation for the first time after brain death determination occurred in only 18% of the cases. In 58% of the cases, the issue of organ donation was discussed before the first EEG but after confirming the absence of all brain stem reflexes, and in 24% of the cases, the issue of organ donation was discussed after the prognosis was deemed catastrophic but before a neurologist or neurosurgeon assessed and determined the absence of all brain stem reflexes as required by the Dutch brain death determination protocol. Conclusions: The phases in the process of brain death determination and the time at which organ donation is first discussed with relatives have changed over time. Possible causes of this change are the introduction of the Donor Register, the reintroduction of donation after circulatory death and other logistical factors. It is unclear whether the observed shift contributed to the high refusal rate in The Netherlands and the increase in family refusal in our hospital in the second studied period. Taking published literature on this subject into account, it is possible that this may have a counterproductive effect.

Donation after circulatory death (DCD) can be performed on neurologically intact donors who do not fulfill neurologic or brain death criteria before circulatory arrest. This commentary focuses on the most controversial donor-related issues anticipated from mandatory implementation of DCD for imminent or cardiac death in hospitals across the USA. We conducted a nonstructured review of selected publications and websites for data extraction and synthesis. The recommended 5 min of circulatory arrest does not universally fulfill the dead donor rule when applied to otherwise neurologically intact donors. Scientific evidence from extracorporeal perfusion in circulatory arrest suggests that the procurement process itself can be the event causing irreversibility in DCD. Legislative abandonment of the dead donor rule to permit the recovery of transplantable organs is necessary in the absence of an adequate scientific foundation for DCD practice. The designation of organ procurement organizations or affiliates to obtain organ donation consent introduces self-serving bias and conflicts of interest that interfere with true informed consent. It is important that donors and their families are not denied a 'good death', and the impact of DCD on quality of end-of-life care has not been satisfactorily addressed to achieve this.