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Organ donation after circulatory death: current status and future potential

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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. 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.

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Authors and Affiliations

  1. Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK

    Martin Smith

  2. Organización Nacional de Trasplantes, C/Sinesio Delgado 6, Pabellón 3, Madrid, Spain

    B. Dominguez-Gil

  3. Department of Neurology, Boston University School of Medicine, Boston, USA

    D. M. Greer

  4. The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK

    A. R. Manara

  5. Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA

    M. J. Souter

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MS is Editor in Chief of the Journal of Neurosurgical Anesthesiology. BDG is Director General at the Organización Nacional de Trasplantes, Spain. DG is Editor-in-Chief of Seminars in Neurology, and receives research support from Bard Medical, Inc, as PI for the INTREPID Clinical Trial. ARM is the Regional Clinical Lead in Organ Donation for the South West of England. MJS is the Medical Director for Lifecenter Northwest Organ Procurement agency, serving the Pacific Northwest of the USA. The authors have no other conflicts of interest to declare.

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134_2019_5533_MOESM1_ESM.pptx

Supplementary material 1 (PPTX 92 kb). Fig. 1 Evolution of donation after circulatory death (rates per million population) in the most active countriesfrom 2003 to 2017. Source: Global Observatory on Organ Donation and Transplantation(http://www.transplant-observatory.org/)

134_2019_5533_MOESM2_ESM.docx

Supplementary material 2 (DOCX 13 kb). Table 1 Assessing the balance of whether an individual ante-mortem intervention is acceptable in an individualpatient

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Smith, M., Dominguez-Gil, B., Greer, D.M. et al. Organ donation after circulatory death: current status and future potential. Intensive Care Med 45, 310–321 (2019). https://doi.org/10.1007/s00134-019-05533-0

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