Summary: With the continuing disparity between organ supply to match the increasing demand
for kidney transplants in patients with renal failure, donation after the circulatory
determination of death (DCDD) has become an important and increasing global source
of kidneys for clinical use. The concern that the outcomes of controlled DCDD donor
kidney transplants were inferior to those obtained from donors declared dead by neurologic
criteria has largely diminished because large-scale registry and single-center reports
consistently have reported favorable outcomes. For uncontrolled DCDD kidney transplants,
outcomes are correspondingly acceptable, although there is a greater risk of primary
nonfunction. The potential of DCDD remains unrealized in many countries because of
the ethical concerns and resource implications in the utilization of these donor kidneys
for transplantation. In this review, we discuss the origin and definitions of DCDD
donors, and examine the long-term outcomes of transplants from DCDD donor kidneys.
We discuss the controversies, challenges, and ethical and legal barriers in the acceptance
of DCDD, including the complexities of implementing and sustaining controlled and
uncontrolled DCDD donor programs. The lessons learned from global leaders will assist
a wider international recognition, acceptance, and development of DCDD transplant
programs that will noticeably facilitate and address the global shortages of kidneys
for transplantation, and ensure the opportunity for people who had indicated their
desires to become organ donors fulfill their final wishes.
Keywords
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REFERENCES
- An economic assessment of contemporary kidney transplant practice.Am J Transplant. 2018; 18: 1168-1176https://doi.org/10.1111/ajt.14702
- The reality of inadequate patient care and the need for a global action framework in organ donation and transplantation.Transplantation. 2022;
- Third WHO Global Consultation on Organ Donation and Transplantation: striving to achieve self-sufficiency, March 23–25, 2010, Madrid, Spain.Transplantation. 2011; 91: S27-S28https://doi.org/10.1097/TP.0b013e3182190b29
- The operation. A human cardiac transplant: an interim report of a successful operation performed at Groote Schuur Hospital, Cape Town.S Afr Med J. 1967; 41: 1271-1274
- Categories of non-heart-beating donors.Transplant Proc. 1995; 27: 2893
- New classification of donation after circulatory death donors definitions and terminology.Transpl Int. 2016; 29: 749-759https://doi.org/10.1111/tri.12776
Global observatory on donation and transplantation. Accessed April 20, 2022. http://www.transplant-observatory.org
- Changes in end-of-life practices in European intensive care units from 1999 to 2016.JAMA. 2019; 322: 1692-1704https://doi.org/10.1001/jama.2019.14608
- EuReCa ONE-27 Nations, ONE Europe, ONE Registry: a prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe.Resuscitation. 2016; 105: 188-195https://doi.org/10.1016/j.resuscitation.2016.06.004
- European Resuscitation Council Guidelines 2021: adult advanced life support.Resuscitation. 2021; 161: 115-151https://doi.org/10.1016/j.resuscitation.2021.02.010
- Effect of donor age and cold storage time on outcome in recipients of kidneys donated after circulatory death in the UK: a cohort study.Lancet. 2013; 381: 727-734https://doi.org/10.1016/S0140-6736(12)61685-7
- Early results of a controlled non-heart-beating kidney donor programme.Nephrol Dial Transplant. 2009; 24: 1992-1996https://doi.org/10.1093/ndt/gfp070
- Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac death in the UK: a cohort study.Lancet. 2010; 376: 1303-1311https://doi.org/10.1016/S0140-6736(10)60827-6
- Ethical, legal, and societal issues and recommendations for controlled and uncontrolled DCD.Transpl Int. 2016; 29: 771-779https://doi.org/10.1111/tri.12720
- Ethical and legal issues in non-heart-beating organ donation.Transplantation. 2005; 79: 1143-1147https://doi.org/10.1097/01.tp.0000160761.86036.6c
- Ethical, psychosocial, and public policy implications of procuring organs from non-heart-beating cadaver donors.JAMA. 1993; 269: 2769-2774
- Expanding controlled donation after the circulatory determination of death: statement from an international collaborative.Intensive Care Med. 2021; 47: 1059-1060https://doi.org/10.1007/s00134-021-06435-w
- Non-heart beating organ donation: old procurement strategy–new ethical problems.J Med Ethics. 2003; 29: 176-181https://doi.org/10.1136/jme.29.3.176
- Non-heart-beating organ donation - solution or a step too far?.Anaesthesia. 2007; 62: 431-433https://doi.org/10.1111/j.1365-2044.2007.05093.x
- Donation after circulatory death.Br J Anaesth. 2012; 108: i108-i121https://doi.org/10.1093/bja/aer357
- Reasons for withdrawing treatment in patients receiving intensive care.Anaesthesia. 1998; 53: 523-528https://doi.org/10.1046/j.1365-2044.1998.t01-1-00407.x
- End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom.Intensive Care Med. 2005; 31: 823-831https://doi.org/10.1007/s00134-005-2644-y
- Defining Futile and Potentially Inappropriate Interventions: a policy statement from the Society of Critical Care Medicine Ethics Committee.Crit Care Med. 2016; 44: 1769-1774https://doi.org/10.1097/CCM.0000000000001965
- Bespoke end-of-life decision making in ICU: has the tailor got the right measurements?.Crit Care Med. 2015; 43: 909-910https://doi.org/10.1097/CCM.0000000000000837
- A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries.J Intensive Care Soc. 2016; 17: 295-301https://doi.org/10.1177/1751143716647980
- Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations.Br J Anaesth. 2018; 120: 138-145https://doi.org/10.1016/j.bja.2017.10.002
- Decision making in perceived devastating brain injury: a call to explore the impact of cognitive biases.Br J Anaesth. 2018; 120: 5-9https://doi.org/10.1016/j.bja.2017.11.007
- Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review.Intensive Care Med. 2020; 46: 1803-1851https://doi.org/10.1007/s00134-020-06198-w
- Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients.BMJ. 2008; 336: 425-429https://doi.org/10.1136/bmj.39461.643438.25
- The ICH score: a simple, reliable grading scale for intracerebral hemorrhage.Stroke. 2001; 32: 891-897https://doi.org/10.1161/01.str.32.4.891
- Diffusion-weighted imaging score of the brain stem: a predictor of outcome in acute basilar artery occlusion treated with the Solitaire FR device.AJNR Am J Neuroradiol. 2014; 35: 1117-1123https://doi.org/10.3174/ajnr.A3870
- Death and organ donation: meeting the needs of multiethnic and multifaith populations.Br J Anaesth. 2012; 108: i88-i91https://doi.org/10.1093/bja/aer385
- Ethical controversies at end of life after traumatic brain injury: defining death and organ donation.Crit Care Med. 2010; 38: S502-S509https://doi.org/10.1097/CCM.0b013e3181ec5354
- Organ donation after cardiac death: legal and ethical justifications for antemortem interventions.Med J Aust. 2007; 187: 168-170https://doi.org/10.5694/j.1326-5377.2007.tb01178.x
- Best practice guideline for donation after circulatory determination of death (DCDD) in Australia.Edition 1.0. October 2021https://www.donatelife.gov.au/sites/default/files/2022-01/ota_bestpracticeguidelinedcdd_02.pdfDate accessed: March 15, 2022
- Donation after circulatory death today: an updated overview of the European landscape.Transpl Int. 2020; 33: 76-88https://doi.org/10.1111/tri.13506
- National recommendations for donation after cardiocirculatory death in Canada: donation after cardiocirculatory death in Canada.CMAJ. 2006; 175: S1https://doi.org/10.1503/cmaj.060895
- Statement on controlled organ donation after circulatory death.2017https://www.asahq.org/standards-and-guidelines/statement-on-controlled-organ-donation-after-circulatory-deathDate accessed: March 15, 2022
- Therapeutic hypothermia in deceased organ donors and kidney-graft function.N Engl J Med. 2015; 373: 405-414https://doi.org/10.1056/NEJMoa1501969
- International guideline development for the determination of death.Intensive Care Med. 2014; 40: 788-797https://doi.org/10.1007/s00134-014-3242-7
- Enabling donation after cardiac death in the emergency department: overcoming clinical, legal, and ethical concerns.J Emerg Med. 2017; 52: 588-592https://doi.org/10.1016/j.jemermed.2016.11.025
- DCDD donors are not dead.Hastings Cent Rep. 2018; 48: S29-S32https://doi.org/10.1002/hast.949
- Donation after brain circulation determination of death.BMC Med Ethics. 2017; 18: 15https://doi.org/10.1186/s12910-017-0173-1
- Protocols for uncontrolled donation after circulatory death: a systematic review of international guidelines, practices and transplant outcomes.Crit Care. 2015; 19: 268https://doi.org/10.1186/s13054-015-0985-7
- Uncontrolled donation after circulatory determination of death: a systematic ethical analysis.J Intensive Care Med. 2018; 33: 624-634https://doi.org/10.1177/0885066616682200
- Uncontrolled DCD: when should we stop trying to save the patient and focus on saving the organs?.Hastings Cent Rep. 2018; 48: S33-S35https://doi.org/10.1002/hast.950
- The circulatory-respiratory determination of death in organ donation.Crit Care Med. 2010; 38: 963-970https://doi.org/10.1097/CCM.0b013e3181c58916
- Resumption of cardiac activity after withdrawal of life-sustaining measures.N Engl J Med. 2021; 384: 345-352https://doi.org/10.1056/NEJMoa2022713
- A systematic review of autoresuscitation after cardiac arrest.Crit Care Med. 2010; 38: 1246-1253https://doi.org/10.1097/CCM.0b013e3181d8caaa
- Autoresuscitation after asystole in patients being considered for organ donation.Crit Care Med. 2012; 40: 158-161https://doi.org/10.1097/CCM.0b013e31822f0b2a
- Time to cardiac death after withdrawal of life-sustaining treatment in potential organ donors.Am J Transplant. 2009; 9: 2157-2165https://doi.org/10.1111/j.1600-6143.2009.02758.x
- Donor hemodynamics as a predictor of outcomes after kidney transplantation from donors after cardiac death.Am J Transplant. 2016; 16: 181-193https://doi.org/10.1111/ajt.13432
- DCD donor hemodynamics as predictor of outcome after kidney transplantation.Am J Transplant. 2018; 18: 1966-1976https://doi.org/10.1111/ajt.14676
- Association between delayed graft function and graft loss in donation after cardiac death kidney transplants-a paired kidney registry analysis.Transplantation. 2017; 101: 1139-1143https://doi.org/10.1097/TP.0000000000001323
- Prediction of time to death after terminal withdrawal of life-support in non-heartbeating organ donation: unaccounted variables and window of opportunity.Crit Care Med. 2012; 40: 986-988https://doi.org/10.1097/CCM.0b013e318236e2f3
- Prediction of potential for organ donation after cardiac death in patients in neurocritical state: a prospective observational study.Lancet Neurol. 2012; 11: 414-419https://doi.org/10.1016/S1474-4422(12)70060-1
- Predicting donor asystole following withdrawal of treatment in donation after cardiac death.Transplant Proc. 2010; 42: 3949-3950https://doi.org/10.1016/j.transproceed.2010.09.080
- Prospective multicenter observational cohort study on time to death in potential controlled donation after circulatory death donors-development and external validation of prediction models: the DCD III study.Transplantation. Published online March 8, 2022. 2022; https://doi.org/10.1097/TP.0000000000004106
- Non-utilization of kidneys from donors after circulatory determinant of death.Transplant Direct. 2022; 8: e1331
- In situ normothermic perfusion of livers in controlled circulatory death donation may prevent ischemic cholangiopathy and improve graft survival.Am J Transplant. 2019; 19: 1745-1758https://doi.org/10.1111/ajt.15241
- Abdominal normothermic regional perfusion in controlled donation after circulatory determination of death liver transplantation: Outcomes and risk factors for graft loss.Am J Transplant. 2022; 22: 1169-1181https://doi.org/10.1111/ajt.16899
- Normothermic regional perfusion vs. super-rapid recovery in controlled donation after circulatory death liver transplantation.J Hepatol. 2019; 70: 658-665https://doi.org/10.1016/j.jhep.2018.12.013
- Abdominal normothermic regional perfusion in donation after circulatory death: a systematic review and critical appraisal.Transplantation. 2020; 104: 1776-1791https://doi.org/10.1097/TP.0000000000003345
- Liver transplantation outcomes from controlled circulatory death donors: static cold storage vs in situ normothermic regional perfusion vs ex situ normothermic machine perfusion.Ann Surg. 2022; 275 (Published online March 3): 1156-1164https://doi.org/10.1097/SLA.0000000000005428
- A systematic review and meta-analyses of regional perfusion in donation after circulatory death solid organ transplantation.Transpl Int. 2021; 34: 2046-2060https://doi.org/10.1111/tri.14121
- Improved short-term outcomes of kidney transplants in controlled donation after the circulatory determination of death with the use of normothermic regional perfusion.Am J Transplant. 2021; 21: 3618-3628https://doi.org/10.1111/ajt.16622
Dalle Ave AL, Bernat JL.Donation after brain circulation determination of death. BMC Med Ethics. 2017;18(1):15. doi: https://doi.org/10.1186/s12910-017-0173-1.
- Improving the outcomes of organs obtained from controlled donation after circulatory death donors using abdominal normothermic regional perfusion.Am J Transplant. 2017; 17: 2165-2172https://doi.org/10.1111/ajt.14214
- Consensus statement on normothermic regional perfusion in donation after circulatory death: report from the European Society for Organ Transplantation's Transplant Learning Journey.Transpl Int. 2021; 34: 2019-2030https://doi.org/10.1111/tri.13951
- Organ donation after circulatory death: current status and future potential.Intensive Care Med. 2019; 45: 310-321https://doi.org/10.1007/s00134-019-05533-0
- Uncontrolled donation after circulatory death: European practices and recommendations for the development and optimization of an effective programme.Transpl Int. 2016; 29: 842-859https://doi.org/10.1111/tri.12734
- Donation after circulatory death and its expansion in Spain.Curr Opin Organ Transplant. 2018; 23: 120-129https://doi.org/10.1097/MOT.0000000000000480
- Use of marginal organs from non-heart-beating cadaveric kidney donors.Transplantation. 2001; 72: 1376-1380https://doi.org/10.1097/00007890-200110270-00007
- Long-term outcome of kidney transplant using non-heart-beating donor: multicenter analysis of factors affecting graft survival.Clin Transplant. 2003; 17: 518-521https://doi.org/10.1046/j.1399-0012.2003.00080.x
- Victims of cardiac arrest occurring outside the hospital: a source of transplantable kidneys.Ann Intern Med. 2006; 145: 157-164https://doi.org/10.7326/0003-4819-145-3-200608010-00003
- Kidney transplantation from donors after cardiac death: uncontrolled versus controlled donation.Am J Transplant. 2011; 11: 1427-1434https://doi.org/10.1111/j.1600-6143.2011.03562.x
- Transplantation of kidneys from uncontrolled donation after circulatory determination of death: comparison with brain death donors with or without extended criteria and impact of normothermic regional perfusion.Transpl Int. 2016; 29: 432-442https://doi.org/10.1111/tri.12722
- Similar 5-year estimated glomerular filtration rate between kidney transplants from uncontrolled and controlled donors after circulatory death-a Dutch cohort Study.Transplantation. 2017; 101: 1144-1151https://doi.org/10.1097/TP.0000000000001211
- Kidney transplantation from donors after uncontrolled circulatory death: the Spanish experience.Kidney Int. 2019; 95: 420-428https://doi.org/10.1016/j.kint.2018.09.014
- Uncontrolled donation after circulatory death: a cohort study of data from a long-standing deceased-donor kidney transplantation program.Am J Transplant. 2019; 19: 1693-1707https://doi.org/10.1111/ajt.15243
- Kidney transplant from uncontrolled donation after circulatory death donors maintained by nECMO has long-term outcomes comparable to standard criteria donation after brain death.Am J Transplant. 2019; 19: 434-447https://doi.org/10.1111/ajt.14991
- Kidney transplant from uncontrolled donation after circulatory death: contribution of normothermic regional perfusion.Transplantation. 2020; 104: 130-136https://doi.org/10.1097/TP.0000000000002753
- Kidney transplantation following uncontrolled donation after circulatory death.Curr Opin Organ Transplant. 2020; 25: 144-150https://doi.org/10.1097/MOT.0000000000000742
- Death, permanence and current practice in donation after circulatory death.QJM. 2017; 110: 199-201https://doi.org/10.1093/qjmed/hcw184
- Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation or uncontrolled donation after the circulatory determination of death following out-of-hospital refractory cardiac arrest-an ethical analysis of an unresolved clinical dilemma.Resuscitation. 2016; 108: 87-94https://doi.org/10.1016/j.resuscitation.2016.07.003
- European Resuscitation Council Guidelines 2021: adult advanced life support.Resuscitation. 2021; 161: 115-151https://doi.org/10.1016/j.resuscitation.2021.02.010
- Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation. 2020; 142: S366-S468https://doi.org/10.1161/CIR.0000000000000916
- Derivation of the uncontrolled donation after circulatory determination of death protocol for New York city.Am J Transplant. 2011; 11: 1417-1426https://doi.org/10.1111/j.1600-6143.2011.03582.x
- Uncontrolled donation after circulatory death: ethics of implementation.Curr Opin Organ Transplant. 2019; 24: 358-363https://doi.org/10.1097/MOT.0000000000000648
- Guide on the decision-making process regarding medical treatment in end-of-life situations.2019 (Accessed April 20, 2022.)
- Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients.Med Intensiva. 2017; 41: 285-305https://doi.org/10.1016/j.medin.2017.03.004
- Emergency department staff and the organ donation process: recommendations from the joint working group of the National Transplant Organization and the Spanish Society of Emergency Medicine (ONT-SEMES).Emergencias. 2016; 28: 193-200
- Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine.Crit Care Med. 2008; 36: 953-963https://doi.org/10.1097/CCM.0B013E3181659096
- Early ECPR for out-of-hospital cardiac arrest: best practice in 2018.Resuscitation. 2018; 130: 44-48https://doi.org/10.1016/j.resuscitation.2018.05.004
- Extracorporeal cardiopulmonary resuscitation for cardiac arrest: a systematic review.Resuscitation. 2018; 131: 91-100https://doi.org/10.1016/j.resuscitation.2018.07.029
- What follows refractory cardiac arrest: death, extra-corporeal cardiopulmonary resuscitation (E-CPR), or uncontrolled donation after circulatory death?.Resuscitation. 2016; 108: A3-A5https://doi.org/10.1016/j.resuscitation.2016.08.028
- Caring for patients or organs: new therapies raise new dilemmas in the emergency department.Am J Bioeth. 2017; 17: 6-16https://doi.org/10.1080/15265161.2017.1299239
- An integrated program of extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation and uncontrolled donation after circulatory determination of death in refractory cardiac arrest.Resuscitation. 2018; 133: 88-94https://doi.org/10.1016/j.resuscitation.2018.10.016
- End-of-life conversations with families of potential donors: leading practices in offering the opportunity for organ donation.Transplantation. 2017; 101: S17-S26https://doi.org/10.1097/TP.0000000000001696
- Ethics in approaching families about organ donation from patients in out-of-hospital asystole.Emergencias. 2016; 28: 55-61
- Update of a systematic review of autoresuscitation after cardiac arrest.Crit Care Med. 2018; 46: e268-e272https://doi.org/10.1097/CCM.0000000000002920
- Lower rate of family refusal for organ donation in non-heart-beating versus brain-dead donors.Transplant Proc. 2009; 41: 2304-2305https://doi.org/10.1016/j.transproceed.2009.06.039
- Report of a national conference on donation after cardiac death.Am J Transplant. 2006; 6: 281-291https://doi.org/10.1111/j.1600-6143.2005.01194.x
- Ethical issues of organ donation after circulatory death: considerations for a successful implementation in Chile.Dev World Bioeth. Published online November 13, 2021. 2021; https://doi.org/10.1111/dewb.12338
- Kidney donation after circulatory death (DCD): state of the art.Kidney Int. 2015; 88: 241-249https://doi.org/10.1038/ki.2015.88
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Published online: January 04, 2023
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