Knowledge base
The field, in reference form.
A public reference for U.S. organ donation and transplant: the donation pathway, donor types, allocation and policy, law and ethics, and the workforce. Reviewed by named professionals. Educational reference, not medical advice.
The donation pathway (the spine)
The end-to-end deceased-donation process: referral, evaluation, authorization, donor management, recovery, preservation and transport, allocation, transplantation, and follow-up. Every clinical, workforce, and policy article is locatable against a pathway stage.
- Deceased donationDeceased donation is organ and tissue donation after a donor's death, determined by neurologic or by circulatory criteria.
- Donor evaluation and infectious-disease testingDeceased-donor evaluation includes medical and social history and PHS-guideline infectious-disease testing, including universal nucleic acid testing for HIV, HBV, and HCV.
- Donor management and optimizationAfter death by neurologic criteria, the donor is physiologically managed in the ICU toward donor management goals to preserve organ function.
- Hospital referral and the duty to notify the OPOUnder 42 CFR 482.45, hospitals must refer every imminent death and death to their organ procurement organization; clinical triggers prompt the call.
- Organ donationOrgan donation is the giving of organs or tissue from a donor for transplantation into a recipient.
- Organ preservation and machine perfusionRecovered organs are preserved by static cold storage or by hypothermic or normothermic machine perfusion, using solutions such as UW/Belzer, HTK/Custodiol, and Celsior.
- Organ procurement (recovery surgery)Recovery surgery is the surgical retrieval of organs from a deceased donor, using aortic cross-clamp and in-situ cold flush, with technique differing between DBD and DCD.
- Organ transplantationOrgan transplantation is the surgical replacement of a failing or absent organ with a healthy organ from a donor.
- The donation pathwayThe donation pathway is the end-to-end deceased-donation process, from hospital referral through transplantation and follow-up.
Donor types
Deceased donation (DBD, DCD, NRP); living donation (directed, non-directed, paired exchange); and donor-quality concepts such as KDPI/KDRI.
- Deceased donationDeceased donation is organ and tissue donation after a donor's death, determined by neurologic or by circulatory criteria.
- Donation after brain death (DBD)Donation after brain death is recovery of organs after death is determined by neurologic criteria, per the 2023 multi-society consensus.
- Donation after circulatory death (DCD)Donation after circulatory death is recovery after death determined by circulatory criteria, classified by the Maastricht categories as controlled or uncontrolled.
- KDPI/KDRI and donor-quality conceptsThe Kidney Donor Profile Index and Kidney Donor Risk Index express deceased-donor kidney quality; they replaced the Standard versus Expanded Criteria Donor framework in 2012.
- Kidney paired donation / exchangeKidney paired donation matches incompatible donor-recipient pairs through swaps and chains, including the national OPTN KPD program.
- Living donationLiving donation is donation of an organ or partial organ by a living person, most commonly a kidney or a segment of liver.
- Normothermic regional perfusion (NRP)Normothermic regional perfusion restores in-situ circulation to abdominal (A-NRP) or thoracoabdominal (TA-NRP) organs in DCD; its relationship to the dead donor rule is actively debated.
Solid organs
Kidney, liver, heart, lung, pancreas, and intestine/multivisceral transplantation.
- Heart transplantationHeart transplantation is the orthotopic replacement of a failing heart for end-stage heart failure.
- Intestinal and multivisceral transplantationIntestinal and multivisceral transplantation treats irreversible intestinal failure when total parenteral nutrition can no longer be sustained.
- Kidney transplantationKidney transplantation is the most common solid-organ transplant and the preferred treatment for many patients with end-stage renal disease.
- Liver transplantationLiver transplantation is the orthotopic replacement of a diseased liver, used for end-stage liver disease, acute liver failure, and selected liver cancers.
- Lung transplantationLung transplantation, performed as a single or double-lung procedure, treats end-stage lung disease.
- Pancreas transplantation (SPK/PAK/PTA)Pancreas transplantation restores insulin secretion in type 1 diabetes, performed as simultaneous pancreas-kidney, pancreas-after-kidney, or pancreas-transplant-alone.
- XenotransplantationXenotransplantation is cross-species transplantation; it is an emerging field.
Vascularized composite allotransplantation (VCA)
Hand and face transplantation (also uterus, abdominal wall). Added to the OPTN definition of organ effective July 3, 2014; restorative rather than life-saving.
- Face transplantationFace transplantation is facial vascularized composite allotransplantation.
- Hand transplantationHand transplantation is upper-extremity vascularized composite allotransplantation.
- Vascularized composite allotransplantation (VCA)VCA transplants composite tissue such as hand or face; it was added to the OPTN definition of organ in 2014 and is restorative rather than life-saving.
Tissue and eye banking
Cornea, skin, bone and musculoskeletal tissue, heart valves, vessels, and amniotic membrane; tissue banks; eye banks; and FDA HCT/P regulation.
- Amniotic membraneAmniotic membrane is a placental tissue graft used in ocular surface and wound repair.
- Bone and musculoskeletal allograftsBone and musculoskeletal allografts include bone, tendon, and ligament grafts used in orthopedic and reconstructive surgery.
- Corneal transplantation (keratoplasty)Corneal transplantation (keratoplasty) replaces diseased corneal tissue, with techniques including PK, DALK, DSAEK, and DMEK.
- Eye banking and the EBAAEye banks recover and distribute corneal and ocular tissue; the Eye Bank Association of America sets Medical Standards and certifies technicians.
- FDA regulation of human tissue (HCT/Ps)The FDA regulates human cells, tissues, and cellular and tissue-based products under 21 CFR 1271, distinguishing 361 from 351 products under Current Good Tissue Practice.
- Heart-valve homograftA heart-valve homograft is a cryopreserved human heart-valve allograft used in cardiac surgery.
- Skin allograftSkin allograft is donated human skin used as a temporary biologic dressing, notably in burn care.
- Tissue bankA tissue bank recovers, screens, processes, stores, and distributes human tissue allografts under AATB accreditation.
- Tissue donation and transplantationTissue donation provides banked human allografts, including cornea, skin, bone, heart valves, blood vessels, and amniotic membrane.
Transplant immunology
HLA and tissue typing, the crossmatch, PRA/cPRA, ABO compatibility, donor-specific antibodies, rejection, immunosuppression, GVHD, and tolerance.
- ABO compatibility and ABO-incompatible transplantationABO blood-group compatibility governs transplantation; ABO-incompatible transplantation is possible with desensitization and accommodation.
- Crossmatch (CDC, flow, virtual)The crossmatch detects recipient antibodies against donor antigens, by complement-dependent cytotoxicity, flow cytometry, or as a virtual crossmatch.
- Donor-specific antibodies (DSA)Donor-specific antibodies, preformed or de novo, target donor HLA and can drive antibody-mediated rejection.
- Graft-versus-host diseaseGraft-versus-host disease occurs when donor immune cells attack the recipient; it is seen mainly after hematopoietic stem-cell transplantation.
- Human leukocyte antigen (HLA) and tissue typingThe human leukocyte antigen system is the human major histocompatibility complex; HLA class I and II typing supports donor-recipient matching.
- Immunosuppression in transplantationImmunosuppression prevents rejection using induction and maintenance regimens drawn from several drug classes, with characteristic complications.
- Panel-reactive antibody / cPRA and sensitizationPanel-reactive antibody, expressed as calculated PRA (cPRA), measures a candidate's degree of sensitization and is used in allocation.
- Transplant immunologyTransplant immunology is the study of the immune response to a transplanted graft and the means of preventing rejection.
- Transplant rejectionTransplant rejection is the immune attack on a graft, classified as hyperacute, acute (T-cell-mediated and antibody-mediated), or chronic.
- Transplant tolerance and mixed chimerismTransplant tolerance is graft acceptance without ongoing immunosuppression; mixed chimerism is one experimental route to it.
Allocation and policy
OPTN policy, the match run, MELD, KDPI, continuous distribution and the Composite Allocation Score, organ-specific allocation, geographic distribution, and the waiting list.
- Continuous distribution and the Composite Allocation ScoreContinuous distribution replaces hard allocation boundaries with a weighted Composite Allocation Score; it is live for lung and in development for other organs.
- Geographic distribution and acuity circlesOrgan distribution is moving from donation service areas and regions to acuity circles defined by nautical-mile distances.
- Heart allocation status systemU.S. heart allocation uses a six-status urgency system, effective October 18, 2018.
- KDPI/KDRI and donor-quality conceptsThe Kidney Donor Profile Index and Kidney Donor Risk Index express deceased-donor kidney quality; they replaced the Standard versus Expanded Criteria Donor framework in 2012.
- Lung Allocation Score (LAS)The Lung Allocation Score governed U.S. lung allocation from 2005 to 2023, when it was replaced by continuous distribution.
- MELD / MELD-Na / MELD 3.0 (and PELD)The Model for End-Stage Liver Disease (and its successors) and the pediatric PELD score rank liver-transplant candidates by medical urgency.
- National transplant waiting listThe national transplant waiting list is the registry of candidates awaiting a deceased-donor organ; figures are point-in-time.
- OPTN allocation policyOPTN allocation policy governs how deceased-donor organs are offered to candidates in the United States.
- The match runThe match run is the computerized, rank-ordered candidate list generated for each donor organ.
Law and ethics
NOTA, the UAGA, the UDDA and brain death, the dead donor rule, consent models, financial neutrality, the Declaration of Istanbul, and trafficking.
- Consent models: opt-in vs opt-out (presumed consent)Donation consent models range from opt-in (first-person authorization) to opt-out (presumed consent); evidence suggests organizational capacity, not law alone, drives donation rates.
- Declaration of Istanbul (organ trafficking and transplant tourism)The Declaration of Istanbul is an international ethical framework against organ trafficking and transplant tourism, adopted in 2008 and updated in 2018.
- FDA regulation of human tissue (HCT/Ps)The FDA regulates human cells, tissues, and cellular and tissue-based products under 21 CFR 1271, distinguishing 361 from 351 products under Current Good Tissue Practice.
- Financial neutrality and the prohibition on valuable considerationU.S. law bars the transfer of organs for valuable consideration; financial neutrality permits reimbursement of donor costs, as through the NLDAC.
- National Organ Transplant Act (NOTA)The National Organ Transplant Act of 1984 established the national transplant system in the United States and prohibited the sale of organs.
- Normothermic regional perfusion (NRP)Normothermic regional perfusion restores in-situ circulation to abdominal (A-NRP) or thoracoabdominal (TA-NRP) organs in DCD; its relationship to the dead donor rule is actively debated.
- Organ trafficking and transplant tourismOrgan trafficking and transplant tourism are the illicit trade in organs and travel for commercial transplantation; the global response centers on the Declaration of Istanbul.
- The dead donor ruleThe dead donor rule holds that organ recovery must not cause death and that vital organs are taken only from the dead; it is ethically contested.
- Uniform Anatomical Gift Act (UAGA)The Uniform Anatomical Gift Act is the legal basis for donation in the United States, establishing binding first-person authorization.
- Uniform Determination of Death Act and brain deathThe Uniform Determination of Death Act sets the whole-brain standard for death by neurologic criteria; a Uniform Law Commission revision study has been under way since 2021.
Actors and institutions
OPOs, transplant centers, the OPTN, UNOS, the SRTR, HRSA, HLA laboratories, tissue and eye banks, and donor registries.
- Donor registry (and Donate Life America)Donor registries record first-person authorization; Donate Life America coordinates the National Donate Life Registry and donor-designation efforts.
- Histocompatibility (HLA) laboratoryA histocompatibility laboratory performs HLA typing, antibody testing, and crossmatching to support allocation and transplantation.
- HRSA Division of TransplantationThe HRSA Division of Transplantation provides federal oversight of the U.S. transplant system and administers the OPTN and SRTR contracts.
- Organ Procurement and Transplantation Network (OPTN)The OPTN is the national network that operates the U.S. transplant system under federal contract.
- Organ procurement organization (OPO)An organ procurement organization is a federally designated nonprofit responsible for deceased organ donation within a defined service area.
- Scientific Registry of Transplant Recipients (SRTR)The SRTR maintains transplant outcomes data and publishes program-specific reports and ratings.
- Transplant center / hospitalA transplant center is a hospital program that evaluates candidates and performs transplants under CMS Conditions of Participation (42 CFR 482 Subpart E).
- United Network for Organ Sharing (UNOS)UNOS is the nonprofit that served as the sole OPTN contractor from 1986; it operates within the OPTN modernization transition.
Workforce and roles
The donation-and-transplantation workforce organized by pathway stage and cross-cutting function across OPOs, transplant centers, tissue banks, eye banks, and HLA laboratories.
- Clinical / pre- and post-transplant coordinatorThe clinical transplant coordinator guides candidates and recipients through evaluation, waitlisting, and post-transplant follow-up at a transplant center.
- Independent Living Donor Advocate (ILDA)The Independent Living Donor Advocate protects the prospective living donor's interests and informed consent, independent of the recipient team; the role is federally mandated.
- Organ procurement coordinator / recovery coordinatorThe organ procurement coordinator is the core OPO clinical field role: identifying and managing the deceased donor and placing organs via the OPTN.
- Tissue and eye bank technical rolesTissue and eye bank technical roles cover recovery, processing, and laboratory work, certified through CTBS (tissue) and CEBT (eye).
- Transplant surgeon / recovery surgeonTransplant and recovery surgeons perform organ implantation and deceased-donor recovery; abdominal training follows ASTS-accredited fellowships.
- Workforce and roles in donation and transplantationThe donation-and-transplantation workforce spans OPOs, transplant centers, tissue banks, eye banks, and HLA labs, organized by pathway stage and cross-cutting function.
Public health, epidemiology, and the donation gap
The waiting list, annual transplant volume, the supply-demand shortage, registries, and Donate Life America.
- National transplant waiting listThe national transplant waiting list is the registry of candidates awaiting a deceased-donor organ; figures are point-in-time.
- The organ donation gapThe organ donation gap is the persistent shortfall between the number of patients waiting for a transplant and the number of organs available.
History and milestones
Murray 1954, Barnard 1967, Starzl, the cyclosporine era, and NOTA 1984.
- Christiaan BarnardChristiaan Barnard performed the first human-to-human heart transplant in 1967.
- Ciclosporin (cyclosporine) and the immunosuppression eraCiclosporin, approved in 1983, transformed transplant survival and opened the modern immunosuppression era.
- History of organ transplantationOrgan transplantation advanced from the first successful kidney transplant in 1954 through the first heart transplant in 1967, the cyclosporine era, and NOTA in 1984.
- Joseph MurrayJoseph Murray performed the first successful kidney transplant in 1954 and shared the 1990 Nobel Prize in Physiology or Medicine.
- Thomas StarzlThomas Starzl was a pioneer of liver transplantation.
Global and comparative systems
Spain and the ONT, the UK and NHSBT, Eurotransplant, the WHO Guiding Principles, and the evidence on opt-out versus opt-in.
- Comparative donation systems and PMP metricsDonation systems are compared using donors per million population (PMP); the evidence indicates organizational capacity, not consent law, is decisive.
- EurotransplantEurotransplant is a multinational allocation organization serving eight countries and managing a national organ-balance system.
- NHS Blood and Transplant and UK deemed consentNHS Blood and Transplant runs UK donation and transplantation; deemed (opt-out) consent rolled out across the UK from 2015 to 2021.
- The Spanish Model and the ONTSpain's Organizacion Nacional de Trasplantes operates the Spanish Model, built on in-hospital transplant coordinators and a world-leading deceased-donation rate.
- WHO Guiding Principles on transplantationThe WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation set eleven principles, endorsed by the World Health Assembly in 2010 (WHA63.22).
Patient- and donor-family-facing
How to register, what can be donated, the recipient journey, donor-family aftercare and bereavement, and common myths and FAQs.
- Common myths and FAQs about donationA neutral correction of common myths and frequently asked questions about organ and tissue donation.
- Donor-family aftercare and bereavementDonor-family aftercare provides post-donation bereavement support and correspondence to donor families.
- How to register as an organ donorRegistration records first-person authorization through a state registry or the National Donate Life Registry.
- Organ donationOrgan donation is the giving of organs or tissue from a donor for transplantation into a recipient.
- The transplant recipient journeyThe recipient journey runs from evaluation and waitlisting through transplant to lifelong follow-up.
- What can be donatedOrgans, eyes, and tissue can be donated; a single donor can save and heal many recipients.
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