Deceased donation

Deceased donation is the donation of organs and tissue after a person has died.[1] It is the source of most transplanted organs. Death for the purpose of donation is determined by one of two sets of criteria: neurologic criteria (the irreversible cessation of all functions of the entire brain, including the brainstem), giving donation after brain death (DBD); or circulatory criteria (the permanent cessation of circulatory and respiratory function), giving donation after circulatory death (DCD).[1][2] In both pathways, the donor must be declared dead before organ recovery, the so-called dead donor rule.[3]

Deceased donation follows the regulated sequence described in The donation pathway: hospital referral, evaluation, authorization, donor management, recovery, preservation and transport, allocation, transplantation, and follow-up. This article focuses on the donor types and the clinical determinations that distinguish them.

Donation after brain death (DBD)

In DBD, death is determined by neurologic criteria while the heart continues to beat with mechanical ventilatory support, so organ perfusion is maintained until recovery.[2] Brain death is the irreversible loss of all functions of the entire brain, including the brainstem; its U.S. legal basis is the Uniform Determination of Death Act (1981).[4] The clinical determination follows a standardized examination, updated in the 2023 consensus practice guideline of the American Academy of Neurology and partner societies, and typically includes establishing an irreversible and proximate cause, excluding confounders (such as hypothermia, sedation, and severe metabolic derangement), demonstrating coma and absent brainstem reflexes, and an apnea test, with ancillary testing when the clinical examination cannot be completed.[5] Because the donor's circulation is intact, DBD historically yields the widest range of transplantable organs.

Donation after circulatory death (DCD)

In DCD, death is determined by circulatory criteria after the cessation of circulation and respiration.[2][6] Controlled DCD generally follows a planned withdrawal of life-sustaining treatment in a patient with a non-survivable injury who is not brain-dead; after asystole, a mandatory hands-off observation period (commonly two to five minutes) confirms that circulation will not spontaneously resume before death is declared and recovery begins.[6] Because organs experience a period of warm ischemia during the dying process, DCD organs are more vulnerable to injury, and minimizing warm-ischemia time is critical. DCD cases are classified by the Maastricht system (categories I-V), which distinguishes uncontrolled from controlled circumstances.[6] Improvements in machine perfusion and recovery technique have substantially increased the use of DCD organs.

Normothermic regional perfusion (NRP)

Normothermic regional perfusion (NRP) is a recovery technique used in controlled DCD in which, after death is declared, the donor's circulation is restored regionally, to the abdominal organs (A-NRP) or the thoracoabdominal organs (TA-NRP), using extracorporeal perfusion, while blood flow to the brain is surgically interrupted.[7] NRP can improve the quality and number of organs recovered after circulatory death.

NRP is ethically and legally contested, and this article presents the debate neutrally. Critics argue that restoring circulation after a death declared on the basis of the permanent cessation of circulation is in tension with the determination of death and the dead donor rule, and that interrupting cerebral blood flow to keep death "permanent" raises further concerns; the American College of Physicians has called for caution and a pause pending resolution of these questions.[7][8] Proponents and several professional analyses hold that, with surgical exclusion of cerebral circulation and appropriate safeguards, NRP can be performed consistent with the donor's prior death determination, and the technique is in clinical use at some U.S. and international centers.[8][9] Professional bodies and the OPTN have published white papers and convened community engagement to develop ethical guidelines; as of 2026 no single national standard has fully resolved the controversy.[8][9]

Donor evaluation, management, and recovery

Deceased donors undergo medical and social-history evaluation and infectious-disease testing, including universal nucleic-acid testing for HIV, hepatitis B, and hepatitis C under the 2020 U.S. Public Health Service guideline.[10] After authorization, donors (particularly DBD donors) are physiologically managed in the intensive care unit to defined donor-management goals to preserve organ function.[11] Recovery is a surgical operation, often with multiple organ-specific teams; in DBD the aorta is cross-clamped and organs flushed with cold preservation solution, while DCD requires rapid recovery after the determination of death.[12] These stages are detailed in The donation pathway.

Donor-quality concepts

Donor organs vary in expected quality. For kidneys, the Kidney Donor Profile Index (KDPI) and the underlying Kidney Donor Risk Index (KDRI) express donor quality as a percentile, replacing the older standard-versus-expanded-criteria-donor dichotomy in 2012.[13] Such metrics inform allocation and the informed-consent discussion with candidates.

See also

• Living donation · The donation pathway
• Organ donation · Organ transplantation
• Transplant immunology

References

• HRSA/OPTN. Deceased donation. https://www.hrsa.gov/optn/patients/organ-donation/deceased-donation
• Organ donation overview. organdonor.gov (HRSA). https://www.organdonor.gov/learn/process/deceased-donation
• The dead donor rule (contested). PMC8283419. https://pmc.ncbi.nlm.nih.gov/articles/PMC8283419/
• Uniform Determination of Death Act and brain death. StatPearls. NBK538159. https://www.ncbi.nlm.nih.gov/books/NBK538159/
• Greer DM, et al. Determination of Brain Death/Death by Neurologic Criteria: The 2023 AAN/AAP/CNS/SCCM Consensus Practice Guideline. Neurology. 2023. doi:10.1212/WNL.0000000000207740. https://www.neurology.org/doi/10.1212/WNL.0000000000207740
• United Network for Organ Sharing. Understanding donation after circulatory death (DCD). https://unos.org/news/understanding-donation-after-circulatory-death-dcd/
• OPTN. White paper analyzes ethical issues in normothermic regional perfusion. https://optn.transplant.hrsa.gov/news/white-paper-analyzes-ethical-issues-in-normothermic-regional-perfusion/
• Ethical Issues in Normothermic Regional Perfusion in Controlled DCD: A Scoping Review. PMC11927451. https://pmc.ncbi.nlm.nih.gov/articles/PMC11927451/ ; Omelianchuk A. Hastings Cent Rep. 2024. doi:10.1002/hast.1584
• Ethical and legal considerations in NRP for DCD. PubMed 40079519. https://pubmed.ncbi.nlm.nih.gov/40079519/
• Jones JM, et al. PHS Guideline for assessing solid organ donors for HIV, HBV, HCV, 2020. MMWR Recomm Rep. 2020;69(4):1-16. https://www.cdc.gov/mmwr/volumes/69/rr/rr6904a1.htm
• Deceased donor management/optimization. PMC8445737. https://pmc.ncbi.nlm.nih.gov/articles/PMC8445737/
• Organ procurement (recovery surgery). PMC9994842. https://pmc.ncbi.nlm.nih.gov/articles/PMC9994842/
• HRSA/OPTN. A Guide to Calculating and Interpreting the KDPI. https://www.hrsa.gov/sites/default/files/hrsa/optn/kdpi_guide.pdf