Donation after circulatory death (DCD)

Donation after circulatory death (DCD), also called donation after circulatory determination of death, is a form of deceased organ donation in which death is determined by circulatory (cardiac) criteria, the permanent cessation of circulation and respiration, rather than by neurologic criteria.[1][2] It is distinguished from donation after brain death (DBD), in which death is determined by the irreversible loss of all functions of the entire brain while circulation is maintained mechanically. In DCD, organs are recovered after the heart has stopped and a period of observation has confirmed that circulation will not return.[1][3]

Once a small share of deceased donation, DCD has grown rapidly and now accounts for a substantial fraction of deceased donors in several countries. In the United States, more than 7,200 DCD donors represented about 43 percent of all deceased donors in 2024.[1][4] Most clinical DCD is "controlled," occurring in patients on life support whose families have decided to withdraw treatment.[2][5] DCD is associated with longer periods of warm ischemia than DBD, which has historically limited organ yield and quality; this has driven the adoption of preservation technologies such as machine perfusion and normothermic regional perfusion.[5][6]

Definition and contrast with DBD

Deceased donation rests on a determination of death that, in most jurisdictions, may be made by either of two standards: irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain.[3] DBD donors are declared dead by the neurologic standard, and because their circulation is maintained by mechanical ventilation until recovery, their organs are perfused with oxygenated blood up to the moment of procurement.[2] DCD donors are declared dead by the circulatory standard: circulation and respiration have stopped and will not resume, after which organ recovery proceeds.[1][3] The principal practical consequence is that DCD organs sustain a period without circulation, warm ischemia, between the onset of arrest and the start of cold preservation.[5]

The Maastricht classification

DCD donors are categorized using the Maastricht classification, first proposed at a workshop in Maastricht in 1995 and revised by a European expert working group at the 6th International Conference in Organ Donation in Paris in 2013 (the "modified Maastricht classification").[7][8] The first distinction is between uncontrolled DCD (categories I and II), in which circulatory arrest is unexpected, and controlled DCD (categories III and IV), in which arrest is anticipated.[7][8]

| Category | Description | Type | |---|---|---| | I | Dead on arrival (death found, not witnessed) | Uncontrolled | | II | Unsuccessful resuscitation (witnessed arrest) | Uncontrolled | | III | Awaiting cardiac arrest after a planned withdrawal of life-sustaining treatment | Controlled | | IV | Cardiac arrest in a patient already declared dead by neurologic criteria | Controlled | | V | Cardiac arrest following medically assisted dying (euthanasia), recognized in some jurisdictions such as Belgium | Controlled |

Category III is the most common controlled DCD scenario.[7] Category V reflects the legal situation in countries permitting euthanasia and was added in the Belgian modification of the classification.[8][9] Some programs use uncontrolled DCD (categories I-II); others, including the United Kingdom national program, currently use only controlled categories III and IV.[5][10]

The controlled DCD process

In controlled DCD, organ donation is considered only after an independent decision has been made, by the clinical team and family, on grounds unrelated to donation, to withdraw life-sustaining treatment from a patient with a non-survivable injury who does not meet brain-death criteria.[2][5] Life-sustaining treatment (typically mechanical ventilation and vasoactive support) is then withdrawn, beginning the agonal phase, during which blood pressure and oxygenation decline toward circulatory arrest.[5] After circulation stops, a mandatory observation or "no-touch" period, commonly 2 to 5 minutes of continuously absent circulation, is observed to exclude spontaneous return of circulation (autoresuscitation) before death is declared.[1][2][11] The declaration of death is made by the treating physician, who is independent of the transplant team; only afterward may the recovery team proceed.[1][11] The interval of absent or inadequate circulation before cold preservation constitutes warm ischemia.[5]

Permanence versus irreversibility

The conceptual basis of the circulatory determination of death in DCD is debated. The legal standard in many jurisdictions speaks of "irreversible" cessation of circulation, yet in controlled DCD circulation could in principle be restarted by resuscitation during the no-touch period.[11][12] Most professional accounts therefore reason that the relevant standard is permanence, circulation has ceased and, because a valid decision has been made not to attempt resuscitation, it will not return, and that permanent cessation reliably predicts and is followed by irreversible cessation within the observation period.[11][12] Proponents hold that this satisfies the dead-donor rule, which requires that donors be dead before vital organs are recovered.[11][12] Critics argue that grounding a death determination in permanence rather than strict irreversibility is conceptually unstable, particularly when later interventions restore circulation; this question is central to debates over normothermic regional perfusion.[12][13]

Warm ischemic time and organ suitability

Because DCD organs experience warm ischemia, time limits are applied to protect organ quality. Functional warm ischemic time is generally measured from the point at which the donor's blood pressure or oxygen saturation falls below defined thresholds during the agonal phase until the start of cold or machine perfusion, and acceptable limits differ by organ.[5][6] Kidneys and livers are the organs most commonly recovered from DCD donors; lungs, pancreas, and, increasingly, hearts are also recovered under suitable conditions.[4][5] Organs not recovered within their warm-ischemia tolerance are not used.[5]

Strategies to improve DCD outcomes

To mitigate warm ischemic injury and assess organ viability, DCD programs increasingly use in-situ and ex-situ perfusion. Machine perfusion, hypothermic or normothermic, performed on the organ outside the body, can recondition and evaluate DCD kidneys, livers, lungs, and hearts.[6] In-situ techniques restore circulation to the donor's organs before recovery; the principal example is normothermic regional perfusion (NRP), which re-establishes warm, oxygenated blood flow to the abdominal or thoraco-abdominal organs after death is declared. NRP has been reported to improve organ utilization and outcomes relative to rapid recovery, but it is ethically contested and is the subject of a separate article.[6][13][14]

Epidemiology and growth

DCD has been the fastest-growing component of deceased donation in several systems. In the United States, the OPTN/SRTR 2024 Annual Data Report recorded 7,284 DCD donors among roughly 16,989 deceased donors, about 43 percent, and documented large increases in DCD use across organ types, including DCD kidneys rising to about 30.5 percent of deceased-donor kidney transplants in 2024 (from 10.5 percent in 2013) and DCD hearts reaching about 17 percent of heart transplants in 2024 (from zero in 2013).[1][4] In the United Kingdom, NHS Blood and Transplant reports that controlled DCD donors have grown to roughly half of all deceased donors in recent years.[10] These figures are point-in-time registry values and should be re-confirmed against the linked primary sources.

See also

• Donation after brain death (DBD)
• Normothermic regional perfusion (NRP)
• Organ procurement (recovery surgery)
• Organ preservation and machine perfusion
• The dead-donor rule

References

• United Network for Organ Sharing. Understanding Donation after Circulatory Death (DCD). https://unos.org/news/understanding-donation-after-circulatory-death-dcd/
• Association of Organ Procurement Organizations. Donation After Circulatory Death (DCD). https://aopo.org/dcd-process/
• Uniform Determination of Death Act (UDDA), 1981; codified in state law. National Conference of Commissioners on Uniform State Laws. (Two-standard determination of death: circulatory-respiratory or whole-brain.)
• Lentine KL, Smith JM, et al. OPTN/SRTR 2024 Annual Data Report: Overview / Deceased Organ Donation. Scientific Registry of Transplant Recipients. https://srtr.hrsa.gov/adr/2024/Overview/ (as of the 2024 Annual Data Report).
• Manara AR, Murphy PG, O'Callaghan G. Donation after circulatory death. BJA Education / Continuing Education in Anaesthesia, Critical Care & Pain. 2017. https://www.bjaed.org/article/S1743-1816(17)30254-8/fulltext
• Hessheimer AJ, et al. (and related reviews). Machine perfusion and regional perfusion in DCD organ recovery. (Secondary review of preservation strategies in DCD.) See also normothermic-regional-perfusion-nrp.md references.
• Thuong M, Ruiz A, Evrard P, et al. New classification of donation after circulatory death donors: definitions and terminology. Transplant International. 2016;29(7):749-759. doi:10.1111/tri.12776. PMID:26991858. https://onlinelibrary.wiley.com/doi/abs/10.1111/tri.12776
• Detry O, Le Dinh H, et al. Categories of donation after cardiocirculatory death (Belgian modified classification of Maastricht). Transplant Proc. 2012. PMID:25420844. https://pubmed.ncbi.nlm.nih.gov/25420844/
• Bollen J, et al. Organ donation after euthanasia (Maastricht category V). (Discussion of euthanasia-associated DCD in Belgium and the Netherlands.)
• NHS Blood and Transplant. Donation after circulatory death, ODT Clinical. https://www.odt.nhs.uk/deceased-donation/best-practice-guidance/donation-after-circulatory-death/ (as of 2024-2025 reporting; controlled DCD ≈ half of UK deceased donors).
• Bernat JL, et al. The circulatory-respiratory determination of death in organ donation; permanence vs. irreversibility. (Conceptual analysis of the no-touch interval and the determination of death in DCD.)
• Dalle Ave AL, Sulmasy DP, Bernat JL. The ethical obligation of the dead donor rule. Med Health Care Philos / related analyses. (Permanence-vs-irreversibility debate.)
• Omelianchuk A, Capron AM, Ross LF, Derse AR, Bernat JL, Magnus D. Neither Ethical nor Prudent: Why Not to Choose Normothermic Regional Perfusion. Hastings Cent Rep. 2024;54(4):14-23. doi:10.1002/hast.1584. https://onlinelibrary.wiley.com/doi/10.1002/hast.1584
• OPTN Ethics Committee. Ethical Analysis of Normothermic Regional Perfusion (white paper). Organ Procurement and Transplantation Network / HRSA, 2024. https://optn.transplant.hrsa.gov/news/white-paper-analyzes-ethical-issues-in-normothermic-regional-perfusion/