Donation After Circulatory Death

Donation after circulatory death is the recovery of organs from a donor whose death is certified on circulatory rather than neurologic criteria, after the irreversible cessation of circulation and respiration. Because organs are without circulation for a period before recovery, this pathway introduces a window of warm ischemia that shapes how donors are categorized and how organs are preserved and assessed.

Definition

Donation after circulatory death is organ donation in which death is determined by circulatory criteria after the irreversible cessation of circulation and respiration, followed by organ recovery.

Scope

The topic covers the definition and classification of donation after circulatory death, the controlled and uncontrolled donor categories, the consequences of warm ischemia for organ viability, and the preservation strategies used to recover usable organs. It is a reference overview and does not provide procurement protocols or individualized clinical guidance.

Core questions

• How does donation after circulatory death differ from donation after brain death?
• What distinguishes controlled from uncontrolled circulatory-death donation?
• How does warm ischemia affect the viability of recovered organs?
• What preservation strategies make circulatory-death organs usable?

Key concepts

• Circulatory determination of death
• Controlled versus uncontrolled donation
• Modified Maastricht categories
• Warm ischemia time
• Organ preservation and machine perfusion
• No-touch (stand-off) period

Mechanisms

Death is certified after circulation and respiration have irreversibly ceased, typically following a mandatory observation period to confirm irreversibility, after which organs are recovered. Unlike donation after brain death, where circulation is supported until procurement, circulatory-death organs experience a period of warm ischemia between the loss of circulation and recovery or re-perfusion, which can impair function. The modified Maastricht classification distinguishes uncontrolled donation (after unexpected cardiac arrest) from controlled donation (after planned withdrawal of life-sustaining treatment), and preservation strategies such as cold storage, hypothermic machine perfusion, and normothermic perfusion are used to limit ischemic injury and to assess organ viability before transplantation.

Clinical relevance

Donation after circulatory death substantially enlarges the deceased-donor pool, and preservation technologies influence how many of these organs can be transplanted with acceptable outcomes. This entry describes the pathway and its principles for reference and does not provide procurement or clinical management instructions.

Epidemiology

Circulatory-death donation accounts for a growing share of deceased donation in several countries and is a major contributor to expanding the organ supply. Organs from these donors carry a higher exposure to warm ischemia, which is associated with greater early graft dysfunction in some organs, motivating the use of machine-perfusion preservation.

Evidence & guidelines

The modified Maastricht classification (Thuong and colleagues, 2016) standardizes circulatory-death donor terminology. Preservation evidence includes a randomized comparison of machine perfusion versus cold storage in deceased-donor kidneys (Moers and colleagues, 2009) and a randomized trial of normothermic liver preservation (Nasralla and colleagues, 2018); the broader role of such organs in the donor supply is reviewed by Tullius and Rabb (2018).

History

Donation after circulatory death was in fact the earliest form of deceased donation, predating the acceptance of brain-death criteria, but it declined once donation after brain death became standard. As the organ shortage grew, interest in circulatory-death donation revived, the Maastricht categories were defined and later modified to standardize terminology, and machine-perfusion preservation emerged to mitigate the ischemic injury characteristic of this pathway.

Debates

How should warm ischemia be limited and organ viability judged?

Circulatory-death organs are exposed to warm ischemia that can impair function, and there is ongoing debate over acceptable ischemic time limits and over how machine-perfusion preservation should be used to recondition and assess these organs.

Key figures

• Magi Thuong
• Cyril Moers
• David Nasralla

Seminal works

• thuong-2016
• moers-2009
• nasralla-2018

Frequently asked questions

How does donation after circulatory death differ from donation after brain death?

In donation after circulatory death, death is certified after circulation and respiration irreversibly stop, so organs undergo a period of warm ischemia before recovery, whereas in donation after brain death circulation is supported until procurement.

What is the difference between controlled and uncontrolled donation after circulatory death?

Controlled donation follows a planned withdrawal of life-sustaining treatment in a setting prepared for recovery, while uncontrolled donation follows an unexpected cardiac arrest; the modified Maastricht classification formalizes these and related categories.