Trends in donation after cardiac death.

: The deceased cardiac donor (DCD) can provide organs that are suitable for transplantation. However, in order to increase recovery and utilization of this under-utilized organ donor source, a number of issues remain to be resolved. First, the public understanding is essential for support of this end-of-life option to donate after cardiac death. Extensive education of donor hospitals will be needed to identify potential donors and arrange for their care. Organ procurement organizations will have to commit to the extra effort required to identify and manage these donors and to design recovery techniques to maximize procurement of abdominal and thoracic organs. Pulsatile machine perfusion may be needed for assessing viability of DCD kidneys, although the evidence is lacking that pump preservation improves survival of DCD kidneys that are transplanted. It will also be important to identify transplant centers and suitable patients within those centers that will accept DCD organs. Preselecting recipients will speed allocation as has been the case for expanded criteria donors. Special efforts to minimize reperfusion injury should be made initially to protect what might be more "injury-prone" DCD organs and calcineurin inhibitors should probably be avoided during the early posttransplant period. The graft survival rates for DCD kidneys and pancreata have been comparable to those for conventional deceased donor grafts, whereas graft survival rates for DCD liver recipients have been significantly poorer than with conventional livers. Thus, we need to continue exploring approaches to improve patient and graft survival for DCD liver transplant recipients.