More than 110,000 people are waiting to receive a lifesaving organ in the United States. Additionally, more than 6,000 people die every year while on the organ transplantation waitlist. And countless others don’t even make it to the list. To save the lives of these people in our communities, the role of hospitals in the organ donation process cannot be understated.
The process starts at the hospital when staff, such as the bedside nurse, a designated representative, a unit clerk or a care technician, make the initial referral to the local organ procurement organization. This referral is for a ventilated patient where death is imminent. Timing is crucial as the referral needs to happen within an hour of any imminent death trigger or cardiac death before the patient is removed from the ventilator and while the organs are still viable.
Once the referral is made, the organ procurement organization reviews the case to assess donor potential. If appropriate, they then coordinate with hospital staff to support the family and facilitate the donation process with care and compassion.
It’s important for hospitals to stay up to date on advancements in deceased donor management so an organ referral is made even for cases that would have been an automatic “rule out” for organ donation in the past. The evolution of practices like machine perfusion provides more flexibility in managing these cases, allowing additional time for progression to death while preserving organ function. These opportunities reflect a shift toward nuanced, case-by-case evaluation rather than rigid criteria.
The following areas of advancement in deceased donor management have resulted in higher utilization of organs for transplantation.
Advanced Age Donors
Advanced age is no longer a strict exclusion criterion, particularly when overall organ function and clinical history support donation. These donors were traditionally considered primarily for liver donation, given the liver’s robust regenerative ability to recover function in a new recipient.
Clinical practices are advancing to broaden donor eligibility and optimize organ usage. A broader range of organs—such as kidneys, livers, lungs, hearts, pancreas and intestines—are under active evaluation, bolstered by advancements in preservation technology and enhanced outcome data.
Only a few years prior, a 72-year-old would certainly have been excluded as a kidney donor solely based on age. However, with the advancements in clinical evaluation and machine perfusion technology, the kidneys from the same donor were transplanted successfully. This example exemplifies a transition in practice—prioritizing organ function rather than age—and emphasizes how innovation is enhancing life-saving opportunities by broadening donor eligibility.
High Glasgow Coma Scale Scores
Historically, only donors with a GCS of 5 or below were considered viable for donation. Today, donors with a higher GCS score, which indicates retained neurological function, are being thoughtfully assessed and, when appropriate, converted to the Donation After Circulatory Death pathway.
This approach is supported by advancements like normothermic regional perfusion, which restores oxygenated blood flow after circulatory arrest, significantly improving the viability of organs such as kidneys and livers. Clinical studies and surgeon observations have shown that kidney graft function in NRP-supported DCD cases can be comparable to that of living donors. These innovations expand donor eligibility while aligning with ethical and clinical standards, enabling more successful transplants through timely, coordinated care.
Normothermic Regional Perfusion
Normothermic regional perfusion is a specialized method performed in the donor after circulatory death. It restores blood flow to abdominal organs using extracorporeal membrane oxygenation technology, improving viability for organs like the liver, kidneys and pancreas. This technique enhances organ viability, expands donor eligibility to include older donors and improves transplant outcomes. Based on surgeon experience, kidney function in these cases is often comparable to outcomes seen in living donor kidney transplants. Improvements in recipient hospital length of stay further reinforce its clinical value.
While normothermic regional perfusion has raised ethical considerations related to the restoration of circulation after death, these concerns are addressed through strict protocols and transparency. Ultimately, the intent aligns with the wishes of donors and families maximizing the longevity and impact of the gift of life. This method is performed under strict protocols to ensure ethical and legal integrity, and it’s initiated only after death is formally declared, with no intervention to hasten the dying process.
The process is overseen by a multidisciplinary team, including transplant clinicians and ethics committees, to ensure transparency and compliance. Families are informed about the procedure, and consent is obtained in alignment with legal and ethical standards. All actions are carefully documented to support accountability and uphold public trust in the donation process.
Machine Perfusion
The use of hypothermic and normothermic machine perfusion systems has significantly improved preservation, assessment and recovery of marginal organs. This technology allows for real-time evaluation and optimization of organ function prior to transplantation, leading to greater utilization and success rates. Machine perfusion is a critical tool in modern transplantation, helping preserve and assess organs before transplant. Two main types are used:
- Hypothermic machine perfusion keeps organs cold to reduce metabolic injury, most commonly used for kidneys with devices like the LifePort and Waters RM3.
- Normothermic machine perfusion maintains organs at body temperature using oxygenated perfusate, allowing real-time assessment and improved preservation. Devices like the OrganOx metra (liver) and TransMedics OCS (heart, lung, liver) are widely used in this space.
Hospitals play an important role in procuring organs for patients in their communities. Understanding the advancements in organ donation and donor management for organ transplantation will help expand the organ donor pool and potentially save thousands of lives across the country every year.
Aninda Dutta, FACHE, is vice president, business intelligence and data solutions/strategy officer, Donor Network West. Justin Johnson, RN, is executive vice president/COO, Donor Network West. Janice Whaley, PhD, is president/CEO, Donor Network West, and an ACHE member.