Donation After Circulatory Death Now Dominates at Nearly Half of U.S. Organ Procurement Organizations

The practice of recovering organs for transplantation from donors whose hearts have stopped beating - rather than from donors who are brain-dead but still have circulation - has crossed a threshold in the United States. Donation after circulatory death (DCD) now accounts for roughly half of all deceased donors nationally, and at 44 percent of organ procurement organizations, it is already the more common form of donation.

That is the headline finding from a study published in JAMA, which examined the evolution of the donor pool over recent decades. The research identifies a structural transformation in transplantation medicine - and flags a set of clinical challenges that come with it.

A Different Biology of Donation

DCD differs from donation after brain death in a fundamental way: after circulatory death, organs experience a period without oxygenated blood flow before recovery. This warm ischemic time creates physiological stress in tissues that was historically considered a disqualifying limitation. Kidneys, livers, and other organs subjected to warm ischemia were thought to perform poorly after transplantation compared with those recovered from brain-dead donors whose hearts continued to beat.

Two developments changed the practical calculus. Normothermic regional perfusion uses an external circuit to restore blood flow to the donor's abdominal organs after cardiac arrest, limiting ischemic damage before recovery. Machine perfusion devices then continue protecting organs after removal from the body by pumping oxygenated, nutrient-rich solution through them during transport. Together, these technologies have expanded the range of DCD organs that perform acceptably after transplantation.

More Complex Donors

The expansion of DCD has been accompanied by a shift in donor characteristics. Contemporary DCD donors are older, have higher body mass indices, and are more likely to carry comorbidities such as diabetes or hypertension than DCD donors from earlier periods. This reflects a deliberate expansion of acceptance criteria - organs that would once have been declined are now being used successfully, enabled by improved preservation techniques.

But it also creates new challenges. Organs from medically complex donors carry different risk profiles and may perform less predictably. The clinical decisions involved in selecting, preserving, allocating, and using these organs require expertise and standardized protocols that are still being developed across the transplant system.

The study highlights a need to establish best practices for DCD organ selection, preservation, and allocation - practices that account for the growing complexity of the donor population rather than relying on protocols developed for a more limited set of donors.

Regional Variation

The national aggregate data obscures substantial regional variation in DCD utilization. Across the 55 organ procurement organizations in the United States, the proportion of donors who are DCD ranges from as high as 73 percent in some regions to as low as 11 percent in others. This variation almost certainly reflects a mix of factors - institutional expertise, local hospital culture around end-of-life care, referral patterns, and variation in how DCD is presented to families - rather than genuine differences in the underlying population of potential donors.

That variability suggests that regions with low DCD rates may have significant room to expand donation through adoption of best practices from higher-performing organizations. With over 100,000 people currently waiting for transplants in the United States, identifying and closing that gap has direct clinical stakes.

Implications for Practice and Policy

The shift toward DCD carries implications beyond clinical logistics. As DCD becomes the dominant form of deceased donation rather than a specialized practice at high-volume centers, the ethical and consent frameworks surrounding it require broader implementation. The separation between the decision to withdraw life-sustaining treatment and the decision about donation - a structural feature of DCD protocols designed to protect patient and family interests - must be consistently and transparently implemented across all settings where DCD occurs.

Public understanding of DCD, including awareness of how it differs from brain death donation, matters for maintaining public trust in the donation system. Education programs and transparent communication from healthcare institutions will be essential as DCD moves from niche to norm.