REVIEW

CURRENT
OPINION Organ donation: from diagnosis to transplant
Chiara Robba a, Francesca Fossi b, and Giuseppe Citerio b,c

Purpose of review
Organ transplantation has largely expanded over the last decades and despite several improvements have
been made in the complex process occurring between the identification of organ donors and organ
transplant, there is still a chronic inability to meet the needs of patients. Consequently, the optimization of
the transplant process through its different steps is crucial, and the role of the intensivists is fundamental as
it requires clinical, managerial and communication skills to avoid the loss of potential donors. The purpose
of this review is to provide an update on the transplant process from the early identification of the donor, to
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transplant. The two main pathways of organ donation will be discussed: donation after death by
neurologic criteria and the donation after cardiac death (DCD).
Recent findings
Recent evidence demonstrates that appropriate intensive care management is fundamental to increase organ
availability for transplantation. The expansion of pool donation requires a strong legal framework supporting
ethical and organizational considerations in each country, together with the implementation of physicians’
technical expertise and communication skills for family involvement and satisfaction. New evidence is available
regarding organ donor’s management and pathway. The importance of checklists is gaining particular interest
according to recent literature. Recent clinical trials including the use of naloxone, simvastatin and goal directed
hemodynamic therapies were not able to demonstrate a clear benefit in improving quality and number of
transplanted organs. Ethical concerns about DCD are recently being raised, and these will be discussed
focusing on the differences of outcome between controlled and uncontrolled procedure.
Summary
The major change in the process of organ donation has been to implement parallel DCD and donation
after brain death pathways. However, more research is needed for improving quality and number of
transplanted organs.
Keywords
brain death, healthcare organization, organ donation, transplant

INTRODUCTION transplantation, ensuring an accurate diagnosis of

Organ donation is a complex and critical process
involving a multidisciplinary team of healthcare
& &&
professionals [1 ,2 ]. Nowadays, organ donation
can occur through two different pathways, that is
death by neurologic criteria (DNC, a more compre-
hensive terminology substituting ‘brain death’) and
donation after cardiac death (DCD).
The occurrence of a catastrophic brain injury
leading to irreversible loss of brain functions is the
first step of the DNC process. After the diagnosis of
DNC, intensivists have the role to identify the
potential brain dead donor and activate a cascade
of procedures, including discussion with the family
about organ donation, as well as the medical man-
agement of the organ donor and the activation of
&& &
the transplant system [3 ,4 ].
In this context, the role of the intensivist is
pivotal and should aim at the integration of the
different steps for the achievement of a successful
DNC, the optimization of transplanted organs, and
supporting both families and medical staff through
the whole process.
Donor’s shortage has led to the necessity of
exploring new pathways to have more organs for
transplant. In fact, according to WHO, 136 860 solid
organs were transplanted all over the world in 2016
with an increase of 7.25% compared with 2015.
a
Anaesthesia and Intensive Care, San Martino Policlinico Hospital,
IRCCS for Oncology and Neuroscience, Genoa, bSchool of Medicine
and Surgery, University of Milano-Bicocca, Milan and cNeurointensive
Care Unit, San Gerardo Hospital, ASST-Monza, Monza, Italy
Correspondence to Giuseppe Citerio, School of Medicine and Surgery,
University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy.
Tel: +0 39 2334316; fax: +0 39 2334340;
e-mail: giuseppe.citerio@unimib.it; ORCID: 0000-0002-5374-3161
Curr Opin Anesthesiol 2020, 33:146–155
DOI:10.1097/ACO.0000000000000826

www.co-anesthesiology.com Volume 33  Number 2  April 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Organ donation Robba et al.

However, this achievement satisfied the global need

KEY POINTS
 The determination of death by neurologic criteria relies
on the clinical assessment of the absence of brainstem
reflexes, motor responses and respiratory drive,
provided that the patient is comatose, normothermic,
without any sedation or metabolic derangements and
with a known, irreversible, unsalvageable brain lesion.
This is a universal concept.
 DCD can be considered either in cases when a
cardiopulmonary resuscitation has failed or withdrawal
of care is planned; in the first case – related to an
unexpected cardiac arrest – it is defined as
uncontrolled DCD, whereas in the latter case, it is
called controlled DCD.
 The primary duty of the clinician is any way to respect
patients’ wills, as well as to support the families of
the donor.
of transplant by less than 10% [5].
Therefore, DCD has been recently considered
when a cardiopulmonary resuscitation has failed
or withdrawal of care is planned. In EU (28 coun-
tries), in 2018, on 11 325 actual deceased organ
donors 9540 were DNC while 1785 were DCD. This
tendency is not present in Latin American countries
while, globally, international activities in organ
transplantation worldwide in 2017 estimates on
37 447 actual deceased organ donors 29 462 were
DNC and 7985 DCD [6].
Despite the organ donation pathway has
improved over the last decades by the implementa-
&&
tion of checklists [7 ], clinical protocols and a more
organized multidisciplinary approach, research is
still lacking in this field and evidence is still needed
to ensure the best strategy and management of the
transplant process. This review aims to provide an
update regarding the pathways of the organ dona-
tion process from the identification of the potential
donors to the organ transplant (Fig. 1).

FIGURE 1. The process from the determination of brain death or cardiac death to organ retrieval.

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Intensive care and resuscitation

Diagnosis of death by neurologic criteria arrest). Profound therapeutic hypothermia may

The determination of DNC relies on the clinical
assessment of the absence of brainstem reflexes,
motor responses and respiratory drive, provided that
the prerequisites are respected, that is normother-
mia, absence of sedation influence or metabolic
derangements and a known, irreversible, unsalvage-
able brain lesion [8]. Hypothermia can be due to the
loss of all brain functions or to environmental expo-
sure or iatrogenically induced (e.g. postcardiac
alter neurologic examination and delay drug metab-
olism. Therefore, a normal core temperature (36 8C)
should be ensured before starting the process.
Guaranteeing a normal SBP with a target at least
100 mmHg is also recommended, achieving firstly
an euvolemic state, optimizing fluid treatment and
then counteracting the vasoplegia using vasopres-
sors/inotropes [9–11] (Table 1). The first step of the
determination of DNC includes the conduction of a

Table 1. Pathophysiology, clinical manifestations and treatment goals for each organ damaged after brain death

Level of
Pathophysiology of injury Clinical manifestation Treatment goals evidence

Heart
Vagal and cardiomotor nuclei
become ischemic
Unopposed sympathetic
stimulation
Loss of spinal sympathetic
pathways
Total sympathetic denervation
Hypothalamus and electrolyte imbalance
Loss of hypothalamic control
Thyroid
Anterior and posterior pituitary
failure
Thermal homeostasis
Anterior and posterior pituitary
failure
Lung
Catecholamines surge
Peripheral and pulmonary
vasoconstriction
Increase pulmonary capillary
pressure
Neurogenic pulmonary edema
Coagulation and hemostasis
Release of thromboplastin from
the ischemic brain (general
prothrombotic state)
Hemodynamic instability
Intense vasoconstriction:
hypertension, tachycardia, and a
secondary increase in myocardial
oxygen demand (subendocardial
ischemia)
vasoplegia and hypotension;
electrocardiographic abnormalities
and arrhythmias
Central diabetes insipidus (86% of
cases): depletion of antidiuretic
hormone causes large loss of water
and diluited urine, hypernatremia
and high plasma hyperosmolarity
Thyroid abnormalities (es. ‘sick
euthyroid syndrome’): generally
low T3 levels and normal T4 levels
Temperature dysregulation:
consequence of loss of
hypothalamic control and
increased peripheral vasoplegia
Cardiovascular consequences
coagulopathy
Increased pressure in the pulmonary
endothelial damage (neurogenic
pulmonary edema and lung injury)
Coagulopathy, with increased risk of
disseminated intravascular
coagulation and piastrinopenia
Normotensive, euvolemic state (no high-level II.1
evidence regarding the use of monitoring and
treatment goals, as well as of the use of fluids
and vasopressors/inotropes)
Volume replacement III
Aggressive fluids administration may have
detrimental effects
Desmopressin or vasopressin is often required
Corticosteroids treatment may improve III
hemodynamic instability and graft and recipient
survival
Hormones replacement suggested just when
hemodynamically unstability occurs
Reasonable to maintain core temperature at least III
above 35 degrees
Normothermia should be maintained through
invasive or non invasive devices (including warm
air or water blankets and warmed intravenous
fluids)
Ventilator management: lung protective ventilation II.1
strategies avoiding actelectasis
A threshold of 50 000/ml platelets has been III
suggested as trigger for transfusion
International normalized ratio <1.5 before surgery
The suggested threshold for red blood cell
transfusion is similar to the targets in the general
population (specific RCTs are lacking)

Level of evidence adapted from Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979.
RCTs, randomized controlled trials.

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careful neurological assessment, which includes the
evaluation of coma, and the absence of voluntary
&&
movements and motor response to pain [6,7 ,8–
10,12]. The absence of brainstem activity is a core
component of neurological assessment. The DNC
patient is unable to breathe and ventilation is replac-
ing this function. The apnea test [13,14] is a key
component of the DNC determination and it is
required in all countries, with some minor differ-
ences according to individual laws. The test is con-
sidered valid and positive when the increase of
arterial partial pressure carbon dioxide (PaCO2) does
not result in the activation of the respiratory centers.
The PaCO2 target of 60 mmHg, that is an increase of
at least 20 mmHg from the baseline, is considered
the threshold to achieve in most countries, with
possibly normocapnia (PaCO2 of 35–45 mmHg),
normoxia and hemodynamic stability before start-
ing the test.
In specific situations, these prerequisites can
be challenging to achieve, in particular in patient
under extracorporeal membrane oxygenation
&&
(ECMO) [15 ,16], even though recent evidence sug-
gests that it is feasible with a low incidence of
&&
complications [16,17 ]. The worldwide increasing
use of ECMO for cardiac or respiratory support, and
the consequent increase of brain-dead ECMO sup-
ported patients, is posing questions regarding the
DNC diagnosis in this group of patients. ECMO can
have consequences upon the testing of brainstem
and in particular on apnea reflexes: pharmacoki-
netic alterations can occur because of membrane
sequestration and of decarboxylation that may
affect the performance of the apnea test. Moreover,
hemodynamic instability can result in an additional
difficulty in meeting the prerequisites [18].
Hemodynamic stability can be difficult to
achieve and maintain during apnea test [16]; to per-
form an apnea test under ECMO support, the fraction
of inspired oxygen to the membrane should be
increased up to 100%, and gas flow progressively
sweeped to 1 l/min, reducing elimination of carbon
dioxide and allowing a typical apnea test. Apnea can
be confirmed as absence of breathing after mechani-
cal ventilation being discontinued; to avoid hypoxia
and derecruitment, positive end-expiratory pressure
and recruitment manoeuvres can be applied. New
&& &
protocols have being developed [19 ,20 ].
Ancillary tests are not mandatory in all countries
[21–24]. When facultative, these should be reserved
for the cases when the confounding factors or seda-
tion cannot be excluded, or clinical examination
cannot be performed appropriately or in cases of
any doubts in the tests. Several exams are available
including Angio-computed tomography (CT) with/
without CT perfusion, electroencephalography and
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Organ donation Robba et al.
transcranial doppler. The choice should be made
based on local and legal protocols and the specific
characteristics of each patient (such as patients under
ECMO with difficulties in the transportation) [25].
Recent evidence show promising results for CT
perfusion, demonstrating increased sensitivity com-
pared with Angio-CT [26,27]. So, CT perfusion, in
addition to Angio-CT might be useful as an additional
&&
ancillary test [28 ], especially in children [29].
Organ donation after circulatory death
Organ donation after a circulatory arrest is an
increasingly used strategy especially in the context
of a continuing shortage of DNC organ donors, and
the high request and need for organs to be trans-
planted [30]; also, it does not imply the need for
fulfilling DNC criteria. DCD can be considered
either in cases when a cardiopulmonary resuscita-
tion has failed or withdrawal of care is planned; in
the first case, related to an unexpected cardiac arrest,
it is defined as uncontrolled DCD, whereas in the
latter case, it is called controlled DCD.
Controlled DCD includes a series of steps to
guide the pathway to the organ donation. The first
step, once end of life decision has been taken (inde-
pendently from organ donation), the patient is
evaluated as a potential candidate. Then, according
to the local legislation, the authorization for dona-
tion should be obtained from the patient, who could
have previously authorized donation in case of
death, or from the family. Then, a careful revision
of the patient’s medical history and conditions for
DCD potential should be made, including donor
screening for compatibility and organ allocation.
Then end-of-life care plan is decided and withdrawal
of care is planned and diagnosis of death is made
with a variable ‘no-touch’ observation period of
5–20 min (accordingly to each country law) before
&&
transferring the patient to the operating room [31 ].
In some countries, as Italy, with very long no-touch
period the prolongation of warm ischemia will
require ex-vivo perfusion for a better organ function
evaluation.
Uncontrolled DCD is slowly gaining popularity
for the potential of the increasing donor pool, but at
present not many centers in Europe have established
specific programs, with several legal and ethical
issues. The pathway for uncontrolled DCD starts
with patients with certain characteristics and cardiac
arrest with unsuccessful cardiopulmonary resuscita-
tion. The patient is then considered as a potential
donor and is transferred to the hospital maintaining
ventilation and cardiac compression. At the hospital,
declaration of death is made and the ‘no-touch’
period starts; following the determination of death,
www.co-anesthesiology.com 149
Intensive care and resuscitation
extracorporeal support is restored to maintain organ
perfusion. ECMO or other modalities of organ pres-
ervation (such as ex-vivo perfusion) can be taken into
consideration as an organ preservation measure. For
lung donation, some centers were able to transplant
organs without ECMO, only keeping the lung venti-
lated without circulation, using a careful ex-vivo lung
perfusion phase [32].
Outcomes after DCD appear controversial from
current literature. Many previous studies show that
uncontrolled DCD has poorer outcomes than con-
&&
trolled DCD or death by neurological criteria [33 ].
By contrary, recent publications demonstrate that
function of grafts preserved by normothermic recir-
culation in uncontrolled DCD is better according to
&& &&
long-term outcomes [34 ,35 ]. The potential of
this technique is huge, with a possible increase of
donor by 220 007 per year in the USA [36].
Family involvement: communication of death
by neurologic criteria and organ donation
Communicate DNC to families [37,38] is a compli-
cated matter, regardless of the family’s medical
background or experience. Moreover, even the
most informed relative can object to the diagnosis
due to moral or religious issues, or even refuse it.
Popular culture and the media, in general, are often
imprecise and confusing [39,40]. Family members
have the critical role in the decision process and
often can experience posttraumatic stress, anxiety
and depression. The prerequisite for organ donation
is to obtain valid informed consent. There are
mainly two legal different consent systems, an
opt-in (or explicit consent of the patients when
alive), and opt-out (where everybody is considered
a potential donor and the consent is assumed unless
&
otherwise specified) [41 ]. However, self-determina-
tion is at the heart of the process and discussion,
consisting in the knowledge and respect of the
patient’s wishes.
The dialogue should be carefully conducted,
clear and honest. The clinician should be well
informed and have clear all the steps of the diag-
nostic process, while also being trained to use the
right words not to be misunderstood [42]. Being
capable to recognize different backgrounds while
being scientifically prepared will also help the prac-
titioner himself to face the inevitable distress of
facing the other’s grief.
Even though the process of organ donation
differs in each country, there are some common
‘good practices’ that we can follow [30,43,44].
As clinicians, we must be certain that the gravity
of the patient’s condition is clear from the very
beginning and to leave the right amount of time
150 www.co-anesthesiology.com
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to process the bad news before even asking about the
patient consent or denial to be an organ donor.
The first and strongest predictor of donation
consent is the knowledge of the patients’ wishes
[45]; however, families are often not aware of the
patient’s wishes [46]. In these situations, communi-
cation and accurate information about organ dona-
tion aid the decision-making; in a recent survey,
among more than 100 families, only 32% could
answer questions about organ donation [47].
Also, to use the patient’s name, communication
of the news in a comfortable environment, leave
room for questions, patience, kindness and atten-
tion (event just by turning off electronic devices
such as phones or pagers) will improve the chances
of clarity and the likeliness of a donation.
It is common practice in some countries to
separate the organ donor manager from the clini-
cian that takes care of the diagnostic process: having
two different figures can help in the process.
Management of the donor in death by
neurologic criteria
Because mortality in the waiting list remains high
[48], a fundamental step of organ donation, once
the potential donor has been identified and a diag-
nosis of death has been made, is to ensure the
highest quality of transplantable organs, to maxi-
mize the number of organs potentially available for
donation. However, this can be challenging because
of the pathophysiology of DNC and the systemic
changes triggered by the neurological dying
sequence. Brainstem death leads to the so-called
sympathetic storm, with an extensive increase in
circulating catecholamine levels and systemic vaso-
constriction, affecting all the organs [49].
Hemodynamic instability with initial hyperten-
sion, tachycardia, and following vasoplegia and
&&
hypotension often occur [31 ], as well as electro-
cardiographic abnormalities and arrhythmias. The
goal of treatment is to achieve a normotensive,
euvolemic state, but the maintenance of hemody-
namic stability is challenging, and no high-level
evidence are available regarding the use of monitor-
ing and treatment goals, as well as of the use of fluids
and vasopressors/inotropes. Dopamine has been
suggested as the catecholamine of first choice and
its use may result in a lower need for dialysis [10,11];
norepinephrine may result in increased pulmonary
permeability and cardiac afterload, synthetic col-
loids should be avoided as they may induce delayed
graft failure after renal transplantation [50].
Central diabetes insipidus is the most common
endocrine problem in brain-dead donors, occurring
in up to the 86% of cases [51] and it is characterized
Volume 33  Number 2  April 2020

by a large loss of water and diluted urine, hyper-
natremia and high plasma hyperosmolarity, as a
consequence of depletion of antidiuretic hormone.
Volume replacement is suggested to ensure euvole-
mia, but aggressive fluids administration may have
detrimental effects, and administration of desmo-
pressin or vasopressin is often required.
Thyroid abnormalities, including the ‘sick
euthyroid syndrome’ may occur, with generally
low T3 levels and normal T4 levels; however, the
role of hormones replacement has still to be estab-
lished and it is suggested just when hemodynami-
cally instability occurs [11].
Similarly, corticosteroids treatment may improve
hemodynamic instability and graft and recipient
survival, but high-quality randomized controlled
trials (RCTs) are lacking [52].
Experimental studies showed that simvastatin
administered in the donor can be vasculoprotective
and inhibiting cardiac allograft ischemia-reperfu-
sion injury. A recent research analyzed 84 multi-
organ donors randomly assigned to receive 80 mg of
simvastatin and it was proved that donor simva-
statin treatment can safely and inexpensively reduce
biomarkers of myocardial injury after heart trans-
plantation [53 ].
&&
Temperature dysregulation as a consequence of
loss of hypothalamic control and increased peripheral
vasoplegia can result in profound hypothermia with
consequent cardiovascular consequences and coagul-
opathy. However, mild hypothermia (34–358) com-
pared with normothermia (36.5–37.58) is associated
with improved renal function in transplanted patients
[54] and it seems to be reasonable to maintain core
temperature between 35 and 37.58 [48]. Normother-
mia should be maintained through invasive or non-
invasive devices, including warm air or water blankets
&&
and warmed intravenous fluids [55 ].
The elevation of left atrial pressure, raised
hydrostatic pressure increase in pulmonary capillary
permeability cause increased pressure in the pulmo-
nary endothelial damage, with increasing risk of
neurogenic pulmonary edema and lung injury
&&
[56 ]. Respiratory targets and ventilator manage-
ment are not clear, but the use of lung-protective
ventilation strategies avoiding atelectasis seems to
be a reasonable approach, especially in patients
eligible for transplanted lungs [57].
Other systemic derangements include coagulop-
athy due to release of thromboplastin from the
ischemic brain, with a general prothrombotic state
which can lead do microemboli and increased risk of
disseminated intravascular coagulation and throm-
&&
bocytopenia [56 ]. A threshold of 50 000/ml plate-
lets has been suggested as a trigger for transfusion,
and international normalized ratio less than 1.5
0952-7907 Copyright ß 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Organ donation Robba et al.
before surgery. The suggested threshold for red
blood cell transfusion is similar to the targets in
the general population as specific RCTs are lacking
in this population.
Finally, an extensive infection screening should
be performed; bacteraemia and sepsis are not contra-
indications to transplant, provided that an appropri-
ate antibiotics therapy has been initiated for 48 h [11].
Management of the donation after cardiac
death donor
In DCD we can distinguish between acceptable and
nonacceptable interventions according to WHO [5].
Blood samples, life-sustaining treatment and altering
the time and place of treatment withdrawal are con-
sidered as acceptable, because they are in the patient’s
best interests if they wished to be an organ donor
without inducing any harm. On contrary, systemic
heparinization, CPR and femoral cannulation can
inflict distress to a patient or family and accelerate
death and therefore considered non acceptable.
Organization of the process to an organ
transplant: summary of recent evidence
The success of organ donation depends on the orga-
nization of every single step of a process that involves
many healthcare professionals. Once the potential
donor has been identified, several tasks have to be
quickly completed to get to the transplanting phase,
and each one of these steps requires an appropriate
training and professional development program.
As described above, early identification and
management of potential donor is fundamental;
however, suboptimal identification and referral of
potential donors can be related to several factors
including the lack of specific training; the use of
checklists has shown to be useful and easy tools for
diagnosis approach (such as the ABC approach:
Aetiology of Brain Injury, Brain death alerts, Contra-
&&
indications to donation [3 ]). Patients potentially
eligible for donation are those with devastating
brain injury, with the suspect of DNC, as well as
patients in whom withdrawal of care has been
planned or with cardiac arrest not responsive to
cardiopulmonary resuscitation.
Once the diagnosis has been made, the following
step is the family approach and to obtain consent for
organ donation. Thereafter, donor clinical manage-
ment to optimize donated organs becomes a priority;
strategies to optimize donated organs include the use
of checklists, continuous organs evaluation, before
organ retrieval, ex-situ organ preservation, recondi-
tioning and before transplantation [58]. Some organs
such as lung and hearth may not be used for
www.co-anesthesiology.com 151
 152
Table 2. Ongoing researches retrieved from ClinicalTrials.gov (search on 14 November 2019) about organ donations

NCT number Title Status Conditions Enrollment

NCT01974206 A Study to Evaluate the Efficacy and Safety of a Vaccine, ASP0113, Active, not Kidney transplantation cytomegalovirus 150
in Cytomegalovirus (CMV)-Seronegative Kidney Transplant recruiting (CMV) negative recipients
Recipients Receiving an Organ From a CMV-Seropositive Donor
NCT03213171 Promoting Organ Donor Registration in Family Physician Offices Active, not Organ donationjRegistration for 6
recruiting deceased organ donation
NCT03600285 Prospective, Single-Arm, Study to Assess the Safety and Performance Active, not Kidney preservation and transportation 32
of the TB1-K Device for Organ Preservation in Donor Kidneys for recruiting
Transplantation
Intensive care and resuscitation

NCT04127266 Expanding Pancreas Donor Pool by Evaluation of Unallocated Not yet Unallocated pancreas organs 100
Organs After Brain Death (EXPLORE) recruiting

www.co-anesthesiology.com
NCT03089489 Lung PGD Biomarkers in Organ Donors Not yet Lung transplant failure 50
recruiting
NCT02836301 RCT- Comparing Testimonial Versus Documentary Organ Donation Not yet Organ donation 1716
Video Education recruiting
NCT03861962 Re-evaluation of Donor-specific Anti-HLA Alloantibodies Not yet Organ transplantation 20 000
Immunoassay After Organ Transplantation, From Antigen Level to recruiting
Epitope Level
NCT03995901 A Safety and Efficacy Study of FCR001 vs. Standard of Care in de Recruiting Transplanted organ rejection 120
Novo Living Donor Kidney Transplantation
NCT02162511 CD34þ Cell Enriched and T Cell Depleted Allogeneic Stem Cell Recruiting Malignant diseasesjNonmalignant 30
Transplantation for Patients With Mismatched Related Donors or diseases
Borderline Organ Function
NCT02525510 Deceased Organ Donor Interventions to Protect Kidney Graft Recruiting Brain deathjOrgan donationjOrgan 2800
Function transplant failure or rejectionjDelayed
graft function
NCT03803423 Dissemination of the Donor Application: Utilizing Social Media to Recruiting End stage renal diseasejEnd stage liver 1000
Identify Potential Live Organ Donors disease
NCT03179020 Donation Network to Optimize Organ Recovery Study Recruiting Brain deathjOrgan donation 1200
NCT03665675 Donor CMV Specific CTLs in Treating CMV Reactivation or Infection Recruiting Allogeneic hematopoietic stem cell 20
in Participants Who Have Undergone Stem Cell Transplant or transplantation
Solid Organ Transplant recipientjCytomegalovirusjDonorjSolid
organ transplantation recipient
NCT03786991 EPI-STORM: Cytokine Storm in Organ Donors Recruiting Organ donationjLiver transplantation 105
NCT03439995 Goal of Open Lung Ventilation in Donors Recruiting Brain deathjOrgan donationjOrgan 400

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

transplant failure or rejection
NCT04007419 Health Promoters and Organ Donation Recruiting Organ donationjDonor designation/ 825
registration
NCT03170414 Observational Study of Solid Organ Transplantation Utilizing HIV- Recruiting HIVjAwaiting organ transplant 10
Positive Donors in HIV-Positive Recipients

Volume 33  Number 2  April 2020

 Table 2 (Continued)

NCT number Title Status Conditions Enrollment

NCT02109575 Quantitative Detection of Circulating Donor-Specific DNA in Organ Recruiting Cardiovascular diseasejAcute rejection 480
Transplant Recipients (DTRT-Multi-Center Study) of cardiac transplantjCardiac
transplant rejectionjHeart transplant
failure and rejection
NCT02469207 Regenerative Cellular Therapies, Physiology, Pathology and Recruiting Graft rejectionjTransplantationjDiabetes 50
Developmental Biology mellitus
NCT03984747 Study for the Prediction of Active Rejection in Organs Using Donor- Recruiting Kidney transplant rejectionjAllograft 500
derived Cell-free DNA Detection rejectionjKidney transplant;
complications
NCT03098706 Therapeutic Hypothermia in ‘Expanded Criteria’ Brain-dead Donors Recruiting Organ donorjBrain deathjKidney 516
and Kidney-graft Function transplant; complicationsjCritical
illnessjHypothermia
NCT03086044 Transplanting Hepatitis C Positive Thoracic Organs Recruiting Hepatitis CjAwaiting organ transplant 100

0952-7907 Copyright ß 2019 Wolters Kluwer Health, Inc. All rights reserved.
NCT03343535 Trial to Evaluate the Safety and Effectiveness of the Portable Organ Recruiting Lung transplantation 90
Care System (OCS, Ѣ) Lung System for Recruiting, Preserving
and Assessing Non-Ideal Donor Lungs for Transplantation
NCT03252795 Uterus Transplantation From a Multiorgan Donor Recruiting Infertility, femalejMayer Rokitansky 20
Kuster Hauser syndrome

RCT, randomized controlled trial.

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

www.co-anesthesiology.com
Organ donation Robba et al.

153
Intensive care and resuscitation
transplantation after initial evaluation ‘relax and
repair approach’ but can be revaluated after few hours
of days following the stabilization of the acute effects
of the sympathetic storm.
Together with the use of checklists, other factors
that can optimize this step include multidisciplinary
briefings with surgeons, high-quality intensive care
with specific training, communication skills and
experience.
Finally, despite the huge effort in increasing
the supply of organs through education and
research, just a few RCTs have been published on
this topic – probably because of legal and ethical
concerns and infrastructures issues – and should be
encouraged [59].
Future directions
Ongoing RCTs are mainly directed toward optimiz-
ing the process of organ donation. Table 2 summa-
rized the most interesting ongoing researches
retrieved from ClinicalTrials.gov (search on 14
November 2019).
CONCLUSION
There is still the current inability to meet the trans-
plant needs of patients. The intensivist plays a
crucial role in the pathway leading to organ donation
and its steps, which are often challenging and
complex. From potential donor identification to
the diagnosis of death, organ preservation and the
activation of the process leading to transplant,
clinical communicational and managerial skills are
required. Maintenance of organ preservation and
clinical management of patients with DNC is funda-
mental and may require a huge effort from the clini-
cal point of view as well as a large amount of
resources.
The primary duty of the clinician is to preserve
patients’ will, as well as to support the families of the
donor. The role of DCD – both controlled and
uncontrolled needs further development in both
research and clinical fields and could be a good
option to reduce the global organ shortage with
increasing demand. Expanding the potential and
the pool for donation further requires the incorpo-
ration of local programs into national guidance
considering ethical and legal considerations.
Research is lacking in this field and there is no
high-level evidence that can guide the clinical prac-
tice and the management of the process, and further
studies are warranted to help the clinician in
the progression and development of this complex
process.
154 www.co-anesthesiology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Acknowledgements
None.
Financial support and sponsorship
The current work was not supported by any sponsorship.
Conflicts of interest
The authors have nothing to declare. The authors are all
opting for organ donation at the end of their lives.
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