A Potential Solution to the Shortage of Solid Organs for Transplantation.

In the United States, the majority of deaths occur unexpectedly, outside hospitals or in emergency departments.1 Rarely do these deaths provide opportunities for organ donation. In Europe, unexpected deaths provide substantial numbers of transplantable organs through uncontrolled donation after circulatory determination of death (UDCDD).2 UDCDD considers decedents candidates for donation even when death is unexpected, regardless of location, as long as preservation begins after all life-sustaining efforts have been exhausted. More than 124 000 patients are wait-listed for organs in the United States, a number that increases annually despite attrition from 10 500 who die or become too sick for transplantation.1 United States policy currentlypromotesorgan recovery from3sources;neurologicdeaths, controlledcirculatorydeaths,and livedonors for kidneys and partial livers. However, these approaches are incapable of meeting increasing US demand for transplants. During controlled donation after circulatory determination of death (CDCDD), the time from cessation of life support to circulatory arrest often exceeds 60 minutes. Prolonged hypotension leads to irreparable organ damage, thus limiting the effect of CDCDD on organ supply.3 Live donation primarily affects kidney supply; it is unlikely that altruistic donation will ever meet demand. Although many changes in public policy regarding cadaveric donation are debated (markets and presumed consent), none is likely to become law or make substantial differences in organ supply. The US organ donation system is neglecting the much larger pool of potential donors who could provide organs following unexpected death outside an intensive care unit. In 2006, theUS Institute ofMedicine projected that implementationofUDCDDprotocolsnationwidecouldgenerate22 000moredonationopportunities annually in the United States, substantially reducing waiting times for transplantation.4 If deaths by traumatic causes are added to the Institute ofMedicine estimate, the potential donor pool could increase by as much as 63%.5 UDCDD requires initiation of organ preservation soon after death. If thewarm ischemic time,which represents the time organs receive inadequate circulation to sustain cellular function, exceeds an organ-specific threshold,organsarenotviable.Europeanprograms initiate organ preservation without requiring explicit consent,2 a concept theUSpublicwill not allowdespite supportingUDCDD.6 Therefore, someUS programs restricted eligibility to deceased persons who had previously registered for organ donation. However, UDCDD programs in the United States experienced recruitmentproblemsbyrestrictingeligibility topreviously registered organ donors.6