How to initiate DCD program for liver transplantation

Donation after circulatory death (DCD) arguably has the greatest potential to provide transplantable organs. The vast majority of people die of causes that do not lead to brain death (98 %) [1] and thus DCD could meet the needs of organ transplantation based upon the actual numbers of potential donors alone. DCD liver transplantation has also played a unique role in the genesis of solid organ transplantation and paved the way for early pioneers of the speciality. There are many challenges, however, to start successful DCD programs. In contemporary practice, despite large numbers of potential donors, DCD is not the ideal solution to the shortage of organs for transplantation due to complications relating primarily to ischaemia-reperfusion injury which are responsible for primary non-function (PNF) and/or delayed graft function. The liver is particularly sensitive to ischaemia-reperfusion injury and displays organ-specific damage in terms of biliary ischaemia. Ethical issues, societal idiosyncrasies and religious beliefs vary between nations and have a vast impact upon organ donation. Some of the more important issues that affect DCD follow. Controlled DCD was not possible in some countries, such as Spain, where withdrawal of life-sustaining treatment was not an accepted practice. However, this is changing and a pilot controlled DCD is on its way; as all religious scriptures were created before organ donation no religion states organ donation should be prohibited though some individuals perceive this to be so [2]; there is a perception by some people that efforts at resuscitation, provided by healthcare professionals, would be negatively influenced if uncontrolled DCD was a possible outcome for the patient in cardiac arrest [3]; certain noninvasive and invasive procedures are required during uncontrolled DCD before consent for donation can be sought. Finally, there are difficult logistic issues surrounding liver procurement, particularly for uncontrolled DCD. Thus the process of DCD is presented with strong challenges from society, individuals and the technical and logistical process of liver procurement itself.