Donation after circulatory death (DCD) refers to organ donation from patients who do not meet brain death criteria but have life-sustaining therapy withdrawn due to a non-survivable condition. After withdrawal of care, the patients heart stops and death is declared based on circulatory criteria (no pulse or blood pressure).
Unlike donation after brain death (DBD), DCD organs inevitably endure a period of warm ischemia – a time without oxygenated blood flow – between circulatory arrest and organ preservation. This warm ischemic injury has been a major limitation in DCD transplantation, contributing to higher rates of graft dysfunction and post-transplant complications.
For example, DCD livers historically showed significantly more graft non-function and ischemic cholangiopathy (bile duct injury) than DBD livers. Similarly, DCD kidneys have higher rates of delayed graft function. These challenges led to cautious donor selection and lower utilization of DCD organs in traditional practice.
Normothermic Regional Perfusion (NRP)has emerged as an innovative solution to address warm ischemic injury in DCD. NRP is an in-situ perfusion technique that temporarily restores circulation to the donors organs after death is declared, using an extracorporeal circulation circuit to oxygenate blood at normal body temperature. This technique was pioneered in Europe, where transplant teams sought ways to improve outcomes from DCD donors.
The concept of ECMO-assisted organ recovery dates back to the1980s in Spain, when surgeons first used a perfusion circuit to support organs after cardiac arrest in an uncontrolled donor suffering cardiac arrest. This early Spanish experience demonstrated the feasibility of regional perfusion to salvage kidneys and other organs that otherwise would suffer irreversible warm injury.
By 2019, nearly 50% of all DCD cases in Spain were managed with abdominal NRP, and the technique had spread to the United Kingdom, Italy, France, Belgium, the Netherlands and Switzerland, where NRP was a critical component of DCD organ recovery. The rapid adoption in Europe was driven by accumulating evidence of far superior graft outcomes with NRP. Indeed, many European nations, including Italy, France and Norway, have made NRP mandatory for DCD organ recoveries given advantages in organ utilization and organ function.
Despite European success, the United States was initially slower to adopt normothermic regional perfusion in DCD. This was primarily driven by the significant number of Organ Procurement Organizations (OPOs) and transplant centers across the country and variation in hospital, OPO and transplant center comfort with the technical complexity of NRP. However, in recent years the U.S. transplant community has moved rapidly toward embracing NRP, spurred by positive data and the urgent need to expand the donor pool.
In the United States, preliminary use of the technology occurred in 2019 and 2020, but since that point utilization has accelerated rapidly. By late 2023, a national survey showed thatÊ49 of 55 (89%) had at least one DCD donor recovered utilizing NRP. In 2025, that number has increased significantly, and NRP has become the standard of care for DCD recoveries in many OPOs.
The historical approach to DCD donation included the use of a super rapid organ recovery technique. Following a mandatory standoff period to confirm irreversible cessation of circulation, the surgical team immediately initiates a highly time-sensitive organ procurement procedure. The focus is on rapidly cannulating the aorta to infuse cold preservation solution and begin in situ organ cooling as quickly as possible. This minimizes warm ischemia time and resultant organ injury. Conversely, promptly reestablishing blood flow using NRP can limit warm ischemic damage, replenish cellular energy (ATP), wash out toxic metabolites and even allow functional assessment of organs before procurement.
NRP involves connecting the deceased donor to a form of cardiopulmonary bypass or ECMO (extracorporeal membrane oxygenation) circuit to perfuse the organs with warm, oxygenated blood after circulatory death has been declared. There are two main variants of NRP in practice:
- Abdominal NRP (A-NRP): Perfusion is limited to abdominal organs (liver, kidneys, pancreas, etc.). The thoracic aorta is occluded (above the diaphragm or via an intra-aortic balloon) to exclude the heart and brain from circulation, and cannulas are placed in either the femoral artery and vein or directly into the aorta and vena cava. A-NRP is typically used when only abdominal organs will be transplanted. It restores blood flow to abdominal viscera at normothermia, during which time the organs are reconditioned from the warm ischemia insult and can undergo viability testing. After this point the organs are cooled and recovered.
- Thoraco-Abdominal NRP (TA-NRP): Perfusion is extended to include the heart (and potentially the lungs) in addition to abdominal organs. In TA-NRP, the arch vessels to the brain are clamped and vented to atmosphere, allowing the heart and abdominal organs to be reperfused while excluding any cerebral circulation. TA-NRP effectively reanimates the heart in situ, enabling transplantation of the heart along with other organs.
The most important component of the NRP organ recovery is that NRP restores perfusion only to the thoraco-abdominal organs while ensuring no brain perfusion. This is achieved by occluding the descending aorta, aortic arch or great vessels depending on the intended organs for transplant before any perfusion is initiated and undertaking careful monitoring during the procurement procedure.
During NRP, the circuit maintains normal body temperature (~37¡C) and target flows to mimic physiologic perfusion. Surgeons monitor parameters such as blood pressure, blood gases (lactate clearance) and organ function indices. After this controlled reperfusion period, organs are cooled and flushed with preservation solution as in standard practice. The entire NRP process essentially serves as an in vivo resuscitation and evaluation period, bridging the gap between the donors death and organ procurement.
The ultimate measure of any organ preservation technique is its impact on how many organs can be transplanted and how well those transplants perform. Across abdominal and thoracic organs, normothermic regional perfusion has shown transformative benefits in both organ utilization rates (the percentage of recovered organs that are successfully transplanted) and post-transplant outcomes.
A multitude of studies have highlighted that NRP increases utilization of DCD hearts, livers and kidneys for transplant – a critical component of increasing the donor pool. In the case of liver and kidney transplant, data has emerged demonstrating a significant decrease in complications and improved graft survival.
Heart transplant has arguably been the most impacted, as traditionally the hearts from DCD donors could not be utilized for transplant. However, NRP and advanced perfusion devices proved that many hearts can be resuscitated and successfully transplanted even after a period of standstill. This development represents a new frontier in heart transplantation.
There are two approaches to recovering DCD hearts: direct procurement with ex situ perfusion (DPP) using a device like the TransMedics Organ Care System, or in situ reanimation via TA-NRP. Both have been used in different programs.
TA-NRP has the advantage of also benefiting abdominal organs and possibly being less costly (using standard ECMO circuits), whereas ex situ devices allow portability and were adopted early in places without NRP. Regardless of method, the accumulated global experience demonstrates that outcomes for DCD heart transplants are essentially equivalent to traditional heart.
Despite decades of successful use in Europe and now profound documented benefits in the United States, NRP does raise ethical concerns among some. This primarily relates to the determination of death. Although NRP is initiated after circulatory death, it restores blood flow to the organs, raising concerns that circulation to the brain could be inadvertently reestablished, potentially undermining the declaration of death.
Proponents of NRP highlight that death is legally and ethically determined by the irreversible cessation of circulatory and respiratory functions. In NRP, blood flow is restored only to the thoracoabdominal region, while circulation to the brain is deliberately and permanently excluded. This ensures there is no possibility of restoring brain function or reversing death.
Imaging studies using techniques such as transcranial Doppler ultrasound, near-infrared spectroscopy (NIRS) and radionuclide perfusion scans have demonstrated the absence of cerebral circulation during NRP. These data support the conclusion that brain circulation Ð and therefore the potential for brain function Ð is not reestablished during NRP, preserving the integrity of death determination.
NRP, whether limited to the abdomen or including the thorax, represents a paradigm shift in DCD organ donation. By reestablishing near-physiologic circulation after death, NRP addresses the Achilles’ heel of DCD – warm ischemic injury – and in doing so, dramatically improves organ utilization and transplant outcomes.
What began as an experimental concept in Spain decades ago has evolved into a proven clinical technique across Europe and is now rapidly gaining ground in the United States. NRP allows transplant teams to recover higher-quality organs from DCD donors, resulting in more transplanted organs and better patient outcomes.
References
Sellers, Marty & Philip, Jennifer & Brubaker, Aleah & Cauwels, Roxane & Croome, Kristopher & Hoffman, Jordan & Neidlinger, Nikole & Reynolds, Andrea & Wall, Anji & Edwards, John. (2024). Normothermic Regional Perfusion Experience of Organ Procurement Organizations in the US. JAMA network open. 7. e2440130. 10.1001/jamanetworkopen.2024.40130.
Joshi Y, Wang K, MacLean C, Villanueva J, Gao L, Watson A, Iyer A, Connellan M, Granger E, Jansz P, Macdonald P. The Rapidly Evolving Landscape of DCD Heart Transplantation. Curr Cardiol Rep. 2024 Dec;26(12):1499-1507.
Glorion M, Briard JN, Roquebert L, Pizzi S, Menaouar A, Borie M, Robert M, Nguyen DK, ChassŽ M, Nasir B, Ferraro P, Der Sarkissian S, Noly PE, Noiseux N. Thoraco-abdominal normothermic regional perfusion does not restore cerebral blood flow or electrical activity despite collateral supra-aortic blood flow in a porcine model. JHLT Open. 2025 Jan 29;8:100221
Frontera JA, Lewis A, James L, Melmed K, Parent B, Raz E, Hussain ST, Smith DE, Moazami N. Thoracoabdominal normothermic regional perfusion in donation after circulatory death does not restore brain blood flow. J Heart Lung Transplant. 2023 Sep;42(9):1161-1165
Adam Gracon, MD, PharmD, FACS
Dr. Adam Gracon is a multi-organ transplant surgeon at the Piedmont Transplant Institute. Dr. Gracon completed his surgical residency at Indiana University. He went on to complete his fellowship in Abdominal Transplant Surgery at the University of Wisconsin. He is board certified by the American Board of Surgery and is a Fellow of the American College of Surgeons. Dr. Gracon has a special interest in donor organ optimization and emerging technology.
Sharon Holloway, MS, MD
Dr. Holloway is a multi-organ transplant surgeon performing liver, kidney and pancreas transplants at Piedmont Transplant Institute. She received her undergraduate degree from the University of North Carolina at Chapel Hill and masters in physiology from Virginia Commonwealth University where she also earned her medical degree. Prior to joining Piedmont Physicians, Dr. Yu completed her fellowship in abdominal transplant fellowship at Emory University Hospital.
