Organ Donation After Circulatory Death: Warm Ischemia Time and Graft Outcomes

Abstract

Introduction: Donation after circulatory death (DCD) expands the donor pool. Irreversible warm ischemia time (WIT) from withdrawal of life support to cold perfusion predicts graft survival. Optimal WIT thresholds for kidney, liver, and lung transplantation need evidence synthesis.
Methods: Systematic review of 28 cohort studies (n=15,892 DCD transplants). Outcomes: primary nonfunction (PNF), delayed graft function (DGF, kidneys), ischemic cholangiopathy (liver), 1-year graft survival. WIT categorized as <20 min, 20–30 min, 30–40 min, >40 min.
Results: For kidneys, WIT <20 min: 1-year survival 92%, DGF 35%; WIT 20–30 min: 88%, DGF 48%; WIT >30 min: 72%, DGF 62%. For livers, WIT >25 min increased ischemic cholangiopathy from 8% to 27% (p<0.001) and 1-year graft loss from 11% to 24%. Lungs tolerated longer WIT: up to 60 minutes with acceptable outcomes if perfused cold antegrade. Donor age >50 worsened outcomes at each WIT interval.
Discussion: WIT is modifiable by rapid recovery techniques (normothermic regional perfusion). A 30-minute threshold is reasonable for kidneys and livers.
Conclusion: Warm ischemia time ≤30 minutes is recommended for DCD kidney and liver transplantation. Lungs can tolerate up to 60 minutes.