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Assessment of the pediatric patient for potential organ donation

Assessment of the pediatric patient for potential organ donation
Harish Vyas, DM, FRCP, FRCPCH
Thomas A Nakagawa, MD, FAAP, FCCM
Section Editor:
George B Mallory, MD
Deputy Editor:
Alison G Hoppin, MD
Literature review current through: Dec 2022. | This topic last updated: Feb 01, 2022.

INTRODUCTION — Organ transplantation is a treatment of choice for selected individuals with end-stage organ failure, transforming the outlook and quality of life of selected recipients. Organ transplantation procedures were first performed in adults in the 1950s and in children in the 1960s. Since then, advances in surgical techniques, immunosuppressive therapies, and treatments for diseases that previously limited organ recovery for transplantation have led to a marked increase in successful transplantation of organs and patient survival. Although organization of an organ donation program is well developed in advanced economies, in resource-limited countries, the unmet need is vast and thousands of children die due to the unavailability of either medical treatment or transplantation program [1,2].

The assessment of the pediatric patient for potential organ donation is discussed in this topic review. The determination of death by neurologic criteria and management of the potential organ donor are discussed separately. (See "Diagnosis of brain death" and "Management of the potential pediatric organ donor".)


Persistent vegetative state — Persistent vegetative state was first described in 1972 and refers to a condition where the brainstem remains intact and functions to maintain autonomic activity. The patient's cortical function has been significantly impaired or lost. In this state, the patient may or may not be aware of self or environment. These patients cannot be declared legally dead, because brainstem function remains intact.

Neurologic determination of death (brain death) — The fundamental definition of neurologic death is similar in most countries, although the procedures required to establish the determination of death may vary [3]. Countries such as the United States and Canada require specific physical examination criteria to determine the death of the entire brain, including the brainstem. This practice differs in the United Kingdom, where only testing of brainstem reflexes is required to determine death. If examination criteria cannot be met, ancillary studies are required to determine death by neurologic criteria. Additionally, in the United States and many other countries, two examinations separated by an observation period are required for children. The observation period depends on the age of the child [4]. The determination of neurologic death, including considerations related to the pediatric patient, is discussed separately. (See "Diagnosis of brain death".)

This topic review will use the term "neurologic death" to describe the condition meeting the legal and medical definitions for death based on the region of practice.

Donation after neurologic determination of death — Donation after neurologic determination of death (DNDD) refers to a donor who is declared dead by neurologic criteria with intact circulatory function, also known as a "brain-dead donor." In the United States, they are also known as "deceased donors" or "standard criteria donors" because this is the most common type of donor.

Donation after circulatory death — Donation after circulatory death (DCD) refers to a donor that does not meet criteria for brain death but has no hope of any sort of meaningful neurologic recovery and in whom the family chooses to withdraw life-sustaining treatment. After death is determined using circulatory criteria (permanent absence of respiration, circulation, and responsiveness), organs may be recovered for transplantation. This type of donation has previously been referred to as donation after circulatory determination of death (DCDD), non-heart-beating organ donation, or donation after cardiac death.

DONOR IDENTIFICATION AND SELECTION — The process of donor identification and selection is similar in many countries. Variations on when to consult and involvement of the organ procurement organization (OPO) may vary based on jurisdiction. The reader is encouraged to review and become familiar with local jurisdictional policies and procedures.

When to consult an organ procurement organization — A significant number of critically ill pediatric patients have chronic or life-limiting conditions. The mortality rate for children in most pediatric intensive care units (PICUs) is low (approximately 5 percent), and parental expectations of survival are high. Therefore, intensivists should actively identify patients at high risk of death and embark on timely conversations with parents. The timing and content of the discussion with the parents depends on the patient's clinical status. In critically unstable PICU patients, it might become necessary to have the initial discussion at the bedside, with ongoing brief updates as the patient's condition evolves. Communicating the risk of death allows the family and the medical team a sound basis for future discussions related to end-of-life care.

At this point, referral to an OPO is a crucial part of the donation process. Early referral to the OPO is considered a best practice to maximize chances of receiving authorization and organ recovery for successful donation and is supported by the American Academy of Pediatrics [5]. This referral should generally occur before neurologic or circulatory death has formally been declared. No assumptions about donor suitability should be made until discussions with the OPO have occurred [6]. The OPO and its medical director make decisions regarding donor suitability and organ recovery, not the medical team managing the potential donor. Consultation with the OPO should be considered for a critically ill child as soon as specific clinical triggers are met [6].

Appropriate clinical triggers for consulting the OPO include:

Survival seems unlikely

Discussions of limiting advanced care (eg, limitation or de-escalation of care, or comfort measures only)

Initiation of a do not resuscitate or allow natural death order

Donation should be viewed as a process. The discussion between the clinician and the OPO can help determine whether the patient may be a suitable donor. Palliative care clinicians are another valuable resource to assist medical teams with discussions about donation while providing additional family support [7]. Early involvement of the OPO can optimize the chance of organ recovery and spare the family the discouraging news that their child cannot be a donor because of an underlying disease process, unsuitable organs, or lack of recipients to receive a transplanted organ. Most OPOs have personnel that can facilitate communication with the family in collaboration with the critical care team. Authorization rates are higher when an organ procurement coordinator is involved in the donation discussion [8]. The OPO also provides experience and support independent of the decision to donate during the time period of donation and withdrawal of life-sustaining treatments. Even if solid organs are not suitable for recovery, tissue donation, including eyes, skin, bone, and heart valves, may be considered [9].

In an audit of a regional PICU in the United Kingdom, referral to an OPO was low despite introduction of National Institute for Health and Care Excellence (NICE) guidelines [10,11]. Possible ways to improve organ donation rates include better education about the process for doctors and nurses, especially during their induction. There is a need for active discussions about the possibility of organ donation during handover for any patient who may be facing end-of-life issues. The medical and nursing staff should frequently participate in organ donation simulation courses to enhance their comfort with end-of-life care and donation.

There is a need for a global consensus on the determination of death, either by neurologic or circulatory criteria. The World Brain Death Project has reviewed global pediatric brain death practices to increase public acceptance and bestow confidence to the professionals [3].

Candidates for donation — It is imperative to discuss each potential donor with the OPO. Historical experience with donor suitability is insufficient because there has been a progressive expansion in the types of donors and organs recovered for transplantation over the last two decades [6]. The decision regarding donor suitability and organ donation is made by the OPO and its medical director, not by the medical team managing the potential donor. Preconceptions about donor eligibility by the health care team and a protective stance with parents or guardians of children because of fear that the family may have endured "too much" with the child's injury and death may have the unintended consequence of denying families the opportunity to help or save the life of another person [12].

Donor characteristics – Donation after neurologic determination of death (DNDD) remains the most common source of organs for transplantation (table 1). Pediatric brain-dead donors have decreased in numbers, while donation after circulatory death (DCD) has increased, contributing more organs for transplantation [13]. Patients who are candidates for DNDD are cared for in an intensive care unit, where vital functions are artificially maintained following irreversible brain damage, using assisted ventilation and, in some cases, inotropic support and hormonal replacement therapy. Following determination of neurologic death and identifying the decedent as a potential donor, aggressive intensive medical care must be continued to ensure that donor organs remain viable for transplantation. Good donor management provides a better graft to the transplant recipient, can markedly enhance long-term organ survival in the recipient, and can increase the chance of recovering suitable organs from potential donors. (See "Management of the potential pediatric organ donor".)

The ideal donor for DNDD has an isolated head injury, with limited or no other organ system dysfunction or preexisting comorbid diseases such as diabetes or hypertension. These donors are common in pediatrics, where many children who are declared dead by neurologic criteria have no preexisting neurologic dysfunction [14]. Patients with multisystem organ failure due to trauma, toxic drug ingestion [15], meningitis [16], sepsis, and even some primary brain tumors without metastasis [17,18], who may not be ideal candidates for donation initially, can be aggressively managed following declaration of neurologic death and potentially provide additional organs for transplantation. Although the majority of such patients are already cared for in intensive care units, patients admitted to the emergency department or transferred to operating theaters may also be potential candidates for organ donation, and early notification to the OPO should be encouraged.

The organ donor should ideally meet all of the following criteria. Not all of these criteria are absolute, and input from the OPO is essential:

Neurologic death (for the DNDD donor)

Treatment of any serious infection

Free of malignancy (with the exception of low-grade skin or non-manipulated brain tumors)

Free of systemic disease (eg, systemic lupus or end-stage kidney disease)

Hemodynamically stable (even with inotropic and pressor use)

Contraindications – Contraindications to organ donation include active cytomegalovirus infections and active or uncontrolled malignancies. Other disease processes, such as infectious illnesses or risk factors for these diseases, may also be strong contraindications (see "Evaluation of the potential deceased organ donor (adult)", section on 'Immediate contraindications to donation'). Risk factors for HIV infection, such as intravenous drug use, make the donor a high-risk candidate and may exclude a patient from becoming a donor; however, this is not commonly encountered in children.

Collaboration with the OPO is essential to ensure that opportunities for potential organ donation are not missed. Assessing organ eligibility is best determined by the OPO and may change depending on the time of evaluation and comfort levels of the transplant team [6].

A person with an active coronavirus disease 2019 (COVID-19) infection cannot be a donor. Recommendations are that every potential organ donor be tested for COVID-19. Although there is no known transmission of COVID-19 through organ donation, transplant patients are immunosuppressed, with a higher risk for infection that must be considered and minimized. Data indicate that a single negative COVID-19 test from a nasopharyngeal sample may not reliably exclude active infection [19]. In asymptomatic, COVID-19-infected individuals with a low viral burden, reliability of a single test may not be sufficient [20]. Bronchoalveolar lavage is more reliable to identify the presence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and is required by many OPOs. International organizations have provided recommendations and guidance for organ donor testing [21,22]. Transplant societies have provided recommendations for organ recovery from patients with COVID-19 [23,24]. (See "COVID-19: Issues related to solid organ transplantation", section on 'Donor screening'.)

Other issues related to the COVID-19 pandemic are discussed separately:

Reduced supply of organs from deceased or living donors during the pandemic (see 'Inadequate supply of organs for transplant' below)

Outcomes for solid organ transplants during the pandemic (see "COVID-19: Issues related to solid organ transplantation", section on 'Active COVID-19 in solid organ transplant recipients')

Other considerations – Novel strategies are emerging to help increase the supply of organs needed for transplantation into critically ill patients. As examples:

HIV was formerly a contraindication to organ donation; however, in the United States, changes to protocols allow HIV-positive organs to be transplanted to HIV-positive recipients through the HIV Organ Policy Equity Act (HOPE Act).

Donation from hepatitis B- and C-positive patients may be considered for recipients already infected with the same virus or, in some circumstances, for recipients at risk of imminent death [25]. Organs from patients with hepatitis C are now being transplanted with advanced therapies to treat hepatitis.

Isolated liver disease or end-stage heart disease in the donor precludes transplantation of these damaged organs. However, a disease affecting one organ should not prevent recovery of other organs, unless the disease process causes or would predispose to widespread organ failure. Organs that might have reduced function such as heart and lungs are being recovered and supported with ex vivo perfusion to condition organs for potential transplantation. Ex vivo perfusion for heart, lung, and liver can improve organ performance for previously marginal organs that could not be transplanted. A DCD heart maintained on ex vivo perfusion was transplanted into the first pediatric recipient [26]. This emerging technology has the ability to increase organ availability for transplantation.

FAMILY COMMUNICATION — When a child is dying or has died, the health care team should explain this clearly to the family in a caring, compassionate, and sympathetic manner. Palliative care clinicians can be valuable assets [7], and chaplaincy and social services can also provide additional support for the family [27]. With the onset and declaration of neurologic death, the support and care offered to families should be intensified rather than withdrawn.

Early and continued involvement of the organ procurement organization (OPO) is essential in organ donation discussions with families [9,28]. In the United States, hospitals participating in government-funded programs are mandated to refer all potential organ donors to their local OPO and to inform families of their option to donate [9,29]. Each hospital should have a policy that outlines a strategy for communication and support with families of potential donors. Such policies are ideally developed by a multidisciplinary team consisting of medical staff, nursing personnel, psychologists, child life specialists, chaplain services, OPO personnel, and family service coordinators [9,28].

Parents and family members should be allowed adequate time to grieve and accept the reality of the child's death or impending death. Ideally, the discussion of organ donation should not be raised during the same discussions about death, unless the family raises the issue. The separation of the two discussions, described as "decoupling," has been shown to increase the chance of a positive decision by the family regarding donation for adult patients [9,30]; however, this may not always be the case with children [28]. Importantly, families respond positively if they are exposed to organ donation information prior to the child's death and have time to discuss donation among themselves before death occurs [31]. Offering the family the opportunity for organ donation should become part of the end-of-life care in all intensive care units.

When entering the discussion of organ donation, the clinician's main role is to communicate that the child has died and to ensure that the family understands the finality of neurologic death [30,32,33]. A common reason for parents or legal guardians to deny authorization for donation is lack of acceptance of the child's death. Ensuring that the parents understand that their child is dying or has died is an imperative message that the health care team must consistently convey. Team members must use consistent, uncomplicated terminology. The medical and legal definition of neurologic death is complex and often confusing even for clinicians [34-36], and families do not tend to distinguish between circulatory and neurologic death [37]. Therefore, it may be helpful to use general terms such as "death" when possible, rather than "brain death" or "neurologic death."

SCREENING DONORS — Once the family has authorized donation (either for donation after neurologic determination of death [DNDD] or donation after circulatory death [DCD]), laboratory evaluation of the potential donor continues with both general and organ-specific testing. These screening tests differ from center to center. The goals are to determine tissue type and basic donor immunology, assess organ function, and identify any underlying infection or contraindication to donation (table 2). Laboratory testing generally includes ABO blood type, complete blood count, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), prothrombin time (PT), partial thromboplastin time (PTT), hepatitis B surface antigen and hepatitis B core antibody, hepatitis C antibody, HIV antibody, serologic tests for syphilis (venereal disease research laboratory test or rapid plasma reagin), and cytomegalovirus antibody. The organ procurement organization (OPO) coordinator thoroughly reviews the patient's medical record and completes an extensive donor checklist that includes laboratory and other studies required to determine donor suitability and proceed with the donation process.

The evaluation and decision about whether to recover an organ from a potential donor will be directed by an organ procurement organization (OPO) and transplant surgeons, based upon organ function, disease process, and underlying circumstances that resulted in the donor's death.

Specific organ considerations

Liver — General considerations for donor selection for liver transplantation, including the components of the evaluation by the OPO, donor exclusion criteria and ABO matching, are described separately. (See "Liver transplantation in adults: Deceased donor evaluation and selection".)

Assessment of the potential donor for liver recovery frequently includes the following studies: Serum albumin, PT, and PTT provide an index of liver synthetic function but may be affected by administration of blood products or disseminated intravascular coagulation. Additionally, anoxia or the cause of donor death may compromise liver function. If the AST, ALT, and GGT normalize after resuscitation, the liver may be suitable for transplantation. Organs from donors with serologic evidence of viral hepatitis may also be appropriate for transplantation under special conditions. (See "Liver transplantation in adults: Deceased donor evaluation and selection".)

Kidneys — General considerations for donor selection for kidney transplantation, including the components of the evaluation by the OPO, donor exclusion criteria and ABO matching, and the kidney allocation policy in the United States, are described separately. (See "Kidney transplantation in adults: Risk factors for graft failure" and "Kidney transplantation in adults: Organ sharing".)

Assessment of the potential donor for kidney recovery includes:

Blood urea nitrogen and creatinine – Ideal donors generally have relatively normal serum creatinine levels. Elevated creatinine levels may be a predictor of poor graft function and require further evaluation to determine renal function. However, kidneys with impaired renal function from acute tubular necrosis have been transplanted successfully, with recovery of renal function following transplantation. The recipient may require temporary support with dialysis following transplantation until renal function recovers.

Urinalysis and urine culture – A urinalysis is also important to assess for casts and protein excretion and presence of infection. A urine culture is also sent prior to organ recovery. In some cases, a renal ultrasound is performed to evaluate the anatomy; ultrasound of the donor kidneys is not routine, unless an anatomic variant is suspected.

Intrinsic renal disease and parenchymal trauma are exclusion criteria for donation. Risk factors for graft failure include technical issues during implantation, degree of immune sensitivity in the recipient, and pre-recovery organ injury (eg, ischemia and hypoxia); these apply to donors of all ages. The benefits of living donor transplantation are discussed separately. (See "Kidney transplantation in adults: Risk factors for graft failure".)

Kidneys from donors younger than three years of age are sometimes discarded because there is an increased risk of graft thrombosis; however, the en bloc technique, in which both kidneys are recovered together and transplanted with the vascular pedicle, has been used with good success rates in small adult recipients [38]. The high risk of vascular complications may limit the use of this procedure in children; however, technical advances have allowed en bloc kidneys to be transplanted with improved success [39-41]. Renal mass must be adequate for the size of the recipient and is a predictor of graft failure, so kidneys from small pediatric donors should be allocated first to recipients of similar weight [42]. Each case must be discussed with the transplant surgeon to determine if the kidneys will meet the need of the potential recipient (see "Kidney transplantation in adults: Risk factors for graft failure", section on 'Inadequate renal mass'). Use of therapeutic hypothermia in a deceased organ donor to enhance delayed graft function has not been evaluated in children [43].

Heart — Donor selection for potential cardiac recovery is particularly stringent [44-46]. There should be no history of preexisting coronary or valvular disease. Inotropic support should be minimized and adjusted to maintain a normal blood pressure for age. Increased need for inotropic support with concomitant lactic acidosis may indicate poor cardiac performance and requires careful evaluation for the causes of dysfunction. The use of ex vivo perfusion for heart recovery may allow for physiologic and metabolic evaluation of a heart for transplant consideration [47]. (See "Management of the potential pediatric organ donor", section on 'Inotropes and vasopressors'.)

The OPO and transplant surgeon will make the decision to recover and transplant a heart from a potential donor based on organ function and size, disease process, and underlying circumstances that resulted in the donor's death, just like any other potential organ for transplantation. Organ assessment in intensive care includes:

Chest radiograph


12-lead electrocardiogram

Cardiac enzymes (troponin and creatine kinase-MB)

Cardiac angiography (in selected cases and more common with adult donors)

The echocardiogram should be performed after stabilization of the donor. Echocardiograms performed immediately following neurologic death will likely have evidence of dysfunction and ischemic changes related to the catecholamine storm and hypertension that ensues prior to brainstem herniation. Cardiac performance evaluated by serial echocardiograms often improves over time and with optimal donor management following neurologic determination of death. In some cases, a pulmonary artery catheter may be requested in the older child to further define cardiac function.

Cardiac size may limit transplantation for the potential recipient to accept the donated organ. It might be reasonable to transplant a smaller heart into a bigger person in some cases. Occasionally, the converse (transplanting a bigger heart into a smaller person) is also possible, when the recipient has a longstanding cardiomyopathy with a relatively large heart size. Specific measurements will be conducted to determine if the heart is the appropriate size for the recipient. The ultimate decision to recover and transplant a heart will be made by the surgeon's assessment during the organ recovery procedure.

Lung — Donor lungs are the organ most likely to be compromised for transplantation. Donor lung injury occurs after brainstem death due to hemodynamic instability, neurogenic edema, and hormonal changes, and this can impair graft function in the recipient. In one retrospective study, early lung retrieval from traumatic brain-dead donors did not compromise outcome [48]. Lungs recovered following DCD donors are being recovered and transplanted with good success in adults. The success of these DCD organs is partly due to the fact that lungs from this type of donor have not been subjected to the hemodynamic, neurologic, and hormonal changes associated with neurologic death [49,50]. Criteria defining the ideal characteristics of a lung donor include age less than 60 years; a normal chest radiograph; good gas exchange; and no history of either primary pulmonary disease, aspiration, or cardiopulmonary surgery. Ex vivo perfusion of lungs following DNDD and DCD has potential to significantly increase lung recovery for transplantation. Relative and absolute exclusion criteria are discussed in detail separately. (See "Lung transplantation: Deceased donor evaluation".)

Recovery of lungs for transplantation requires an in-depth assessment of pulmonary function in the intensive care unit.

A cuffed endotracheal tube (ETT) should be used for all pediatric donors regardless of age. Because the pharynx and larynx are largely functionless in deceased donors, uncuffed ETTs can result in silent aspiration. A cuffed ETT with cuff pressure inflated to above 20 cm H2O will help prevent silent aspiration [51].

Oxygen challenge test and serial arterial blood gas analysis – An oxygen challenge is performed to determine whether the patient's lungs are suitable for transplantation. The potential donor is preoxygenated with a fraction of inspired oxygen (FiO2) of 1.0, and arterial partial pressure of oxygen (PaO2) is measured. If the PaO2 is >300 mmHg, the lungs are considered suitable for donation in many centers. Values lower than this threshold suggest lung injury, infection, and/or atelectasis. Because low values may be caused by atelectasis, alveolar recruitment may be achieved by strategies to improve oxygenation. Serial analysis of arterial blood gas between oxygen challenge tests provides further information about respiratory function and response to interventions. (See "Management of the potential pediatric organ donor", section on 'Respiratory'.)

Chest radiographs – Serial radiographs should be performed every 4 to 12 hours (or as recommended by the OPO protocol) to assess for development of infiltrates, worsening pathology, or improved recruitment.

Bronchoscopy – Bronchoscopy is a valuable tool for the initial assessment of the potential lung donor. It may identify potential pathogens to guide antimicrobial therapy; the procedure also provides the possibility of therapeutic bronchial toilet. (See "Management of the potential pediatric organ donor", section on 'Respiratory'.)

Lung transplantation typically requires size matching of the donor and recipient. This is commonly based on donor and recipient height, although some centers also use estimates of lung volume made from chest radiographs. Lobar transplantation or reduction of the lung size by surgical stapling has been reported for pediatric recipients when donor lung size is excessive [52-54]. (See "Lung transplantation: Deceased donor evaluation", section on 'Size matching'.)

INADEQUATE SUPPLY OF ORGANS FOR TRANSPLANT — Unfortunately, the gap between organ availability and recipient need is increasing [55]. This has resulted in many individuals that continue to die while waiting for a needed organ [55,56]. This is particularly true for children, and especially those under one year of age, who have the highest death rate waiting for a needed organ transplant. Maximizing recovery of organs from the existing donor pool is imperative, and the option of donation should be preserved for all families facing end-of-life issues with their child [6].

Challenges to recovery of organs from pediatric donors include size and weight constraints and technical challenges of transplantation in smaller children. In addition, a family's decision about organ donation can be influenced by individual factors, cultural beliefs, resistance to organ donation, and issues related to authorization or consent including inappropriate timing of donation conversations and confusion regarding death of their child. When approached in a sensitive manner, most families report that organ donation is a "positive experience" [28,31,57,58]. Medical staff perceptions and misunderstanding about organ donation, missed opportunities for donation (including medical examiner denials in cases of homicide), and inadequate donor management continue to result in loss of viable organs for transplantation [6]. Adverse publicity associated with reports of unauthorized or inappropriate use of organs may also contribute to public mistrust resulting in denial of authorization for donation [59].

The majority of organs recovered for transplantation are from donation after neurologic determination of death (DNDD), also referred to as "brain-dead" or "standard criteria donors" [55,60]. The donor pool of DNDD has remained stable and has not grown sufficiently to supply the needed number of organs to transplant all patients on the waiting list. This supply and demand issue exists for several reasons. The absolute number of pediatric deceased organ donors has declined in some jurisdictions, reflecting reduced pediatric mortality rates [61]. Pediatric morbidity and mortality has been reduced from improved medical therapies; eradication of life-threatening diseases, including use of antibiotic therapies and more effective immunizations; and use and refinement of passenger safety-restraint systems, helmets, and other safety measures. Additionally, care provided by specialists trained in pediatric intensive care has significantly improved chances for survival of children with life-threatening disease [62]. Nonetheless, there has been a corresponding increase in the volume of pediatric kidney and heart transplants, reflecting better use of existing donors.

The global coronavirus disease 2019 (COVID-19) pandemic in 2020 has created challenges with organ recovery and restricting transplantation surgery [63]. This descriptive study demonstrated a decline in the pediatric heart transplant volume in early 2020, followed by an increase in the later part of the year. A similar trend was also noted in another study [64]. In the United States, deceased pediatric donors in 2020 were slightly less than in 2019. DCD donation was not affected, although the total number of pediatric transplants were decreased, partly because of restricted living donor transplants during the height of the pandemic that limited elective surgeries [55].

During the pandemic, deceased-donor kidney transplantation was reserved for lifesaving indications in patients in whom dialysis was not possible or when perfect match was present without donor-specific antibodies. Transplantation of heart, liver, and lungs was continued for very sick recipients whose survival without transplantation was expected to be fewer than six months [65].

Outcomes for solid organ transplants during the COVID-19 pandemic are discussed separately. (See "COVID-19: Issues related to solid organ transplantation", section on 'Active COVID-19 in solid organ transplant recipients'.)

STRATEGIES FOR INCREASING ORGAN AVAILABILITY — As the gap between the number of patients waiting for a transplant and the number of available organs continues to grow, a variety of strategies have been used to expand the donor pool, including organizational and educational initiatives and use of nonstandard criteria donors. In the United States, the Organ Donation Breakthrough Collaborative initiated in 2003 significantly increased rates of organ donation [66]. These initiatives have resulted in more organs being recovered and transplanted in children over the past 15 years, with a significant decrease in children dying while awaiting an organ [67]. These statistics do not include other children who are removed from the waiting list because their condition deteriorates and they become too sick to transplant [55].

Organizational and educational initiatives — Important components to enhance education and organizational awareness about organ donation include placing hospital-based organ procurement coordinators within active donor hospitals, encouragement of early involvement of the organ procurement organization (OPO) in the donation process, and collaboration with intensive care specialists. Collaboration between the OPO and pediatric intensivists is particularly crucial for successful pediatric donation to occur [31,68].

In the United States, donor registries have been established, which allow healthy individuals to express their intent to donate their organs after death. Authorization for donation in children must be obtained from parents or legal guardian. Ongoing education about donation with families and loved ones is essential, so that a decision is made before a tragic event, which can create more stress when a family is faced with making decisions about end-of-life care and donation [28]. Information about donation can be introduced during well-child visits, with anticipatory guidance for the adolescent [9].

Donation after circulatory death — A large proportion of the increase in donors and organs recovered is due to donation after circulatory death (DCD) (see 'Donation after circulatory death' above). While most donated organs still come from donation after neurologic determination of death (DNDD), the use of organs from DCD donors has substantially increased the supply of organs available for pediatric and adult recipients [67,69-72]. A consensus agreement clarifies the Maastricht definitions and terminology regarding DCD donation and recommends organ-specific guidelines for kidney, pancreas, liver, and lung transplantation [73].

Graft survival of DCD organs is similar to that of organs recovered from DNDD donors [56,66,74-76]. The ethics of transplantation of organs from DCD donors has been extensively reviewed and supported by many medical societies [5,9,71,77-79]. Most children's hospitals in the United States have developed DCD policies, but considerable variation exists among these policies regarding procedures and personnel declaring death [80]. Canada has successfully established DCD guidelines specifically for the pediatric population [81]. Although few organs are recovered from DCD donors at any one institution, the total number from all children's hospitals has substantially increased the number of organs available for transplantation.

DCD requires close collaboration with the OPO to determine donor suitability, which includes estimated time to circulatory arrest and recovery of organs (warm ischemic time). Often, withdrawal of life-sustaining medical therapies is performed in the operating room or in the perioperative area to minimize organ ischemic time. It is important to recognize that the timing of circulatory death following withdrawal of medical therapies for DCD can be very unpredictable [69]. OPOs utilize tools to predict whether a potential donor will arrest within the required time period for organs to be recovered [82-85]. Families should be made aware of the possibility that donation may not be possible if circulatory arrest does not occur within a specified time period. Specific provisions should be established to provide palliative care if the patient does not expire within the specified time period for organ recovery [7].

Neonatal donation — Neonatal donation is another promising area of growth that may increase the number of organs available for transplantation [86,87]. Historically, there were concerns about establishing "brain death" in the neonate. However, one study suggested that brain death could be determined based on the clinical evaluation [88], and the revised pediatric brain death guidelines in the United States indicate that brain death can be determined in infants 37 weeks estimated gestational age and older [4]. Infants younger than 37 weeks gestation were excluded since no experience to determine brain death in this age group exists. Cerebral edema or intracranial bleeding can lead to severe neurologic injury in the newborn. Brain death may not occur, because of altered intracranial pressure dynamics with open fontanels and non-fused sutures. Withdrawal of life-sustaining medical therapies is the more predominant mode of death in all intensive care units including neonatal intensive care units.

Organ recovery from neonatal DCD donors to increase the pool of organs for transplantation is increasing. One study observed that 8 percent of neonatal intensive care unit deaths were potentially appropriate for DCD organ donation [86]. Another study also concluded that recovery from neonatal DCD donors are an important source of transplantable organs [89]. En bloc kidney recovery from small pediatric donors is being increasingly attempted with good success (see 'Kidneys' above), and the possibility of en bloc kidney transplantation from neonatal donors is ongoing [90]. Procurement of other organs has been more contentious [91]. Hearts recovered from neonatal DCD donors have been transplanted with good success [74,81,86,92]. Liver cells are being recovered from DCD donors and are being used in clinical trials for liver cell therapy for congenital metabolic disorders of the liver in children [93,94]. Other possible candidates for DCD donation include anencephalic infants [95-97].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Management of potential deceased organ donors".)


Importance of soliciting organ donation – Organ transplantation is the treatment of choice for end-stage organ failure in carefully selected individuals, but many candidates die while waiting for a needed organ because of the increasing gap between the numbers of donors and recipients. This is particularly true for children, for whom size and weight constraints place additional burdens on finding suitable organs for transplantation. (See 'Inadequate supply of organs for transplant' above.)

Terminology and types of organ donors – Most organs used for transplantation continue to come from donation after neurologic determination of death (DNDD), also known as "standard criteria donors." However, more organs are being recovered from donors who have died after meeting criteria for donation after circulatory death (DCD). Neonatal donation is another area of growth that is providing more needed organs for children. (See 'Terminology' above and 'Donation after circulatory death' above and 'Neonatal donation' above.)

Timing and initial outreach – Early identification and management of the potential donor increases the likelihood of successful recovery of organs for transplantation. Ideally, the process requires a specialized team led by pediatric intensivists, in close consultation with the local organ procurement organization (OPO) and transplant clinicians and surgeons. The option of organ donation should be preserved for all children facing end-of-life issues. (See 'Donor identification and selection' above.)

Family communication

Organ donation is an important part of end-of-life care. Families of all potential donors should be given the opportunity of organ donation. Donation is a decision made by the family, not by the medical team. The critical care team should provide support for the grieving family and communicate clear messages about the finality of neurologic death, using sensitivity and simple terms. Assistance from palliative care clinicians can provide another valuable resource during end-of-life care.

The opportunity of organ donation should ideally be addressed in a separate discussion from withdrawal of life-sustaining medical therapies, unless the parents or family members initiate a conversation regarding donation prior to determination of death. Early involvement of the OPO and transplant coordinators can facilitate effective communication and family support. (See 'Family communication' above.)

Screening tests for donor suitability – Laboratory evaluation of the potential donor is performed to determine tissue type and basic donor serology, assess organ function, and identify any underlying infection or contraindications to donation (table 2). No assumptions about donor suitability should be made until discussions with the OPO have occurred. Pediatric donors are subject to additional organ-specific size considerations. (See 'Screening donors' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Shaun Wilson, DCH, MRCPCH, who contributed to an earlier version of this topic review.

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