Organ procurement is a surgical procedure that removes organs or tissues for reuse, typically for organ transplantation.
Organ procurement is a highly regulated, multidisciplinary process that requires adherence to stringent clinical, ethical, and legal standards.
For deceased donors, rapid identification, rigorous death determination, and aggressive donor optimization are essential to maximize organ yield and quality.
Most countries require that the donor be legally dead for consideration of organ transplantation (e.g. cardiac death or brain death).
For some organs, a living donor can be the source of the organ,living donors can donate one kidney or part of their liver to a well-matched recipient.
Organs cannot be procured after the heart has stopped beating for a long time.
Thus, donation after brain death is generally preferred because the organs are still receiving blood from the donor’s heart until minutes before being removed from the body and placed on ice.
Guidelines require that three clinical criteria be met in order to establish brain death: coma with a known cause, absence of brain stem reflexes, and apnea.
Donation after cardiac death (DCD) involves surgeons taking organs within minutes of the cessation of respirators and other forms of life support for patients who still have at least some brain activity.
This occurs in situations where, based on the patient’s advanced directive or the family’s wishes, the patient is going to be withdrawn from life support.
Once life support has been withdrawn, there is a 2-5 minute waiting period to ensure that the potential donor’s heart does not start beating again spontaneously.
After this waiting period, the organ procurement surgery begins as quickly as possible to minimize time that the organs are not being perfused with blood.
DCD had been the norm for organ donors until ‘brain death’ became a legal definition in the United States in 1981, and since then, most donors have been brain-dead.
If consent is obtained from the potential donor or the potential donor’s survivors, the next step is to perform a match between the source (donor) and the target (recipient) to reduce rejection of the organ by the recipient’s immune system.
In the United States, the match between human donors and recipients is coordinated by groups like United Network for Organ Sharing.
If the heart stopped beating for too long then the organ becomes unusable and cannot be used for transplant.
Organ procurement is a complex process encompassing the identification and evaluation of potential donors, optimization of donor physiology, surgical retrieval of organs, and the ethical, legal, and psychosocial frameworks that ensure safety, equity, and public trust.
Organ procurement from deceased donors follows two principal pathways: donation after brain death (DBD) and donation after circulatory death (DCD).
DBD remains the predominant source of deceased donor organs globally.
DCD is increasingly utilized to expand the donor pool, particularly in cases where brain death criteria are not met but withdrawal of life-sustaining therapy is planned. DCD is classified as controlled (cDCD) or uncontrolled (uDCD).
Controlled DCD occurs after planned withdrawal of life support, with organ recovery initiated following declaration of death based on circulatory criteria.
Most protocols require a 5-minute observation period of apnea and pulselessness, confirmed by arterial monitoring, before organ recovery begins, although this interval may range from 2 to 10 minutes.
Living donation is primarily utilized for kidney and liver transplantation.
Living donors must be thoroughly evaluated for perioperative and long-term risks, with particular attention to cardiovascular, renal, and psychosocial health.
Cardiac stress testing is recommended for donors over 40 years of age or those with risk factors for coronary artery disease.
For deceased donors, aggressive hemodynamic, respiratory, endocrine, and metabolic support is essential to maximize organ yield and quality.
Hemodynamic management targets a mean arterial pressure (MAP) of at least 65–70 mm Hg, using fluid resuscitation and vasopressors as needed.
Lung-protective ventilation at tidal volumes 6–8 mL/kg predicted body weight, appropriate PEEP) is critical for lung and heart procurement.
Endocrine management includes prompt treatment of diabetes insipidus with desmopressin or vasopressin, glucocorticoid therapy and, in select cases, thyroid hormone replacement.
Normothermia (core temperature >35°C) is recommended, and infections should be aggressively treated.
For living donors, perioperative management focuses on minimizing surgical risk, and providing psychosocial support.
The standard approach for deceased donor procurement involves a midline laparotomy for abdominal organs and median sternotomy for thoracic organs.
After systemic heparinization, the aorta is cannulated for cold perfusion with preservation solution, and the inferior vena cava is vented to facilitate rapid cooling.
Organs are then removed individually or en bloc, depending on the procurement plan.
En bloc procurement, allows for the removal of all abdominal organs together, which are then separated.
This approach minimizes warm ischemia, reduces the risk of iatrogenic injury, and is particularly advantageous when the pancreas and intestine are included.
Machine perfusion technologies, including hypothermic and normothermic perfusion, have revolutionized organ preservation.
Normothermic regional perfusion (NRP) in DCD donors restores circulation to abdominal organs after death, improving viability and outcomes for the liver and other organs.
The most widely used technique involves machine perfusion of the organ at either hypothermic (4-10 °C) or normothermic (37 °C) temperatures.
Hypothermic perfusion of kidneys is a relatively widespread practice.
For the heart normothermic preservation has been used in which the heart is provided with warm oxygenated blood and so continues to beat ex-vivo during its preservation.
This technique has also been applied to lungs.
The use of NRP in DCD procurement achieves an organ yield comparable to DBD of 3.71 vs. 3.70 organs per donor.
Cold ischemia time is a critical determinant of graft function, with the heart and lungs requiring the shortest times.
The use of cardiopulmonary bypass and profound hypothermic circulatory arrest can optimize organ recovery from hemodynamically unstable donors, increasing the number available for transplantation.
Cardiac allograft from deceased donors after circulatory death typically recovered with direct procurement and perfusion with normothermic regional perfusion: both techniques yield acceptable outcomes.
The direct procurement and perfusion technique is associated with increased risk of primary graft dysfunction.
The direct procurement and perfusion does not provide resuscitation for the abdominal organs.
Normothermic regional perfusion is more easily adopted and increases organ yield, and has superior outcomes in heart and abdominal organ transplantation is compared with direct procurement and perfusion.
Normothermic regional perfusion is controversial and is prohibited in many hospitals and organ procurement organizations because . thoracoabdominal normothermic regional perfusion reanimates the heart in the donor, and also involves clamping of aortic vessels to prevent brain perfusion which creates the possibility of brain brain perfusion by way of collaterals.
Living kidney donation is associated with a perioperative mortality of less than 0.03%, major complications in less than 3% of cases, and minor complications in 10–20%.
Living kidney donation long-term risk of end-stage renal disease (ESRD) is less than 1% at 15 years for most donors, with higher risks in certain subgroups such as young Black men.
Living liver donation carries higher perioperative risk, including biliary leaks and hepatic insufficiency, but most donors recover normal function.
Psychosocial outcomes for living donors are generally favorable.
For deceased donors, procurement-related injuries occur in approximately 23% of abdominal organs, with a discard rate of 4%.
Kidney recipients from DCD donors have higher rates of delayed graft function (44.7% vs. 22.0% for DBD), but long-term patient and graft survival rates are comparable between DCD and DBD recipients in experienced centers.
Liver recipients from DCD donors have higher rates of biliary complications and retransplantation for ischemic cholangiopathy, but overall patient and graft survival can be acceptable with careful selection and management.
Pancreas and lung transplants from DCD donors show similar short-term complication rates to DBD transplants, with no significant differences in surgical complications or rejection rates.
DBD procurement remains the most cost-effective per organ, with a mean cost per organ of $9,478, compared to $15,179 for DCD organs.
The mean organ yield per donor is 3.54 for DBD and 2.21 for DCD.
Expanding donor criteria and utilizing non-ideal donors increases per-organ costs but remains cost-effective compared to alternatives such as dialysis.
Allocation of organs is managed by national or regional networks, such as the Organ Procurement and Transplantation Network (OPTN) in the United States, using transparent scoring systems that consider medical urgency, compatibility, and geographic location.
The psychosocial impacts of organ procurement are profound for donor families, recipients, and for healthcare teams.
Families of deceased donors experience intense emotional distress, ambiguity, and a complex grieving.
Recipients face challenges related to psychological integration, gratitude, and adherence, with depression and nonadherence associated with poorer outcomes.
Internationally, organ procurement practices, outcomes, and regulatory frameworks vary widely, shaped by differences in healthcare infrastructure, legal systems, and cultural attitudes.
High-income countries report higher organ utilization rates and better recipient outcomes.
Xenotransplantation, particularly using genetically engineered pig organs, is approaching clinical viability: pig-to-human kidney and heart transplantation demonstrating survival of 40 to 60 days in living recipients.
Gene editing technologies such as CRISPR have enabled the targeted removal of key xenoantigens, reducing the risk of hyperacute rejection.
Machine perfusion and cryopreservation technics are transforming organ preservation, enabling dynamic assessment, reconditioning, and potentially long-term storage of donor organs.
Living donor protocols demand comprehensive medical and psychosocial evaluation, with perioperative management tailored to minimize risk and support recovery.
Surgical innovations, including en bloc procurement and machine perfusion, have improved outcomes and expanded the donor pool.
Emerging technologies such as xenotransplantation, bioengineering, and advanced preservation methods hold promise for addressing the persistent shortage of donor organs.
The faster the organ is transplanted into the recipient, the better the outcome.
While the organ is being transported, it is either stored in an icy cold solution to help preserve it or it is connected to a miniature organ perfusion system which pumps an icy solution, sometimes enriched with potassium, through the organ.
This time during transport is called the cold ischemia time.
Heart and lungs should have less than 6 hours between organ procurement and transplantation.
For liver transplants, the cold ischemia time can be up to 24 hours.
For kidney transplants, as the cold ischemia time increases, the risk of delayed function of the kidney increases, and sometimes the kidney function is delayed enough that the recipient requires temporary dialysis until the transplanted kidney begins to function.
WHO:illegal organ trade occurs when organs are removed from the body for the purpose of commercial transactions.
Despite ordinances against organ sales, this practice persists, with studies estimating that anywhere from 5% to 42% of transplanted organs are illicitly purchased.
About 20 patients die each day waiting for an organ on the transplant list.
The UNOS computer matching system finds a match for the organ based on a number of factors including blood type and other immune factors, size of the organ, medical urgency of the recipient, distance between donor and recipient, and time the recipient has been waiting on the waitlist.