CLINICAL AND TRANSLATIONAL RESEARCH

Is the Increase in DCD Organ Donors in the UnitedKingdom Contributing to a Decline in DBD Donors?

Dominic M. Summers,1,3 Claire Counter,2 Rachel J. Johnson,2 Paul G. Murphy,2 James M. Neuberger,2

and J. Andrew Bradley1

Introduction. Organ donation after brain death (DBD) has declined in the United Kingdom, whereas donation aftercardiac death (DCD) has increased markedly. We sought to understand the reasons for the decline in DBD anddetermine whether the increase in DCD was a major factor.Methods. The UK Transplant Registry was analyzed to determine trends in organ donation. Data from the “PotentialDonor Audit,” an audit of all patients younger than 76 years who died in noncardiothoracic UK intensive care units, wasanalyzed to identify trends in clinical demographics and management and to determine whether potential donors(DBD and DCD) were identified and appropriate steps were taken to enable organ donation.Results. There were 7589 (12.8 per million of population [pmp]) deceased organ donors in the United Kingdom from1999 to 2009. The total number of deceased donors increased by 16% (to 14.9 pmp), but DBD donors decreased from744 to 612, and the overall increase in donors was due to an 8-fold increase in DCD donors (33 in 1999 to 2000, 288 in2008 to 2009). Analysis of the Potential Donor Audit over the 5-year period 2004 to 2005 to 2008 to 2009 showed thatthe number of patients dying in intensive care units who were possibly brain stem dead (comatose, apparently apnoeicwith unresponsive pupils) decreased from 1929 in 2004 to 2005 to 1495 in 2008 to 2009 (22.5% reduction). Theproportion of potential DBD donors who became donors increased from 45% to 51%.Conclusion. There is no evidence that the increase in DCD donors has contributed directly to the decline in DBD,which reflects a decrease in the number of patients with brain death.

Keywords: Organ donation, Donation after cardiac death, Donation after brain death, Donor trends.

(Transplantation 2010;90: 1506–1510)

Organ donation after cardiac death (DCD) is increasingmarkedly in the United Kingdom, United States, and

some parts of Europe, and controlled DCD donors now rep-resent around one third of all deceased donors in the UnitedKingdom (1–3). The outcome after transplantation with or-gans from DCD donors is generally good, and such donorsundoubtedly represent an important addition to the organdonor pool (4 –7). However, recovery of organs from DCDdonors is particularly demanding in terms of logistics and

resources, particularly because not all potential DCD donorsproceed to organ donation and for those who do, the timingof donation is both variable and unpredictable (8, 9). More-over, DCD donors provide fewer transplantable organs perdonor than donors with brain death (donation after braindeath [DBD]) (10). DCD donors are not currently used toprovide hearts for transplantation, and there are concernsthat in some cases, other organs from DCD donors may be atrisk of additional complications (5, 6).

Although there has been an increase in the number ofDCD donors in the United Kingdom, the number of DBDdonors has gradually decreased, and there is concern, basedmainly on anecdotal evidence, that many donors who mightpreviously have become DBD donors are proceeding insteadto DCD. The suggestion that the availability of DCD mayhave an adverse impact on DBD is consistent with data fromThe Netherlands where the successful introduction of alarge program of DCD has corresponded with a decrease inDBD (1).

We have sought to clarify the likely extent to which thegradual decline in DBD within the United Kingdom over thepast decade may be attributed to the increase in DCD. Inaddition to national data on deceased donor demographics,we have analyzed information arising from the UK audit of alldeaths in intensive care units (ICUs) to identify potential de-ceased donors.

This work was supported by a Ph.D. grant from National Health ServiceBlood and Transplant (D.M.S.) and Cambridge National Institute forHealth Research Biomedical Research Centre (J.A.B. and D.M.S.).

The authors declare no conflict of interest.1 Department of Surgery, University of Cambridge, Addenbrooke’s Hospital,

Cambridge, United Kingdom.2 Organ Donation and Transplantation, NHS Blood and Transplant, Bristol,

United Kingdom.3 Address correspondence to: Dominic M. Summers, M.B., B.Chir., Depart-

ment of Surgery, Box 202, Addenbrooke’s Hospital, Hills Road, Cam-bridge CB2 0QQ, United Kingdom.

E-mail: Dms39@cam.ac.ukAll authors contributed to study design, data analysis, and interpretation and

preparation of the manuscript.Received 2 August 2010.Accepted 30 September 2010.Copyright © 2010 by Lippincott Williams & WilkinsISSN 0041-1337/10/9012-1506DOI: 10.1097/TP.0b013e3182007b33

1506 | www.transplantjournal.com Transplantation • Volume 90, Number 12, December 27, 2010

RESULTS

Deceased Donor TrendsThe trends in deceased organ donation in the United

Kingdom over the past decade, obtained from analysis of datafrom the UK Transplant Registry held by National HealthService Blood and Transplant, are shown in Figure 1. Figure1(A) depicts the number of deceased organ donors in theUnited Kingdom and shows that the number of DBD donorshas gradually declined over the past decade from 744 (12.3pmp) in the 12 months April 1, 1999 to March 31, 2000 to 612(10.1 pmp) in the corresponding period of 2008 to 2009. Incontrast, the number of DCD organ donors has increasedmarkedly during the same decade from 33 (0.5 pmp) in 1999to 2000 to 288 (4.8 pmp) in 2008 to 2009. The causes of donordeath are shown in Figure 1(B), and it can be seen that forboth DBD and DCD donors, stroke remains the major causeof death, accounting for 43.4% of DCD deaths and 67.4% ofDBD deaths in 2008 to 2009. There was a decline in the pro-portion of deaths attributable to trauma in DBD donors dur-ing the 10-year period from more than 22% in 1999 to 2000 to11% 2008 to 2009, whereas trauma deaths still accounted formore than 15% deaths in DCD donors in 2008 to 2009. Themean number of organs retrieved for transplantation from anindividual donor provides a helpful indicator of organ avail-ability and utilization over time according to donor type(DBD and DCD). The number of organs retrieved per donorincreased gradually for both DBD and DCD donors duringthe 10-year study period (Fig. 1C), although the mean num-

ber of organs donated per DCD donor remained less than thatper DBD donor (mean 2.7 organs/donor vs. 4.0 organs/donorrespectively in 2008 –2009). All deceased donors were furthercategorized according to the American classification for ex-tended criteria kidney donors (11). During the 10-year studyperiod, the percentage of DBD donors categorized as ex-tended criteria donors remained relatively stable at approxi-mately 25%, whereas donation from extended criteria DCDdonors increased markedly from less than 5% in 1999 to 2001to 28% in 2008 to 2009, which marginally exceeded that forDBD donors (Fig. 1D).

Audit of Potential Deceased DonorsThe UK wide audit of potential deceased organ donors

was initiated in April 2003 to determine the true potential forsolid-organ donation and identify shortcomings of the de-ceased organ donation system (12). It has undergone severalrevisions since its inception, but during the study period(April 1, 2004 to March 31, 2009), it aimed to audit compre-hensively all deaths occurring in patients younger than 76years in ICU (excluding those in cardiothoracic ICU) anddetermine whether potential donors were identified andappropriate steps were taken to enable them to proceed toorgan donation. During the 5-year period (April 2004 toMarch 2009), a total of 78,338 deaths were included in theaudit (Fig. 2). The annual number of deaths reported re-mained relatively constant during the audit period (mean15,668 deaths/year).

FIGURE 1. Donor trends April 1, 1999 to March 31, 2009. (A) Total number of deceased organ donors. (B) Donor cause ofdeath for donation after cardiac death (DCD) and donation after brain death (DBD). (C) Mean number of solid organsdonated per donor. (D) Extended criteria donors.

© 2010 Lippincott Williams & Wilkins 1507Summers et al.

A total of 8345 (10.7%) of patients who died in ICUwere found to be potential candidates for brain stem deathtesting, on the basis that they were deeply comatose (GlasgowComa Score 3), apparently apnoeic on a mechanical ventila-tor and had unreactive pupils. During the 5-year audit period,there was a gradual decline (of 22.5%) in the number of po-tentially brain-dead patients identified from 1929 in 2004 to2005 to 1495 in 2008 to 2009 (Fig. 3A).

The majority (6323 or 75.8%) of potentially brain-deadpatients were formally tested for brain stem death, and ofthese, 6160 (97.4%) were found to fulfill the diagnostic crite-ria for brain death. It was notable that the percentage of po-tential brain-dead patients who were tested for brain stemdeath increased during the audit period from 72.1% in 2004to 2005 to 77.9% in 2008 to 2009 (Fig. 3A).

Of the 6160 patients who were confirmed brain stemdead, 39 patients (0.4%) had absolute medical contraindica-tions to organ donation (HIV or known or suspected variantCreutzfeldt-Jakob disease). For the purposes of the audit, theremaining 6121 patients were defined as the potential pool ofDBD organ donors. Approximately half (2980 or 48.5%) ofthese patients subsequently became organ donors with theremainder not progressing to organ donation, predomi-

nantly because of additional medical contraindications to do-nation or lack of consent to donation from the donor family.

The pathway for patients who died in ICU becomingDCD donors was more varied than that for DBD organ do-nors. During the 5-year audit period, the majority (85%) ofthe 667 eventual DCD donors reported through the PotentialDonor Audit (PDA) were from the group of patients who didnot fulfill the preconditions and exclusion criteria for the di-agnosis of brain stem death and who therefore died after thewithdrawal of cardiorespiratory support. However, 78 (12%)DCD donors were patients who could have been, but werenot, tested for brain death, and 23 (3%) were tested but foundnot to fulfill the criteria for brain death (Fig. 2). The propor-tion of DCD donors from these two groups of patients de-clined in the last 4 years of the audit from 20% in 2005 to 2006to 13% in 2008 to 2009. There were 5582 potential DCD do-nors, after excluding those patients with any of the following:absolute medical contraindications (HIV or known or sus-pected variant Creutzfeldt-Jakob disease) to organ donation,“relative medical contraindications” to donation, patientsover locally agreed age limits, patients from centers that didnot have established DCD donor programs, and patients forwhom supportive treatment was not withdrawn. Of the po-

FIGURE 2. The Potential Donor Audit. A prospective au-dit of all deaths of patients younger than 76 years in noncar-diothoracic intensive care units from April 1, 2004 to March31, 2009.

FIGURE 3. Potential Donor Audit trends April 1, 2004 toMarch 31, 2009. (A) Number of potential donors suitable forbrainstem testing and number of potential donors actuallytested. (B) Conversion rates for both donation after cardiacdeath (DCD) and donation after brain death (DBD) donors.

1508 | www.transplantjournal.com Transplantation • Volume 90, Number 12, December 27, 2010

tential DCD donors, a total of 667 (11.9%) became organdonors during the 5-year audit period (Fig. 2). Of the actualDCD donors, a total of 56 (8.4%) had previously been diag-nosed with brain stem death but became DCD donors be-cause of a lack of consent for DBD donation or because theydeveloped hemodynamic instability. However, the conver-sion rate for those identified as potential DCD donors tothose who became actual donors increased markedly duringthe audit period from 5.1% in 2004 to 2005 to 16.1% in 2008to 2009 (Fig. 3B).

DISCUSSIONDCD has become an increasingly important source of

donor organs in several countries, including the United King-dom, but concern has been expressed that DCD donor pro-grams may contribute to a failure to realize the full potentialfor DBD donation (13). This study is one of the first to at-tempt to examine this issue, and our findings suggest that thatthe large majority of DCD donors were not potential DBDdonors but instead represent an additional source of deceaseddonor organs.

Analysis of the UK Transplant Registry confirms thatthe increase in DCD donor numbers has coincided with amodest decrease in the number of DBD donors, as also ob-served in The Netherlands (1), although the overall numberof deceased donors (i.e., DBD and DCD donors) has in-creased. However, the results from the present audit of deathsin ICU suggest that the decline in DBD organ donors corre-lates closely with a decline in the number of patients whofulfill the criteria for brain stem death testing (apnoea, coma,and fixed dilated pupils). Moreover, the number of actualDBD organ donors, as a proportion of all potential DBD do-nors (i.e., those patients who fulfilled the criteria for brainstem death testing), increased progressively during the 5-yearperiod of the UK wide audit of all potential donors, indicatingthat better use has been made of a diminishing potential do-nor pool. It is disappointing that around one fifth of thosepatients with possible brain stem death did not have brainstem death tests performed. The reasons for this were notrecorded during the audit period but could include donorcardiovascular instability and lack of consent from relatives.More clarity on this will be forthcoming because the UK PDAhas recently been modified to capture the reasons why thosewith possible brain stem death are not tested.

The reasons for the gradual decline in the number ofDBD donors in the United Kingdom are not fully understoodbut the decrease corresponds with a marked reduction intrauma deaths over the same time period due, at least in part,to improved road safety (14). There have also been majorchanges to neurosurgical practice, notably increasing use ofdecompressive craniectomy for malignant cerebral edemacaused by trauma or ischemia and early interventional radi-ology for the management of ruptured intracranial aneu-rysms, both of which may prevent the development of brainstem death (15, 16).

Although only a minority of DCD donors in the UnitedKingdom are likely to be brain stem dead at the time of treat-ment withdrawal, a more fundamental question, and one thatis much more difficult to answer, is how many potential DCDdonors would have eventually become brain stem dead had

treatment withdrawal not taken place. This is not a questionthat can be easily addressed, although the very striking inter-national variation in the number of DBD donors—variationthat cannot be explained simply on the basis of family consentrates—suggests that the answer lies either in variations in theepidemiology of acute brain injury, the effectiveness of itstreatment or the management strategies when the potentialfor recovery has been lost. For instance, in 2009, Spain re-ported a total of 32 DBD donors pmp compared with a totalof only 10.5 pmp in the United Kingdom (2, 17). These dif-ferences cannot be attributed to variations in family consentrates (85% vs. 62%, respectively) and point instead to a realdifference in the incidence of diagnosed brain stem death. It isalso worthy of note that although uncontrolled DCD donorsmake a modest contribution to the total deceased donor poolin Spain (2 donors pmp), there is no controlled DCD pro-gram, suggesting that treatment withdrawal on the groundsof futility—such a prominent feature of critical care practicein the United Kingdom—is relatively uncommon in Spain.This study is unable to provide a definitive answer to thismost important question, because the audit of deaths in ICUis unable to quantify those patients who may have proceededeventually to develop brain stem death had treatment notbeen withdrawn. The duration of ICU stay was not recordedin the PDA but may have been useful because changing trendsof ICU stay for DCD and DBD potential donors might haveindicated changes in donor management during the studyperiod. Current practice in the United Kingdom (and in mostinternational transplant communities) is based on the funda-mental principle that decision making over the withholdingor withdrawal of treatment should be determined by what isconsidered to be in a patient’s overall benefit. Although guid-ance recently issued from the Department of Health inEngland describes the circumstances in which delaying treat-ment withdrawal to facilitate DCD can be considered to belawful, there is currently no parallel legal framework that cov-ers potential DBD donors (18, 19). Indeed, any suggestionthat treatments should be continued primarily to promotethe potential for DBD are likely to be met with considerableprofessional caution and resistance (20).

The increase in the number of DCD donors in theUnited Kingdom looks set to continue. The ongoing donoraudit reported here probably underestimates substantiallythe true number of potential DCD donors because the criteriadescribed on the audit form for excluding potential DCDdonors from further consideration is, unlike the DBD auditform, only loosely defined. For example, the absence of a localDCD donor program and a broad range of medical contrain-dications were allowed as exclusion criteria on the audit form(although this has been improved in the new PDA data col-lection introduced from October 2009), which undoubtedlyled to potential DCD donors being overlooked inappropri-ately. It was also notable that during the past decade, as thenumber of DCD donors increased, so too did the proportion ofextended criteria DCD donors (identified on the basis of age,cause of death, and terminal serum creatinine), presumably in-dicating an increased willingness by transplant clinicians to ac-cept DCD donor organs for transplantation on the basis thatthey expected transplant outcomes to be satisfactory.

In conclusion, the findings reported here do not sup-port the suggestion that significant numbers of DCD donors

© 2010 Lippincott Williams & Wilkins 1509Summers et al.

are, or are likely to be, brain stem dead at the time of treat-ment withdrawal, although it is acknowledged that even thesmall numbers that have been identified would make an im-portant contribution to heart transplant programs in theUnited Kingdom. DCD donation is currently a valuablesource of organs for transplantation, and this study highlightsthe potential for further expansion of DCD donation in theUnited Kingdom. The transplant community should con-tinue to work with colleagues in critical care to ensure that allpatients are given the option of donation as a component ofend of life care.

MATERIALS AND METHODS

PopulationThis study is based on two databases maintained by National Health

Service Blood and Transplant. The first is the UK Transplant Registry towhich all the UK solid-organ transplant centers provide mandatory de-mographic and follow-up data for actual organ donors and recipients.The second, as part of the PDA (12), collects data on all deaths of patientsyounger than 76 years in all of the 341 noncardiothoracic ICUs in 284different UK hospitals.

Deceased Donor TrendsData from the UK Transplant Registry was analyzed between April 1, 1999

and March 31, 2009, to identify trends in donor characteristics. Extendedcriteria donors were defined as those donors who were older than 60 years orwere aged between 50 and 60 years and had two of the following conditions:hypertension, terminal creatinine of more than 132 mmol/mL, or death re-sulting from stroke (11).

The Potential Donor AuditThe PDA (12) collects data in a hierarchical fashion (Fig. 2). Basic demo-

graphic information (nonpatient identifiable) is obtained for all patientsyounger than 76 years who die in a noncardiothoracic ICU, together withdate, time, and cause of death. This is followed by questions concerningwhether brain stem death was a likely diagnosis (i.e., the potential donor wasapnoeic, unconscious and with fixed and dilated pupils) and whether brainstem tests were performed and, if so, their outcome. The potential DBD poolis defined as comprising those patients whose death is confirmed using neu-rologic criteria and who do not have an absolute medical contraindication todonation (at the time of the study these included suspected Creutzfeldt-Jakob disease or infection with HIV). The PDA was interrogated betweenApril 2004 and March 2009 to identify any trends in the rate of brain stemtesting and conversion rates (the proportion of potential donors becomingactual donors).

StatisticsStatistics was performed using SAS version 9.1 (SAS Institute Inc., NC).

ACKNOWLEDGMENTSThe authors thank the help from individual donor coor-

dinators and intensive care clinicians for collecting the data.

REFERENCES1. Cohen B, Smits J, Haase B, et al. Expanding the donor pool to increase

renal transplantation. Nephrol Dial Transplant 2005; 20: 34.2. NHSBT. Transplant Activity in the UK 2008 –2009. In: Transplant

NBa, ed, vol. 2010. Bristol, NHS Blood and Transplant 2009.3. Klein A, Messersmith E, Ratner L, et al. Organ donation and utilization

in the United States, 1999 –2008. Am J Transplant 2010; 10(4 pt 2): 973.4. Summers DM, Johnson RJ, Allen J, et al. Analysis of factors that affect

outcome after transplantation of kidneys donated after cardiac death inthe UK: a cohort study. Lancet 2010; 376: 1303.

5. Reich D, Hong J. Current status of donation after cardiac death livertransplantation. Curr Opin Organ Transplant 2010; 15: 316.

6. Salvalaggio P, Davies D, Fernandez L, et al. Outcomes of pancreastransplantation in the United States using cardiac-death donors. Am JTransplant 2006; 6(5 pt 1): 1059.

7. De Oliveira N, Osaki S, Maloney J, et al. Lung transplantation withdonation after cardiac death donors: Long-term follow-up in a singlecenter. J Thorac Cardiovasc Surg 2010; 139: 1306.

8. Suntharalingam C, Sharples L, Dudley C, et al. Time to cardiac deathafter withdrawal of life-sustaining treatment in potential organ donors.Am J Transplant 2009; 9: 2157.

9. Lewis J, Peltier J, Nelson H, et al. Development of the University ofWisconsin donation After Cardiac Death Evaluation Tool. Prog Trans-plant 2003; 13: 265.

10. Devey L, Wigmore S. Non-heart-beating organ donation. Br J Surg2009; 96: 833.

11. Port F, Bragg-Gresham J, Metzger R, et al. Donor characteristics asso-ciated with reduced graft survival: An approach to expanding the poolof kidney donors. Transplantation 2002; 74: 1281.

12. Barber K, Falvey S, Hamilton C, et al. Potential for organ donation inthe United Kingdom: Audit of intensive care records. BMJ 2006; 332:1124.

13. Bernat J, D’Alessandro A, Port F, et al. Report of a National Conferenceon donation after cardiac death. Am J Transplant 2006; 6: 281.

14. Statistics OfN. Road casualties: Deaths on Great Britain’s roads at alltime low. Norwich, The Stationary Office 2008. In: Transport Do, ed,vol. 2010. 2009.

15. Juttler E, Schwab S, Schmiedek P, et al. Decompressive Surgery for theTreatment of Malignant Infarction of the Middle Cerebral Artery(DESTINY): A randomized, controlled trial. Stroke 2007; 38: 2518.

16. Bederson J, Connolly EJ, Batjer H, et al. Guidelines for the managementof aneurysmal subarachnoid hemorrhage: A statement for healthcareprofessionals from a special writing group of the Stroke Council, Amer-ican Heart Association. Stroke 2009; 40: 994.

17. ONT. Organizacion Nacional de Trasplantes. Newsletter transplant:International figures on donation and transplantation 2008. Council ofEurope 2009, vol. 2010. 2009.

18. Coggon J, Brazier M, Murphy P, et al. Best interests and potential organdonors. BMJ 2008; 336: 1346.

19. Department of Health. Legal issues relevant to non-heartbeating organdonation. 2009.

20. Simpson PJ. A code of practice for the diagnosis and confirmation ofdeath. London, Academy of Royal Medical Colleges 2008.

1510 | www.transplantjournal.com Transplantation • Volume 90, Number 12, December 27, 2010