**Abstract**

Normothermic regional perfusion (NRP) is used to restore the flow of oxygenated blood following cardiac arrest and reverse warm ischemic injury in donation after circulatory death (DCD) organ transplantation. The use of NRP in this setting has typically been limited to the abdominal cavity, though its use has recently been expanded to chest to help recover DCD hearts, as well. This chapter evaluates the principles behind the use of NRP in DCD organ transplantation as well as not only technical but also ethical and legal aspects associated with its application and the clinical results that have been achieved to date when it has been used to recover various solid organs through the DCD process.

**Keywords:** controlled donation after circulatory death, kidney transplantation, liver transplantation, uncontrolled donation after circulatory death, warm ischemia

## **1. Introduction**

Donation after circulatory death (DCD) donors, which are declared dead following cardiorespiratory arrest, are an increasingly more common source of organs for transplantation. They may be classified among four categories depending on events and conditions surrounding arrest: category I, dead on arrival (no attempt at resuscitation); category II, sudden cardiac arrest followed by unsuccessful resuscitation; category III, arrest following intentional withdrawal of life support in ventilated patient not meeting brain death criteria; and category IV, cardiac arrest while brain dead. Categories 1, 2 and 4 are classified as uncontrolled DCD (uDCD) and category 3 as controlled DCD (cDCD) [1]. In practice, category III cDCD and, to a lesser extent, category II uDCD donors comprise essentially all DCD donors that are used for transplantation globally. The period of warm ischemia surrounding arrest, however, provokes organ injury, and DCD in general yields fewer organs per donor and ones of inferior quality when compared with donation after brain death (DBD) [2]. For this reason, there has been increasing interest in forgoing rapid cold preservation and recovery following the declaration of death (still the "gold standard" for DCD organ recovery in most transplant centers) and instead using normothermic regional perfusion (NRP) to temporarily restore oxygenated blood flow the abdominal and more recently thoracic organs prior to recovery.

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