**4. Activation of inflammatory system**

Aseptic necrosis of brain tissue leads to the release of numerous inflammatory mediators that trigger and support massive local and systemic inflammatory response driven by both the innate and adaptive immune systems. Catecholamine storm and hypotension with hypoperfusion of organs then contribute to the additional activation of immunologic pathways [19].

One of its harmful consequences is the activation of the cytokine system, polypeptide immunomodulatory molecules that participate in both immune responses and act on cell differentiation, proliferation and activity. Several cytokines have been found in brain tissue and cerebrospinal fluid after brain death. These cytokines are then delivered into circulation through a faulty blood–brain barrier, and continue to stimulate peripheral target cells and organs [20].


*DDAVP, 1-deamino-8-D-arginine-vasopressin; PEEP, positive end-expiratory pressure.*

#### **Table 1.**

*Summary of the principles of donor management (adapted from Anwar et al. [7] and McKeown et al. [15]).*
