Is Warm Ischemic Time no Longer an Absolute Cutoff in Organ Donation After Circulatory Determination of Death? The Italian Experience of Prolonged “No-touch” Period

BACKGROUND: Skepticism and concern regarding the 20-min no-touch period have limited and postponed the donation after circulatory death (DCD) in Italy. However, both controlled (cDCD) and uncontrolled (uDCD) programs have been successfully developed, using mandatory in situ (normothermic regional perfusion) and, in most cases, ex situ perfusion (mechanical perfusion). AIMS: (1) To compare Italian DCD and DBD results at 1-3 y; (2) to analyze organ outcomes and factors associated with cDCD kidney and liver discard. METHODS: Data on all deceased donors and transplants (2017-2021) were prospectively collected in the national registry. Kaplan-Meier graft survival estimates and multivariable logistic regressions were performed. RESULTS: Among 12 663 DBD, 262c DCD, and 220u DCD potential donors (PODs), 73.4%, 82.1%, and 40.3% became utilized donors, respectively. Mean functional warm ischemic time (FWIT) was 46 ± 15 in cDCD-utilized donors and exceeded 60 min in 12.6%; 592 DCD organs were transplanted; 1-y graft survival in cDCD was 93.1% for kidneys and 91.9% for livers, with the same mean donor functional warm ischemia time (DFWIT) duration (44 versus 45 and 45 versus 45 min) for graft survival or failure. Donor age >60, obesity, prior-to-death ECMO, and DFWIT >45 min were independently associated with increased likelihood of kidney and liver discard. CONCLUSIONS: The Italian experience proves that prolonged DFWIT should no longer be considered as an insurmountable barrier in DCD donation. Kidney and liver transplant outcomes from cDCD donors were comparable to DBD. But only gaining organ swift resuscitation and function assessment, with the routine use of in situ and ex situ perfusion, may overcome absolute donor warm ischemic time as an arbitrary cutoff for suitability and reduce inappropriate discard for DCD organs.