Despite the technical and logistical hurdles that must be overcome with the reintroduction of non-heartbeating donor kidneys, the potential of these organs represents the only near-term solution for effectively alleviating the growing disparity between demand and supply. This review provides an argumentative overview of the history of cadaveric kidney transplantation. During the early years of transplantation retrieval of kidneys from non-heartbeating donors necessitated a prolonged period of warm ischemic exposure, with a corresponding minimal ex vivo period since organ preservation was in its infancy. Today we have the inverse situation where warm ischemic times are quite limited and hypothermic preservation times average 24 h because organs are shipped to remote centers due to mandated organ sharing algorithms. The recent experience with the reintroduction of non-heartbeating donors has necessitated combining the worst aspects from both eras: substantial warm ischemia with prolonged hypothermic preservation.
Nevertheless, recent results from several transplant groups poignantly highlight the potential of this approach in expanding the organ donor pool.