To the Editor:

We read the study by Chen et al. [1] that reported the current situation of the use of donation after cardiac death (DCD) for kidney transplantation in China. Compared with the donation after brain death (DBD) in European countries, DCD kidneys of their center have similar graft survival, lower primary nonfunction (PNF) rates and delayed graft function (DGF) rates. They shared their experience and demonstrated the feasibility of DCD donation in kidney transplantation.

In China, liver transplantation also faced the continuing organ shortage crisis. Since the Chinese guidelines for donation after cardiac death were promulgated on March 2010, 27 DCD liver transplantations were performed at our institution until December 2012. The characteristics of the donors and recipients were described in Figure 1. Mean warm ischemic time (asystole to in situ cold perfusion) at recovery was 8.84 min, and the mean cold ischemic time was 6.26 h. The rates of symptomatic nonanastomotic biliary strictures (NABS), bile leaks, hepatic artery stenosis (HAS) and primary nonfunction (PNF) was 14.8%, 7.4%, 11.1% and 3.7%, respectively. As reported by previous papers, DCD livers were associated with a significantly increased risk of graft failure and biliary complications and hepatic artery stenosis [2-4]. However, in our 27 DCD cases, NABS occurred in only four cases and bile leakage in two cases. It is because donors in our center were controlled DCD donors (24 were Maastricht IV), and there was no case whose warm ischemic time was more than 30 min, and only one case whose cold ischemic time was more than 10 h as same as Chen et al. [1] reported.


Figure 1. General characteristics of 27 donors and recipients. (A) The mean age of DCD donors was 38.59 years (range, 15–61 years). Tweenty-three donors were male and four were female. The mean warm ischemic time was 8.84 min, with the longest warm ischemic time being 15 min. The etiology of donor death was irreversible trauma in a majority of cases (59.3%). (B) The mean age of the DCD recipients was 46.03 years (range, 28–60 years), and 26 of them were male. The mean model for end-stage liver disease (MELD) score was 18.73 (range, 7–43) and the mean cold ischemic time was 6.26 h. The main etiology of recipients was chronic hepatitis infection (13 HBV infection and 3 HCV infection).

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However, there still need a standard protocol. For instance, the guidelines for DCD program in China suggested that the adequate observation time after asystole for the declaration of death is 2–5 min, but whether 2 min or 5 min are different on DCD livers' outcomes is still unknown.

In conclusion, the use of DCD donors will contribute to expanding the donor pool in China. With the support of the Chinese government and society, the use of organs from executed prisoners will be abolished thoroughly in the near future.

  • H.-L. Changa

  • K. Qua

  • C. Liu*

  • Y. Lv*

  • L. Yu

  • X.-M. Liu

  • B. Wang

  • Z. Wang

  • M. Tian

  • L. Wang

  • Department of Hepatobiliary Surgery, the First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, China

  • Corresponding authors: Chang Liu, or Yi Lv,

  • aThese two authors contributed equally to this work.


This work was financially supported by Grants from the National Natural Science Foundation of China (Nos. 30872482, 81072051, 81201549 and 81272644).


The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.


  1. Top of page
  • 1
    Chen GD, Shiu-Chung Ko D, Wang CX, et al. Kidney transplantation from donors after cardiac death: An initial report of 71 cases from China. Am J Transplant 2013; 13: 13231326.
  • 2
    Mateo R, Cho Y, Singh G, et al. Risk factors for graft survival after liver transplantation from donation after cardiac death donors: An analysis of OPTN/UNOS data. Am J Transplant 2006; 6: 791796.
  • 3
    Chan EY, Olson LC, Kisthard JA, et al. Ischemic cholangiopathy following liver transplantation from donation after cardiac death donors. Liver transplantation 2008; 14: 604610.
  • 4
    Foley DP, Fernandez LA, Leverson G, et al. Biliary complications after liver transplantation from donation after cardiac death donors: an analysis of risk factors and long-term outcomes from a single center. Ann Surg 2011; 253: 817825.

Corrections made after online publication June 3, 2013: minutes in penultimate paragraph have been updated; author listing has been updated.