For patients with organ failure, transplantation remains the most effective, and often lifesaving, treatment. Yet access to transplant continues to lag far behind need, particularly in kidney disease. Deceased donation plays a central role in closing that gap.
“About three-quarters of the kidneys donated for transplant in the U.S. are from deceased donors,” explains Nebraska Medicine transplant nephrologist Clifford Miles, MD. “That leaves the majority of patients dependent on that pathway.”
As transplantation continues to evolve, understanding the role of deceased donation and emerging approaches like donation after circulatory death (DCD) is critical for referring providers.
Why deceased donation remains essential
While living donation offers important benefits, it’s not a scalable solution for the broader population in need.
Despite increased awareness and strong outcomes, only about 25% of kidney transplant recipients receive organs from living donors. At the same time, demand far exceeds supply.
“There are between 90,000 to 100,000 people on the kidney transplant waiting list,” Dr. Miles says. “But that’s likely just a fraction of the people who would benefit from a transplant.”
He estimates the true number may approach hundreds of thousands nationwide. In that context, even significant gains in living donation would fall short of meeting the need. Expanding access to deceased donor organs remains the most impactful lever for increasing transplant availability.
DCD: Driving growth in organ availability
Historically, most deceased donor organs came from patients declared brain dead. However, that pathway has plateaued.
“The number of brain death donations has been relatively flat,” Dr. Miles says. “All of the growth we’re seeing is coming from donation after circulatory death.”
DCD refers to donation that occurs after a patient has been determined to have a non-survivable condition, and care is withdrawn in alignment with the patient’s wishes and clinical reality. Importantly, the decision that a patient will not survive is made independently of any transplant or donation team.
“The teams managing the patient’s care and the teams involved in donation are completely separate,” Dr. Miles emphasizes. “Those lines are very clear.”
This distinction is critical, particularly as public discourse and media coverage have introduced confusion about the ethics and processes involved.
In practice, DCD has become a major contributor to transplant growth. Today, approximately half of deceased donor transplants nationwide come from DCD donors. At Nebraska Medicine, the impact is similarly significant.
“Last year, just over half of our deceased donor kidney transplants were from DCD donors,” Dr. Miles notes.
For liver transplantation, the shift is even more pronounced, with the majority of Nebraska Medicine transplants now originating from DCD donors.
Understanding outcomes: Short-term differences, long-term success
For referring providers, one of the most important considerations is how DCD affects patient outcomes. While DCD organs may be associated with a higher likelihood of delayed graft function, such as requiring dialysis in the immediate post-transplant period, long-term outcomes are comparable to traditional donation pathways.
“The long-term outcomes are really not different,” Dr. Miles says.
This distinction is critical when counseling patients. From a clinical perspective, the decision is often not between a DCD organ and a “better” option. It is between accepting an available organ now or waiting, sometimes for years, for another opportunity.
“For a patient on dialysis, waiting longer is not a benign option,” he explains.
Prolonged time on dialysis is associated with increased cardiovascular complications and reduced post-transplant outcomes, reinforcing the importance of timely transplantation.
Where living donation fits
Although this article focuses on deceased donation, living donation remains an essential component of the transplant ecosystem, particularly for kidney transplant.
“We tell every patient that living donation is their best option,” Dr. Miles says.
Living donor transplants typically offer shorter wait times and excellent outcomes. However, identifying a donor can be a significant barrier.
Providers should be aware that living donors are often not biologically related to recipients. Friends, spouses, coworkers and even community members may be viable candidates.
“More than half of living kidney donors are not blood relatives,” he notes.
Encouraging patients to explore all potential donor options and directing interested individuals to the transplant center for evaluation can expand opportunities for transplantation.
Referral timing: Earlier is better
Timely referral remains one of the most important ways providers can impact transplant outcomes. Patients do not need to be on dialysis to be referred.
“In fact, the opposite is true,” Dr. Miles says. “There’s a benefit to being transplanted before dialysis is required.”
Referral is typically appropriate at stage 4 chronic kidney disease, allowing time for evaluation, optimization and potential identification of living donors. Delayed referral can limit eligibility. As time on dialysis increases, patients face higher risks of complications such as cardiovascular disease and stroke, which can ultimately preclude transplantation.
“You may miss the window where transplant is an option,” he explains.
A coordinated, multidisciplinary approach
As the state’s only solid organ transplant center, Nebraska Medicine brings together a comprehensive, multidisciplinary team to manage complex transplant patients. This includes transplant surgery, nephrology, hepatology, cardiology, infectious disease and specialized ancillary staff with extensive transplant experience.
“Our teams see transplant patients every day,” Dr. Miles says. “That level of experience extends across the entire system.”
Close collaboration with the organ procurement organization further supports efficient donor evaluation and organ utilization, helping maximize the impact of every donation.
A shared responsibility across health care
Deceased donation and transplantation represent one of the most complex and highly regulated processes in medicine.
“There are multiple safeguards at every step,” Dr. Miles says. “This is a highly coordinated system.”
For providers, understanding that system and communicating accurate information to patients can directly influence outcomes. Every missed opportunity for donation has downstream consequences.
“If we don’t optimize donation,” he says, “we will see more patients die from organ failure that could have been treated.”
Referral and next steps
As transplantation continues to evolve, expanding access will depend on both increasing donor availability and ensuring timely referral of appropriate patients. Providers play a key role in both.
Early referral, patient education and awareness of donation pathways, particularly DCD, can help more patients access life-saving transplants.
Physicians interested in referring a patient for transplant evaluation or learning more about Nebraska Medicine’s transplant program can contact the team directly at 800.401.4444.