India’s organ transplantation program has made steady progress over the past decade, yet the disparity between the number of patients awaiting transplantation and the availability of donor organs remains profound. Deceased donation in the country continues to rely predominantly on donation after brain death, a pathway that, while critical, inherently limits the potential donor pool. Many transplant systems worldwide have addressed this limitation by incorporating donation after circulatory death (DCD), supported by advances in organ preservation techniques such as normothermic regional perfusion (NRP). 1 Evidence accumulated over the past decade demonstrates that organs retrieved following circulatory arrest using NRP can achieve outcomes comparable to those obtained from brain-dead donors while significantly improving organ utilization. 2, 3 These developments offer important lessons for countries like India, where the need to expand the donor pool remains urgent. In India, discussions surrounding DCD have evolved gradually over the past decade. Early analyses highlighted the ethical, logistical, and infrastructural challenges that would need to be addressed before DCD could be implemented in routine practice. 4 More recently, consensus documents from Indian experts have emphasized the importance of structured protocols, multidisciplinary engagement, and the integration of DCD pathways within the existing deceased donation framework. 5 These discussions have laid the conceptual groundwork for considering DCD as a viable component of India’s transplant program. An important development influencing the feasibility of DCD in India has been the 2023 Supreme Court judgment clarifying the legal framework for withholding and withdrawal of life-sustaining treatment (WLST). The judgment provides long-awaited legal clarity for end-of-life decision-making and may help clinicians navigate difficult discussions around the care of dying patients. 6 However, despite this legal framework, WLST is still not widely practiced across many intensive care units in the country. Consequently, controlled DCD programs have yet to gain widespread acceptance. Despite these constraints, early progress has been made. DCD kidney transplantation has already been performed in India, demonstrating feasibility and providing proof of concept. 7 However, transplantation of organs such as the liver, lungs, and pancreas from DCD donors presents additional challenges because of warm ischemic injury following circulatory arrest. In this context, NRP has emerged internationally as a powerful strategy to restore oxygenated circulation to organs following circulatory death, thereby reducing ischemic injury, enabling functional assessment, and improving transplantation outcomes. 1, 2 While machine perfusion technologies have enabled the expansion of DCD transplantation in several countries, their cost remains a major barrier in many low- and middle-income settings. Recognizing this limitation, Indian clinicians and researchers have begun exploring indigenous and cost-effective approaches to organ perfusion. A notable initiative in this direction has been the formation of the NRP consortium, a collaborative network of clinicians, surgeons, perfusionists, and coordinators that began its work in 2024. The consortium, comprising 22 members, has focused on adapting NRP protocols to the Indian context, emphasizing affordability, practicality, and multidisciplinary coordination. 8 One outcome of this collaborative effort has been the development of a low-cost hybrid extracorporeal membrane oxygenation (ECMO) -based circuit for NRP, designed for use in both the intensive care unit and the operating theater. The estimated cost is approximately ₹92, 000 (US1000) when implemented in the ICU and ₹50, 000 (US600) when used in the operating theater with cardiopulmonary bypass. In DCD-IV scenarios, an aortic balloon catheter – commonly used internationally to prevent cerebral reperfusion – may not be necessary because there is no blood flow to the brain in these circumstances. Avoiding this device eliminates an additional cost of roughly ₹30, 000 (US400), further improving feasibility. A key milestone in this development was a comprehensive dry run conducted in August 2025, during which the equipment, workflow, and coordination between teams were tested. These simulations underscored an important principle: the success of NRP depends not only on technology but also on effective multidisciplinary collaboration. The implementation of DCD-NRP requires seamless coordination between intensivists, transplant surgeons, anesthetists, perfusionists, transplant coordinators, and organ allocation authorities. The feasibility of DCD varies across its different categories. Uncontrolled DCD (DCD-V) remains particularly challenging because of the unpredictability of circumstances and the need for rapid organ preservation. In contrast, DCD-IV, where circulatory arrest occurs in a patient who has already been declared brain-dead, may be implemented more readily. In such cases, vascular access lines can often be placed in advance when the patient becomes hemodynamically unstable. Another important pathway is controlled DCD-III, involving patients in whom life-sustaining treatment is withheld or withdrawn. Earlier discussions on DCD in India anticipated this category as a potential avenue for expanding the donor pool. 5 A significant milestone was reached in September 2026, when Manipal Hospitals performed the first DCD-III procedure using withholding of support rather than withdrawal. This approach may be particularly relevant in the Indian context and offers the possibility of including patients with motor neuron disease, certain neurodegenerative disorders, interstitial lung disease, and other advanced illnesses in whom brain death may not occur, but end-of-life decisions are clinically appropriate. However, an important prerequisite in India is that withholding and WLST must first become routine components of end-of-life care in intensive care units, particularly for patients requiring palliative care. Establishing this practice independent of organ donation is essential to maintain public confidence and trust. This consideration is particularly relevant in India, where a substantial proportion of critical care beds are located in the private healthcare sector, and preserving trust between families, clinicians, and institutions remains paramount. Once transparent and ethically grounded end-of-life practices become routine, their integration with organ donation programs may provide a meaningful and ethically sound opportunity to expand the donor pool. The introduction of DCD will also require strengthening the role of transplant coordinators, who remain central to the success of deceased donation programs. Coordinators will require additional training in the ethical, clinical, and logistical aspects specific to DCD, particularly in family counseling and in managing the time-sensitive processes surrounding organ retrieval. Operational challenges must also be addressed. Once NRP is initiated, the window for organ recovery is limited. Current protocols suggest that NRP can be maintained for approximately four hours, during which organ evaluation, retrieval, and allocation must occur. This compressed timeframe necessitates careful planning of allocation strategies, with maximum in-house utilization and streamlined allocation pathways likely to play an important role. International experience over the past decade has consistently shown that transplant outcomes using NRP are comparable to those achieved with organs from brain-dead donors, while improving organ utilization rates. 1, 3 Encouragingly, India has already begun to generate its own experience, and the next phase will require capacity building, including structured training programs, protocol standardization, and the development of centers capable of mentoring emerging programs. Ultimately, the expansion of NRP in India is likely to follow a stepwise progression – beginning with abdominal NRP for liver and kidney transplantation, followed by broader application involving lungs and pancreas, and eventually thoracoabdominal NRP, enabling retrieval of multiple organs. At present, however, intestinal transplantation remains outside the scope of DCD protocols. NRP represents more than a technological innovation; it marks a potential turning point in the evolution of India’s deceased donation program. By combining clinical innovation with cost-conscious design and strong multidisciplinary collaboration, NRP offers a realistic pathway for expanding the donor pool. The challenge now lies in translating early experience into a sustainable national practice through training, protocol development, and institutional commitment. If pursued thoughtfully, NRP-enabled DCD could significantly increase organ availability and offer renewed hope to the many patients in India who continue to wait for life-saving transplantation.
Sunil Shroff (Thu,) studied this question.