The bucharest international (ESOT) consensus on controlled donation after circulatory determination of death

the ability to recover, preserve, assess, and potentially repair donor organs. Yet this rapid progress has also exposed important challenges. Clinical outcomes remain heterogeneous, practices differ across centers and countries, and the use of emerging perfusion technologies raise fundamental questions about donation itself, including how death should be determined and how the dead donor rule should be seen and respected in this context. Despite the rapid evolution of the field, international consensus initiatives dedicated specifically to cDCDD have lacked. In this context, the European Society for Organ Transplantation (ESOT) convened the international cDCDD Consensus in Bucharest in October 2024, the results of which are presented in this Special Issue of Transplant International(1). This effort was deliberately ambitious in both scope and methodology. Four steering committees addressed the adult pathway, the paediatric pathway, normothermic regional perfusion (NRP), and the unifying concept of death. Each committee assembled an international panel of experts and conducted a two-round Delphi process, with statements accepted only after reaching a 75% agreement threshold. The process robustness was further reinforced by an in-person meeting inBucharest which allowed open discussion of the first-round results and refinement of the statements before the second Delphi round. Overall, around 150 experts from five continents contributed to the project. Coordinating four parallel consensus processes, harmonising their methodology, and integrating the outputs into a coherent framework required a substantial organisational effort, reflecting ESOT's commitment to fostering global convergence in donation 1 and transplantation and addressing critical and controversial areas(2).The five contributions are best viewed as complementary components of a single consensus 3 document. At its foundation is the methodology and definitions paper(1) which describes the 4 consensus process but, more importantly, establishes a common language and foundation on 5 which the remaining papers are build and future should be constructed.Inconsistent definitions have long hindered international comparisons. Among the 7 agreed definitions of possible and potential donor, ante-mortem interventions and the critical 8 time-points of the donation pathway, the key one that emerges is the deliberate preference for the 9 term "donation after circulatory determination of death" over the broader expression circulatory 10 death(3). We believe that such attention to semantics is transformative when dealing with 11 technically and ethically intricate issues; we therefore advocate a shared vocabulary as an 12 essential prerequisite for collaboration, research, and benchmarking.Building on this foundation, the adult pathway paper presents thirty-nine recommendations The unifying concept of death paper addresses one of the most challenging issues in cDCDD(7).1 Importantly, consensus was reached on the definition of the unifying brain-based concept of 2 death and the potential benefits of its' adoption. Further agreements were achieved on the 3 adoption of the concept of permanency rather than irreversibility as the relevant standard when 4 determining death, on a five-minute no-touch period and on the reaffirmation of the dead donor 5 rule as the ethical principle that donation must never cause death. Agreement was achieved on 6 fundamental principles but not on every aspect of their clinical application. The operational 7 definition of death and the clinical criteria required for death determination after the no touch 8 period did not reach the predefined consensus threshold. These unresolved issues are among the 9 most important priorities for future scientific, ethical, and legal debate.10 Taken together, the five papers reveal a consistent pattern: strong convergence on fundamental 11 principles and terminology, alongside persistent differences in key areas of clinical practice, 12 including warm ischaemia limits, standards for determining death, and approaches to preventing 13 cerebral perfusion. These differences continue to reflect variations in legal frameworks, 14 healthcare systems, and cultural perspectives across countries. Rather than representing a 15 limitation, these unresolved issues provide a clear agenda for future research, evidence 16 generation, and international harmonization. 17 Undoubtedly, the Bucharest consensus conference and its outputs represent a milestone in the 18 cDCDD area. However, this should be viewed as an ongoing process and through the ESOT-19 Consensus Platform, as a permanent expert environment, and the next iteration of the Bucharest 20 consensus will continue to align clinical guidance with rapidly advancing scientific evidence. In 21 the meantime, we are confident that this work will bring international community towards a 22 more consistent clinical and ethical approach to cDCDD, one that embraces scientific innovation 23 while remaining firmly grounded in the fundamental principles of donation and transplantation.