Why is organ transplantation from cardiac death donors necessary in Japan? An important strategy for heart transplantation in severe donor shortage.

Brain-dead donor (DBD) is the basis for most organ transplants and has been the exclusive method of choice for heart transplantation (HTx). However, the severe shortage of donors has been the common problem worldwide, especially in Japan. Meanwhile, the number of donors after cardiac (circulatory) death (DCD) has increased rapidly in the last 10 years, especially in Europe, thus expanding the donor pool. This strategy has been introduced in HTx since 2014, starting in Australia and the United Kingdom, with acceptable results. In most DCD, organs are removed under withdrawal of life support (WLST), which is called controlled DCD (cDCD). In Japan, we should consider introducing cDCD to supplement DBD, which is compromised by the shortage of donors. In this setting of cDCD, ethical and regulatory arguments arise as to the definition of human death and how to deal with WLST in organ donation. From a regulatory point of view, cDCD has been misunderstood as requiring a separate legislative development, and to dispel this misconception is the important message of this report. The development of an ex vivo machine perfusion system is another issue to start cDCD HTx as well as other organs. This paper outlines the issues involved in the introduction of cDCD for heart transplantation in Japan.