Can a patient who has been on Extracorporeal Membrane Oxygenation (ECMO) be considered an organ donor?

ECMO and Organ Donation

Yes, patients who have been on ECMO can absolutely be organ donors, and this practice is supported by international guidelines and growing clinical evidence demonstrating successful transplantation outcomes from ECMO-supported donors. 1

Guideline-Based Framework for ECMO Donors

Donation After Neurological Death (Brain Death)

Organ donation should be considered in patients who achieve return of spontaneous circulation (ROSC) while on ECMO and subsequently fulfill criteria for death using neurological criteria. 1 This represents the most straightforward scenario where ECMO serves as a bridge to maintain organ perfusion after brain death declaration.

• Non-randomized studies demonstrate that 1-year graft survival is similar between donors who received CPR/ECMO support compared to those who did not, across multiple organs: adult hearts (3,230 organs), adult lungs (1,031 organs), adult kidneys (5,000 organs), adult livers (2,911 organs), and adult intestines (25 organs). 1

Donation After Circulatory Death (DCD)

In comatose patients where withdrawal of life-sustaining therapy is planned, organ donation should be considered after circulatory death occurs, even if the patient was on ECMO support. 1

• ECMO can be used as part of controlled DCD protocols, where it serves as an organ preservation technique after death declaration. 1
• All six international DCD guidelines reviewed recommend femoral arterial and venous cannulation with ECMO for organ preservation, using either normothermic or hypothermic conditions depending on the protocol. 1

Uncontrolled DCD (After Failed Resuscitation)

Organ donation can be considered even in individuals where CPR was not successful in achieving ROSC, provided ECMO is initiated after death declaration for organ preservation. 1

• Graft survival at 1 year was similar when organs were recovered from donors with ongoing CPR compared to other donor types for adult kidneys (199 organs) and adult livers (60 organs). 1

Practical Implementation Considerations

Timing and Technical Requirements

ECMO support must follow locally agreed protocols that distinguish between resuscitation efforts (attempting to save the patient) and organ preservation efforts (after death declaration). 1

• The "no-touch period" after cessation of resuscitation or death declaration varies between protocols (5-20 minutes) and must be observed before organ preservation measures begin. 1
• Maximum allowable times vary by protocol: cardiac arrest prior to CPR (15-30 minutes), CPR to cannulation (90-120 minutes), and cannulation to organ procurement (120-360 minutes). 1

Specific Organ Considerations

Individual organ function assessment is critical, as ECMO history alone does not preclude successful transplantation. 2

• Hearts: Successfully transplanted from ECMO donors with normal function at follow-up, including from donors with recent out-of-hospital cardiac arrest requiring extracorporeal CPR (eCPR). 2
• Lungs: Can be safely procured from donors on venoarterial ECMO support, expanding the donor lung pool in carefully selected cases. 3
• Kidneys and Livers: Successfully transplanted with appropriate organ function after 15 months from donors requiring ECMO to prevent cardiac arrest during the donation process. 4

Critical Pitfalls to Avoid

Do not confuse ECMO used for attempted resuscitation with ECMO used for organ preservation after death declaration—these are ethically and legally distinct interventions. 1, 5

• Premortem cannulation for DCD requires specific informed consent and must follow local legal and ethical requirements. 1
• ECMO techniques used during CPR (mechanical chest compression, extracorporeal circulation) are the same as those used for organ preservation, making clear protocols essential to avoid ethical conflicts. 1

Obtain low-threshold biopsies to exclude poor graft quality predictors such as centrilobular hepatic necrosis or intravascular renal microthrombosis, as warm ischemia during ECMO support may cause organ damage. 1

Carefully consider additional extended criteria donor characteristics (older age, hepatic steatosis, glomerulosclerosis) when combined with ECMO history, as cumulative risk factors may compromise outcomes. 1

Legal and Ethical Requirements

All decisions concerning organ donation from ECMO-supported patients must follow local legal and ethical requirements, as these vary significantly between jurisdictions. 1

• Four of six international guidelines address information provided to next of kin in the field, and five of six address consent requirements for cannulation and procurement. 1
• The role of ECMO as organ-preserving versus life-saving technique must be clearly distinguished and documented. 1

Evidence Quality and Strength

The recommendation to accept organs from ECMO-supported donors is based primarily on guideline-level evidence from the European Resuscitation Council and European Society of Intensive Care Medicine 1, supported by multiple non-randomized studies demonstrating equivalent 1-year graft survival 1, and international consensus protocols for DCD 1. While randomized controlled trials are lacking (and would be ethically challenging to conduct), the consistency of outcomes across thousands of transplanted organs provides robust support for this practice.