DCD vs. Brain Death (DBD) Donors

Medically reviewed by James F. Trotter, MD and Joseph S. Redman, MD, PhD, National Friends Medical Advisory Board · Last reviewed October 1, 2026

Most deceased-donor livers come from brain-death (DBD) or circulatory-death (DCD) donors. Here is how they differ and why your center's DCD policy matters.

Two donor pathways supply most of the deceased-donor liver pool. Both donors are legally dead before any organ is recovered. What differs is how death is determined, and that changes how the liver is handled.

Donation after Brain Death (DBD)

The donor has been declared dead by neurologic criteria; the heart is still beating at organ recovery because a breathing machine keeps oxygen flowing.
Historically the "standard" donor pathway for liver transplant.
Most published outcomes data references DBD donors.

Donation after Circulatory Death (DCD)

The donor has been declared dead by circulatory criteria — the heart has stopped before recovery.
In the usual U.S. setting ("controlled" DCD), the donor has a devastating injury but does not meet brain-death criteria. The family decides to withdraw life support. Only after the heart stops and death is declared does the recovery team begin.
The liver is exposed to a period of warm ischemia between cardiac arrest and recovery — time when it is warm but not getting oxygen — which is the main clinical concern.
DCD donors expand the donor pool but require careful selection and often modern preservation (HOPE or NMP).

Why warm ischemia matters

A liver can tolerate cold storage on ice for hours. It handles warm time without oxygen much less well. The part most sensitive to this injury is the bile ducts, the small tubes that carry bile out of the liver.

The main risk after a DCD transplant is damage to these ducts, called ischemic cholangiopathy or non-anastomotic biliary strictures. Narrowed ducts can cause infections and jaundice, may need repeated procedures to open them, and in some cases lead to a second transplant. The DHOPE-DCD trial's registry summary noted that, in the earlier research it reviewed, these strictures were reported in 29% of DCD liver recipients compared with 11% of DBD recipients.

Note that the "warm time" in DCD happens before the liver is recovered. Machine perfusion cannot undo it, but it can help the liver recover from it and let the team check how the liver is working.

How common are DCD livers?

DCD livers are now a real part of U.S. transplant. According to the OPTN/SRTR 2023 Annual Data Report:

16.7% of liver transplant recipients in 2023 received a DCD liver.
Record transplant numbers in 2023 were driven partly by more livers from older donors and DCD donors, likely helped by wider use of machine perfusion.
DCD livers were still more than three times as likely as DBD livers to be recovered and then not used: 22.8% of DCD livers went unused in 2023, down from 30.0% in 2019, compared with 6.5% of DBD livers.
Five-year graft survival (the new liver still working) was 75.6% for DCD livers and 79.2% for DBD livers.

That last number is important. DCD livers do slightly less well on average, but the gap is small, and most DCD livers work for years.

Why this matters for caregivers

Programs with active DCD use may be able to offer you a transplant sooner, because they accept livers that other programs pass on.
DCD outcomes have improved with HOPE perfusion and NMP. In a U.S. trial of a warm perfusion device, livers from cardiac-death donors were used about twice as often with the device as with ice storage (51% vs. 26%). Some programs also use normothermic regional perfusion (NRP), which restores warm, oxygenated blood flow to the organs inside the donor's body after death is declared.
A program that does not accept DCD livers may have longer waits without an offsetting benefit for you.

Where you are on the list still matters most. A DCD offer comes to you based on your MELD score and distance from the donor hospital, like any other offer. Learn more about how this works on our liver waiting list page.

Questions to ask your transplant team

"Do you accept DCD livers, and what's your protocol — HOPE, NMP, NRP, or standard cold storage?"
"About how many of your liver transplants each year use DCD livers?"
"Would you consider a DCD liver for me? Why or why not?"
"If I get a DCD liver, how will you watch for bile duct problems after transplant?"
"Can I say no to a DCD offer, and would that affect my place on the list?"

You can ask your team to explain the trade-off for your own situation. Someone with a very high MELD and someone with a lower MELD may face very different risks from waiting.

Common misconceptions

"A DCD donor isn't really dead." DCD donors are declared dead before recovery begins. The decision to withdraw life support is made by the family and the donor's medical team, separate from the transplant team.
"DCD livers are second-rate." They carry a somewhat higher risk of bile duct problems, but five-year graft survival is close to that of DBD livers in national data.
"Turning down a DCD liver is always the safe choice." Waiting has its own risks. For some patients, getting sick or dying while waiting is the bigger danger. Our page on understanding your risk can help frame that conversation.

To see how centers compare, use the center comparison map. Related reading: extended criteria donors, HOPE perfusion and normothermic machine perfusion.