The controversy stems from the Bucharest consensus conference, which established standards for controlled donation after circulatory determination of death, known as cDCDD, in adults and issued specific recommendations on the use of normothermic regional perfusion, or NRP. In this technique, blood flow is restored to the abdominal organs, and in some protocols to the thorax as well, after death has been declared, allowing organs to be rewarmed and oxygenated in situ before retrieval. Jorda-Aragón and colleagues argued that the lung has been relegated to a secondary role in these consensus documents and that early lung ventilation, resumed immediately after the mandatory hands-off period and declaration of death, is essential to optimize lung graft preservation. The reply authors do not agree with that assertion, clarifying that the consensus processes were never intended to provide detailed, organ-specific technical guidance except where such guidance was directly relevant to the application of NRP itself.

According to the reply, the management of lungs for transplantation in the context of both abdominal NRP, abbreviated A-NRP, and thoracoabdominal NRP, known as TA-NRP, is appropriately addressed in the dedicated NRP consensus document. The authors fully support measures aimed at achieving early optimal lung preservation, pointing out that there is international experience with combined lung recovery and A-NRP, including published protocols in which mechanical ventilation is resumed soon after death has been formally declared in combination with the initiation of A-NRP. Studies from Spain, including work from the Santander group, have demonstrated that lungs recovered simultaneously with abdominal NRP can achieve outcomes comparable to those from donors after brain death, while French protocols combining in situ abdominal NRP with ex vivo lung perfusion have similarly expanded the pool of viable lung grafts from circulatory death donors.

Yet the picture is far from uniform across jurisdictions. Concerns exist in some countries that the immediate resumption of cyclical ventilation could potentially be associated with restoration of effective cardiac activity, a scenario that would breach the dead donor rule, the ethical cornerstone requiring that organ retrieval must not cause or hasten the donor’s death. In response, safety measures are required in certain protocols to delay the resumption of mechanical ventilation beyond the completion of the hands-off period. These protocols allow for immediate reintubation but require delay of lung insufflation until ten minutes after the onset of mechanical asystole, with cyclical ventilation only during the pulmonary flush at surgical retrieval. National standards in the United Kingdom and best practice guidelines in Australia reflect this cautious approach, prioritizing legal certainty over the theoretical benefits of earlier re-oxygenation of the lung graft.

The technical solution adopted in Spain and other A-NRP centers involves monitoring of the left radial artery during cDCDD as a simple means of detecting any restoration of effective cardiac activity and systemic circulation, or the possibility of restoring cerebral perfusion due to inadequate occlusion of the thoracic aorta. Such an event would be readily identified by the appearance of a pulsatile arterial pressure waveform in the left radial artery in the event of restoration of effective cardiac activity, or by the appearance of non-pulsatile pressure in the left radial artery in the event of inadequate occlusion of the thoracic aorta. This real-time hemodynamic surveillance allows clinicians to proceed with abdominal perfusion while remaining confident that the brain is not being re-perfused, a critical safeguard that has been validated in published research on avoiding donor resuscitation in controlled donation after circulatory death with NRP.

The reply authors emphasize that these differences highlight the importance of ongoing evaluation of post-mortem interventions and the publication of case series or incident sharing. As international clinical experience continues to accumulate, greater harmonization of practices across countries may become possible. However, the specific timing of the resumption of mechanical ventilation following the determination of death was not addressed during the Bucharest consensus deliberations, and consequently no specific recommendation on this issue was made. This gap in the consensus reflects the genuine uncertainty that persists in the field, where the physiological benefits of early ventilation must be weighed against jurisdiction-specific legal interpretations of what constitutes permissible post-mortem intervention.

On the question of thoracoabdominal NRP, which allows simultaneous recovery of the heart and lungs, the reply acknowledges a lack of standardization in combined recovery protocols. As the letter authors point out, the ESOT Bucharest Consensus explicitly acknowledges the potential risks of lung congestion and cardiac distension during TA-NRP, complications that arise because blood returning through the pulmonary circulation cannot be effectively ejected without cardiac function, leading to hydrostatic pressure buildup and pulmonary edema. Left atrial venting, through the insertion of a venting catheter via the interatrial groove at the initiation of TA-NRP, has been proposed as a preventive maneuver. However, although this issue was discussed during the Consensus Conference, no consensus was reached among the panelists, and the reply authors therefore cannot recommend this maneuver based on the findings of the Delphi process that underpinned the consensus.

The exchange underscores a broader challenge in transplantation medicine: the tension between rapid innovation and the need for standardized, evidence-based protocols. The lung, with its distinctive physiological characteristics, including its ability to be oxygenated directly through the airway rather than relying solely on vascular perfusion, presents unique opportunities and challenges in the post-mortem setting. Protocols should incorporate measures to optimize lung oxygenation and preservation while taking advantage of these characteristics, the reply authors argue, but at the same time the acceptability and implementation of specific interventions may remain context-dependent and influenced by the regulatory framework of each country. What is permissible in Spain may be restricted in the United Kingdom or Australia, and vice versa, creating a patchwork of practices that complicates international collaboration and data comparison.

As international experience with the simultaneous recovery of the heart and lungs using TA-NRP continues to grow, the technique may become increasingly standardized, allowing optimal preservation of all organs. The reply authors completely agree with the letter authors that the lung should not be regarded as the forgotten organ in regional perfusion strategies or cDCDD consensus guidelines. The dialogue between these two groups of experts, published as part of the ongoing discussion surrounding the Bucharest consensus, illustrates how the field is evolving through constructive disagreement, with each exchange refining the technical and ethical boundaries of what is possible in donation after circulatory death.

For transplant professionals and the public alike, the debate serves as a reminder that the expansion of organ donation after circulatory death depends not only on surgical innovation but also on careful attention to the legal, ethical, and physiological details that govern every step of the retrieval process. The lungs, far from being forgotten, are now at the forefront of efforts to maximize the number of organs that can be safely and effectively transplanted from this growing donor population, with early in situ oxygenated preservation emerging as a critical factor in determining whether these vital organs ultimately reach the patients who need them.

Subject of Research: Reply to Don’t forget to safeguard the lungs during DCD multi-organ retrieval! Early in situ oxygenated preservation matters

Article Title: Reply to Don’t forget to safeguard the lungs during DCD multi-organ retrieval! Early in situ oxygenated preservation matters

Article References: Miñambres, E., Gardiner, D., & Opdam, H. (2026). Reply to Don’t forget to safeguard the lungs during DCD multi-organ retrieval! Early in situ oxygenated preservation matters. Transplant International, 39, Article 17755. https://doi.org/10.3389/ti.2026.17755

Image Credits: AI Generated

DOI: 10.3389/ti.2026.17755

Keywords: Reply, forget, safeguard, lungs, during, multi-organ, retrieval, Early, situ, oxygenated, preservation, matters