A Look at Organ Donation and the People Who Make It Possible

Organ donation, simply put, is the act of offering someone a second chance at life. Today, more people than ever are eligible to give, and receive, that gift. But misconceptions still get in the way; so, let’s break it all down: what organ donation actually means, who can donate, and how thoughtful innovations—from living liver transplants and paired kidney exchanges to bioreactor organ preservation—continue to change the landscape.

Organ donation happens in two primary ways: after death, or while living.

Deceased organ donation occurs when a person dies and has consented (or their family consents) to donate usable organs. With the right circumstances and support, a single donor can save up to eight lives (and benefit the lives of dozens more by donating tissue, corneas, or even certain heart valves).

Living organ donation, by contrast, involves donating a kidney, a portion of the liver, or, in rare and specific circumstances, the lower lobe of a lung or a portion of the intestine while the donor is alive and healthy.

Due to a profound donor shortage in the United States, the only way to avoid long waitlists in liver and kidney transplantation is through living donation. It not only allows for elective, scheduled surgery but also statistically has better outcomes, shorter recovery times, and shorter hospital stays.

“We think the number of people who die waiting for transplant is unacceptable,” says Jean Emond, MD, Vice Chair of the Department of Surgery. “There’s really an ethical balance here that justifies swift innovation.”

Understanding the Types of Deceased Donation

Deceased donation itself can occur under a few distinct clinical scenarios:

Donation After Brain Death (DBD)

This is the most common type of deceased organ donation. It involves donors who have suffered irreversible brain damage and are declared dead based on neurological criteria while still being kept on a ventilator. Blood continues to circulate, which preserves organ function and gives surgical teams time to coordinate the transplant process.

Donation After Cardiac Death (DCD)

In DCD, the donor’s heart has stopped beating, and death is declared based on circulatory criteria. Because an organ’s cells start dying immediately without blood flow, timing, resources, and speed are critical for viability.

Improved preservation techniques—such as a bioreactive chamber that maintains the physical and chemical conditions of a human body for explanted organs—are significantly expanding the applications of DCD. This technology is so effective that DCD hearts, once thought too fragile to recover after cardiac arrest, are now viable for transplantation.

“Historically, donation after brain death was the only way because we didn't want the heart to be dead. But we can now use a chamber to bring the heart back to life as soon as we retrieve it,” says Hiroo Takayama, MD, PhD, Chief of Adult Cardiac Surgery. “We basically put the heart in a machine and reanimate it as soon as the heart is removed from the donor. It’s pretty amazing.”

Extended Criteria Donation

An increasingly personalized approach to transplantation is also broadening the scope of organs deemed acceptable. Clinicians may now consider extended criteria donors (ECD), people whose organs were historically declined due to age, underlying health conditions like high blood pressure or diabetes, or infections such as hepatitis C.

These aren’t bad organs. With kidney donation, for example, the work is always to determine the right fit for the individual recipient; age and lifestyle are huge factors. As Lloyd Ratner, MD, Director of the Kidney and Pancreas Transplant Program says, “You can always find something wrong with a deceased donor kidney, but we try very hard to find something right.”

At Columbia, 4 out of 5 deceased-donor kidney transplants use kidneys turned down by other institutions. “Getting a kidney is like getting a used car,” says Dr. Ratner. “Some have more miles, and some are easier to maintain. Others just need a small repair, then they’re good for years. We can fix kidneys that have problems with blood vessels, and in many cases, we can make do with organs that are less than perfect.”

When more than 100,000 people are waiting for an organ in the United States, and roughly 87 percent are waiting for a kidney, thinking outside the box (or in the case of the bioreactor, an entirely new kind of box) is essential.

Not Everyone Can Be a Deceased Donor

Despite every advancement, very few people die in a way that allows for organ donation. For organs to remain viable, a donor typically needs to die in an ICU, while still on a ventilator. This rare set of circumstances means that only about one percent of people registered as donors are actually able to donate. Even then, not all donated organs are ultimately used. Factors like poor organ function, advanced age, logistical delays, or the inability to find a timely match can prevent transplantation.

While still a niche practice at the most advanced centers, types of DCD donation are evolving too. “It’s becoming a more complicated question that has a more conservative and more aggressive application,” explains Dr. Takayama. “The conservative way is that once the patient is off the ventilator and the heart stops beating, we quickly open the chest and retrieve the heart. The more aggressive approach, so to speak, is that once the patient is off the ventilator and the heart stops beating, they are placed on ECMO [a machine that temporarily takes over heart and lung function].”

While ECMO acts as the heart and lungs, the machine recirculates the donor’s own blood, which allows surgeons to artificially revive the heart and determine its suitability for transplant while preserving function and extending viability time.

Living Donation Has Many Approaches

Living Liver Donation Is Regeneration in Real Time

The liver is the only solid organ that can regenerate—making living donation possible.

“You take a segment of liver from a healthy person and implant it in a sick person,” explains Dr. Emond. “In a few months, both livers grow to the size their bodies need.”

Using a 3D model of liver segments, transplant teams carefully map the anatomy, determine which lobe can be safely removed, and ensure all critical structures like arteries, veins, and bile ducts are accounted for.

Living liver donation is growing in practice and has become especially common in pediatric cases, where a parent can donate a small portion of their liver through minimally invasive surgery. “There’s no [anti-rejection] medication needed afterward and they go home that day,” Dr. Emond says. “We’re probably the only place in the United States right now doing this operation fully laparoscopically [and now robotically].”

Kidney Swaps: When a Match Isn’t a Direct Match

Not all living donors are compatible with their loved ones, but that doesn’t mean they can’t help. Enter the kidney swap. In a paired exchange, an incompatible donor gives their kidney to someone else, and that recipient’s donor gives a kidney back to their loved one.

“It’s a game of matchmaking that would make Yente proud,” says Dr. Ratner.

These swaps have saved thousands of lives, but they can be logistically tricky. Dr. Ratner advocates for smaller, more frequent swaps—local matches, fewer participants, and less travel. “Bigger isn’t always better,” he notes. “It’s really preferable to do swaps with fewer patients and do them more often.”

When matches are still not possible, transplant teams can now use antibody removal techniques, such as plasmapheresis, or combine two less-than-perfect kidneys to function as one, especially in older adults.

Why It All Matters

Every 10 minutes, another person is added to the transplant list. Whether you choose to register as an organ donor, learn more about living donation, or simply share this story with someone else, you’re helping grow awareness, and ultimately, access.

Knowledge of evolving cutting-edge techniques still needs to spread across the medical community as well. “There are a lot of people who could be donors if surgical teams felt more confident that they could do it safely, says Dr. Emond.

“And they can.”