Considering the characteristics of the donor, including age, previous diseases and Cardiovascular Risk factors (CRF), the Ideal deceased donor refers to a Donor after Brain Death (DBD) less than 40 years of age who died of cranial trauma and without CRF. A lack of ideal donors means that transplant teams are now grafting organs that would previously have been considered unacceptable.

The Standard and the Expanded Criteria donor are, in contrast, relative concepts that may evolve with time. A standard organ connotes an organ of average quality relative to the spectrum currently utilised for transplantation; while an expanded graft connotes an organ of lower than average quality, coming from a donor with characteristics known to be associated with suboptimal transplant outcomes. Expanded-criteria donors (ECDs) originally refer to kidneys from donors older than 60y or patients older than 60 with a significant medical history who have two of the following three features: (cerebrovascular accident as the cause of death, pre-existing hypertension, or terminal serum creatinine greater than 1.5 mg/dl.). The coincidence of multiple risk factors like older donors (>60 years old), obesity with steatosis, CRF and severe atherosclerosis, further exacerbates the extent of Ischemia–Reperfusion injury (IRI) in the graft, especially in some organs with extreme sensitivity to ischemia and reduces the chances of a successful outcome.

We have to move one step further and balance which is the acceptable limit the risk of transmission of infectious disease or for cancer. It’s a need, and the same time controversial, to go more in depth evaluating and assessing patients with past -history of cancer (defining types, time free of illnesses ...) or patients with past or actual HVC and HVB or HIV as possible donors.  Maybe we need a different term for this kind of donors and recipients: Extended Criteria Donors. They fall into 2 categories of risk: (1) graft dysfunction and (2) cancer and infectious disease transmission.

Because we have been involved in a COVID-19 pandemic, it’s mandatory to learn how to manage this new situation in the field of donor assessment and define clear rules regarding recovered patients or sicker ones. It’s important in this specific subject to distinguish between paediatric and adults donors because guidelines seems to be different.

On the other hand, we can improve the “quality “of organs before the retrieval in the ICU, optimising the management preventing the IRI. Regarding BDD implementing a common and pre-emptive management of possible and potential donors based on targeted objectives (haemodynamic, respiratory…) looking for the normality during all the process before and after brain death determination. Regarding cDCD process using the available techniques to optimise the assessment of the organs or even to improve them in the theatre before retrieval.  This will led us to increase the efficiency of the donation process.

The other side of the coin is the recipient. We need to define a specific allocation model, to tailor the best match between this grafts and recipients, taking into account direct effect on important clinical outcome: acute rejection, delayed graft function, and patient and allograft survival or some penalties due to recipient characteristics associated with no survival benefit following a non-standard –criteria donor transplantation, specific combination of donor and recipient factors that are likely to yield detrimental results.