Objectives: In the past 3 years, nearly 90% of organ transplants performed in our country have been from living donors. Low rates of organ donation and family consent in cases of brain death reduce the source of deceased donors. Here, we reported the challenges of determination of brain death and donor care processes in our hospital and offered our recommendations to strengthen these services.
Materials and Methods: We retrospectively analyzed adult patients (n = 5845) treated in adult intensive care units of Manisa City Hospital from June 1, 2024, through November 30, 2025. Demographic information and clinical data were collected for patients diagnosed with brain death (n = 10), including time from admission to brain death determination, time from brain death determination to cardiac arrest, and time from first evaluation to brain death. We also collected data on organ donation and the reason for family donation refusal.
Results: The ratio of brain death cases to total patients was 0.17%. The rate of deceased organ donation of brain death cases was 20%. Time from first evaluation to brain death determination ranged between 7.3 and 169 hours. Time from brain death determination to cardiac arrest ranged between 4 and 91 hours. For brain death determination, apnea test was performed in 7 patients (70%). For all cases, ancillary tests were used. Four-vessel digital subtraction angiography was performed in 3 cases (30%). There were multidrug-resistant infections in 3 cases.
Conclusions: Medical knowledge and practices regarding organ donation and donor care after brain death should be raised to international standards. It remains important for transplant clinicians to increase cooperation between our Ministry of Health and hospital administrators for consideration of current scientific data to reduce organizational challenges. Such cooperative efforts could further strengthen organ transplant services, which are already quite successful in our country.

Key words : Organ donation, Organization, Transplantation services

Introduction
Since the first successful living kidney transplant performed 51 years ago by Prof. Dr. Mehmet Haberal, our country of Türkiye has been a leader in the field of organ transplantation.¹ A huge gap remains between the number of patients waiting for organ transplants worldwide and the number of organ transplants performed.² According to our national legislation, organ donation is not possible in Türkiye after cardiac death.¹ After the COVID-19 pandemic, the number of cases for which brain death (BD) was determined and for which families gave their consent for donation has decreased significantly.³ Low organ donation rates and low family consent rates in cases of BD have reduced the source of deceased donors. There are numerous challenges in BD determination and donor care, including difficulties in diagnosis, inadequate organ support, the pervasive dearth of neuroimaging facilities in centers, and multidrug-resistant infections.^2,3 In this study, we reported the challenges of the determination of BD and donor care process in our hospital and offered our recommendations for strengthening these services.

Materials and Methods
This study was approved by the Manisa Celal Bayar University Faculty of Medicine Health Sciences Ethics Committee (December 3, 2025; No. 20.478.486-3607) and subsequently approved of by the Manisa Provincial Health Directorate (December 29, 2025; No. E-79593712-605-2995477951). We retrospectively analyzed data from the electronic patient information management system and printed intensive care forms of adult patients (n = 5845) who were followed up and treated in the adult intensive care units (ICU) of Manisa City Hospital from June 1, 2024, through November 30, 2025. The evaluation process is shown in Figure 1. Demographic information and clinical data were collected and recorded from patients who had been diagnosed as BD (n = 10) according to our national legislation.⁴ We collected and recorded the following demographic information and clinical data: age, sex, body mass index (measured as kilograms body mass per meter squared), Glasgow Coma Scale (GCS) score at time of ICU admission , cause of BD, comorbidity, length of ICU stay, time from ICU admission to BD determination, time from BD determination to cardiac arrest, and time from first evaluation to BD determination. Regarding the determination of BD, we collected and recorded data for apnea tests (duration, PaCO² level increase) and any ancillary tests such as brain computed tomography (CT) angiography and 4-vessel digital subtraction angiography (DSA). We collected and recorded the following clinical data: primary consultant of patients, presence of neurosurgical procedures, presence of forensic case, ICU category, specialty of the medical doctors who were responsible for BD determination, and presence of multidrug-resistant infections. Organ donation data included family consent status, number and type of donated organs, and the reasons for refusal of consent. Determination of BD was made by 2 medical specialists in accordance with our legislation. The General Directory of Health Services of the Republic of Türkiye Ministry of Health has defined BD criteria as follows: clinically irreversible coma of known etiology, with no spontaneous breathing, no spontaneous movement, and no brainstem response (ie, absence of pupillary, corneal, oculovestibular, oculocephalic, pharyngeal, and tracheal reflexes) and with positive apnea test and ancillary tests if needed.⁴

Statistical analyses
We used SPSS software (version 20.0) for statistical analyses. We expressed variables as mean values ± SD or as number of patients (with percentage of total).

Results
For the period from June 1, 2024, through November 30, 2025, there were 10 cases (age range 24-87 years) of BD determined among 5845 patients treated in the adult ICU of Manisa City Hospital. Among these 10 cases, there were 3 female patients (30%). The demographic information and clinical data of the patients are presented in Table 1. All cases presented as primary cerebral events. The most common cause of BD was intraparenchymal hemorrhage (60%), followed by subarachnoid hemorrhage (30%). All patients with traumatic subarachnoid hemorrhage were forensic cases (2 cases were traffic accidents, and 1 case was fall at home). Neurosurgical procedures were performed for 6 patients (1 case of cerebellar hematoma drainage, 3 cases of external ventricular drainage, and 2 cases of decompressive craniectomy). The GCS scores ranged between 3 and 13. Most of the cases were admitted to the ICU with a GCS score of 3 (60%). Two patients (GCS score of 12 and 13, respectively) were endotracheally intubated in the clinical course due to sudden loss of consciousness. Eight patients were endotracheally intubated at ICU admission. Eight of the patients were followed in level 3 mixed type ICU (80%); 1 patient was followed in level 2 mixed ICU, and 1 case was followed in level 2 neurology ICU. Five patients had uncontrolled hypertension as comorbidity (50%). One patient had extreme morbid obesity with body mass index of 48.4. Table 2 lists data collected during the BD determination period, including length of stay in ICU (range, 2.3-13.8 days), time from ICU admission to BD determination (range, 1.6.-13.1 days), time from BD determination to cardiac arrest (range, 4-91 hours), and time from first evaluation to BD determination (range, 7.3-169 hours). For BD determination, apnea tests were performed in 7 patients (70%). The apnea test duration ranged between 8 and 18 minutes. The PaCO² level increase during the apnea tests ranged between 21 and 45 mm Hg. Among these 7 cases with apnea tests, 1 case met the criterion for PaCO² ≥ 60 mm Hg, and the other 6 cases met the criterion for PaCO² ≥ 20 mm Hg over baseline according to our national legislation.⁴ Brain CT angiography was the ancillary test for 7 cases (70%). The 4-vessel DSA was the ancillary test for 3 cases (30%), and these 3 cases were initial procedures of our hospital to BD determination. The necessity of ancillary tests was decided by clinicians according to clinical conditions of the patients or to fulfill the criteria in the absence of an apnea test. The determination of BD was made by intensivists and neurosurgeons for 7 cases, intensivists and neurologists for 2 cases, and an anesthetist and a neurologist for 1 case. The families of 2 cases decided on organ donation. Among these, 1 case was a forensic case. For each case, liver, 2 kidneys, and 2 corneas were successfully transplanted to the recipients at the other transplant centers according to our national organ sharing system rules. The families of 7 cases did not consent to organ donation, due to religious beliefs and concerns regarding the risks to the donor during procurement surgery. In 1 case, the potential donor was an irregular migrant, so there was no possibility of organ donation according to our national legislation. In 1 case, the patient had previously provided legal consent for future organ donation (via the e-Nabiz [e-Pulse] application, which is the online national personal health record system in Türkiye). However, his family refused organ donation, and the clinical conditions were not suitable for organ donation due to multiple organ dysfunction and presence of multidrug-resistant infection. There were multidrug-resistant infections in 3 cases.

Discussion
We retrospectively evaluated 10 BD cases in our hospital. We discovered the following details. (1) The ratio of BD cases versus total ICU patients was 0.17% in our center. (2) The rate of deceased donor organ donation was 20% in our center (2 deceased donors proceeded to donation from a total of 10 potential deceased donors). (3) The time from first evaluation to BD determination ranged between 7.3 and 169 hours. (4) The time from BD determination to cardiac arrest ranged between 4 and 91 hours. (5) For BD determination, the apnea test was performed in 7 patients (70%). (6) For all BD cases, ancillary tests were used. (7) The 4-vessel DSA was performed as an ancillary test for 3 cases (30%). (8) Most of the relatives of the patients refused organ donation, due to religious belief and thoughts like “unwillingness to relative’s body integrity loss”. (9) In 1 case, the potential donor was an irregular migrant, and so there was no possibility of organ donation according to our national legislation. (10) There were multidrug-resistant infections in 3 cases. The Department of Tissue, Organ Transplantation and Dialysis Services (DTOTDS) operates under the General Directory of Health Services of the Republic of Türkiye Ministry of Health. The DTOTDS is responsible for all organ transplant activity in Türkiye according to national legislation.⁵ The DTOTDS has estimated that the annual number of potential BD donors should be at least half the number of ICU beds available for ICU level 2 and ICU level 3. The DTOTDS has set an expectation that half of the BD-determined cases should conclude with a donation outcome. We have capacity for 86 adults in level 2 and level 3 ICU beds in our hospital. During the 18-month period of our study, approximately 64 BD cases and 32 organ donations would be predicted by DTOTDS. We determined 10 BD cases, and 2 of these proceeded to organ donation. Our ratio was lower than the DTOTDS targets. The aim of our study was to facilitate these efforts by overcoming the difficulties in BD determination, donor care, and family consent. The DTOTDS has reported a family consent ratio of 20% in Türkiye for the year 2025,⁵ and the family consent ratio that we report here in our study is similar. The time from first evaluation to BD determination of the cases ranged between 7.3 and 169 hours. The case with a BD determination time of 169 hours involved a patient with indeterminate brain CT findings in multiple imaging efforts and uncontrolled metabolic disorders, and these circumstances may have contributed to the prolongation of the time for confirmed diagnosis of BD. The time from BD determination to cardiac arrest of the cases ranged between 4 and 91 hours. For the case with the 91-hour BD determination, the decision by the patient’s family was a prolonged process, which eventually concluded against donation. Regarding end-of-life decisions, our national legislation allows for withdrawal of the support when organ donation does not take place. In 2022, the legislation was revised to read, “In cases where brain death is diagnosed, the organ preservation protocols applied are terminated in the absence of family or legal guardian approval regarding organ donation. In case of organ donation by the family or legal guardian, the organ preservation protocols needed for donor care are continued during the period until the transplant of the organ to the waiting patient”.^4,6 Although this revised legislation does authorize specialists’ withdrawal decisions, there remain some obstacles in clinical practice. Our coordination office continues to pursue the necessary additional efforts to overcome these obstacles. The apnea test was performed in 7 patients. The apnea test of 1 case was interrupted due to severe hypoxemia and hypotension. The apnea test of another case was not clinically indicated due to severe hypoxemia. The apnea test of a third case was impossible due to extreme morbid obesity, left total atelectasis, and acute lung injury. Therefore, the BD determination was performed via ancillary tests and clinical decision according to our national legislation.⁴ For all BD cases, ancillary tests were used in the study. The 4-vessel DSA was performed as the ancillary test for 3 cases (30%). The 4-vessel DSA is the gold standard test for BD determination.⁷ These 3 cases were initial procedures of our hospital to BD determination. Brain CT angiography was performed as the ancillary test for 7 cases (70%). The ancillary tests are obligatory in clinical conditions for patients <2 months old (2 tests) and when the apnea test is impossible or interrupted, according to our national legislation. There is no additional necessity for use of ancillary tests. We use 4-vessel DSA in cases for which the apnea test is impossible/interrupted or in cases with indeterminate brain CT angiography findings. In 7 cases, the patients’ families decided against organ donation due to religious beliefs and concerns regarding the risks of donor surgery (unwillingness to risk donor’s bodily integrity). In 1 case, the potential donor was an irregular migrant, and so there was no possibility of organ donation according to our national legislation. One patient had previously recorded organ donation intention via the e-Nabiz application as a legal personal decision. However, his family refused organ donation, and the clinical conditions were not suitable for organ donation due to multiple organ dysfunction and presence of multidrug-resistant infection. The family consent rate was 20% in our study period. There remains a possibility to enhance this rate in our hospital. Gulsoy and colleagues have reported that the reasons against organ donation could be categorized under 5 themes: (1) distrust (communication defects, frustration, anger, not meeting expectations), (2) thoughts that the procedure would not provide benefits, (3) fear (not accepting death, not understanding BD, and experiencing loss), (4) unwillingness to impair body integrity, and (5) anxious concern regarding social reactions. The authors also stated that the organ donation process begins with the patient’s admission to the hospital; if managed correctly, then the process can affect the decision of family in a positive manner.⁸ Our coordination office continues to pursue the necessary additional efforts to increase this rate. There were multidrug-resistant infections in 3 cases (30%). Among 3 infected cases, there was no organ donation with family consent. Organ utilization from deceased donors with multidrug-resistant infection remains inconsistent, and hesitancy to accept organs from these donors may relate to poor outcomes among solid-organ transplant recipients with donor-derived infections.⁹ Our coordination office continues to pursue the necessary additional efforts to increase the rate of collaboration with ICU specialists and infectious disease specialists. In the past 3 years, nearly 90% of organ transplants performed in our country have been from living donors. Deceased organ donation rates were 3.57, 4.25, and 5.48 per million population for the past 3 years in Türkiye. Approximately 35 000 patients with refractory end-stage organ failure are on the transplant wait list.⁵ The DTOTDS decided to promote organ donation rates and deceased organ transplant rates in past 2 years. Our national legislation was revised. To increase the donor source, organ donation has been facilitated in 2 stages through the online government portal and e-Nabiz portal applications. Organ donation has been made a personal legal decision for the individual while they are alive. The GCS has been implemented to raise awareness among potential donors. Cases with a GCS score of ≤6 are reported to organ and tissue transplant coordinators via standard text messaging protocol, and these coordinators are thereby prompted to conduct active ICU visits twice a day. The number of educational meetings, courses, symposiums, and congresses has been increased. 5 Guidelines have been published by the Turkish Ministry of Health, in collaboration with national medical societies, regarding the diagnosis of BD, radiological diagnosis, and donor care.^10-12

Conclusions
Medical knowledge and practices on organ donation and donor care after BD should be raised to international standards. It remains important for clinicians in the field of organ transplantation to increase cooperation with the Turkish Ministry of Health and hospital administrations to consider emerging scientific data in an effort to reduce organizational challenges. This will further strengthen organ transplant services, which are already quite successful in our country.