Selecting suitable solid organ transplant donors: Reducing the risk of donor-transmitted infections

Table 1 Mortality figures by type of transplant for 2010 according to the Scientific Registry of Transplant Recipients 2011 Annual Report¹

Organtansplanted2	Waiting list mortality incidence density3 (deaths per 1000 patient-years)	1 yr posttransplant mortality incidence density (deaths per 1000 patient-years)
Kidney	56.5	34.9
Liver	115.6	123.7
Intestine	71.6	193.5
Heart	115.8	91.8
Lung	154.1	164.2

¹The data and analyses reported in the 2011 Annual Data Report of the United States Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients have been supplied by UNOS and the Minneapolis Medical Research Foundation under contract with HHS/HRSA. The authors alone are responsible for reporting and interpreting these data; the views expressed herein are those of the authors and not necessarily those of the United States Government;

²Data reported in table is for deceased donor only;

³Incidence is reported as deaths per 1000 patient years at risk.

Table 2 Approach to selecting suitable donors for solid organ transplantation

Infections	Diagnostic tools	Treatment considerations
Bacteremia	Blood cultures	Treat donor 24 h
	Antibiogram	Tailored recipient therapy in posttransplant period
Resistant bacteria	Blood cultures	Tailored donor and recipient therapy
	Sterile site cultures
	Antibiogram
Meningoencephalitis	CSF analysis	Tailored therapy if meningitis only
	CSF culture and stain
	Cryptococcus antigen
	NAAT
Syphilis	Treponemal testing	Treat recipients as late latent syphilis
	Nontreponemal testing
Viral hepatitis	Serologic evaluation NAAT	Prophylaxis Tailored therapy HBIG Antivirals
Influenza	Influenza testing	Neuraminidase inhibitor
	Respiratory virus PCR
HTLV 1/2	Routine screening not recommended	No effective treatment, surveillance for recipients of positive donors
Candida infection	Blood cultures Sterile site cultures Antibiogram	Antifungal treatment of donor
		Treat colonization in certain settings
Cryptococcosis	CSF cryptococcal antigen	Antifungal treatment of donors prior to donation
	Serum cryptococcal antigen
Endemic fungi	Urine antigen testing	Antifungal treatment of donors prior to donation
	Serologic evaluation
	Sterile site culture
	Histologic evaluation
Schistosomiasis	Stool examination	Treat living donor successfully prior to donation
	Serologic evaluation
	Rectal biopsy
Strongyloidiasis	Serologic evaluation	Treat recipients from positive donors
	Stool examination
Chagas disease	Enzyme immunoassay	Treat recipient for positive surveillance testing
	Radioimmune precipitation assay

HTLV: Human T-lymphotropic virus; NAAT: Nucleic acid amplification testing; PCR: Polymerase chain reaction; HBIG: Hepatitis B immunoglobulin.

Table 3 Suggested approach to donor-transmitted Mycobacterium tuberculosis

Deceased donors
1TB Risk	2Suggestive radiology	3Donor testing	4Donor treated	Accept allograft	Additional consent	5Recipient treatment	Additional recipient testing
Low	No	Negative	N/A	Yes	None	None	None
Low	Yes	Negative	No/Yes	Yes	Yes	Chemoprophylaxis	None
Low	Yes	Pending	No/Yes	No	N/A	N/A	N/A
Elevated	No	Negative	No/Yes	Yes	Yes	Chemoprophylaxis	None
Elevated	Yes	Negative	No/Yes	Yes	Yes	Chemoprophylaxis	None
Elevated	Yes	Pending	No/Yes	No	N/A	N/A	N/A
Elevated	Yes	Positive	No/Yes	No	N/A	N/A	N/A
Prior active TB	Yes	Negative	Yes	Yes	Yes	Chemoprophylaxis	None
Prior active TB	Yes	Pending	Yes	Yes	Yes	Chemoprophylaxis	None
Prior active TB	Yes	Positive	No/Yes	No	N/A	N/A	N/A
Prior active TB	Yes	Positive	No	No	N/A	N/A	N/A
Active TB	Yes	Positive	No/Yes	No	N/A	N/A	N/A
Living donors
Low	No	Negative	N/A	Yes	No	None	None
LTBI	No	Positive	Yes	No	Yes	None	None
Active TB	No	Positive	No	No	N/A	N/A	N/A
Elevated	Yes	Negative	No/Yes	Yes	Yes	Chemoprophylaxis	None

¹Based on history and physical examination;

²Apical fibrosis and/or pleural thickening on chest radiograph or computerized tomography scan;

³Sputum acid fast bacilli (AFB) smear and culture; molecular testing on smear-positive sputum;

⁴Must be documented treatment with appropriate anti-TB therapy;

⁵Refers to accepted regimen for treatment of latent tuberculosis infection (LTBI). TB: Tuberculosis; N/A: Not applicable.

Table 4 Factors associated with increased risk for human immunodeficiency virus, hepatitis B virus, hepatitis C virus infection and potential donor transmission

People who have had sex with person known or suspected to have HIV, HBV, or HCV in the preceding 12 mo

MSM in the preceding 12 mo

Women who have had sex with a man with a history of MSM in the preceding 12 mo

People who have had sex in exchange for money or drugs in the preceding 12 mo

People who have had sex with a person who has had sex in exchange for money or drugs in the preceding 12 mo

People who have had sex with a person who has injected drugs for nonmedical reasons in the preceding 12 mo

A child who is ≤ 18 mo of age and born to a mother known to be infected with, or at risk for HIV, HBV or HCV infection

A child who has been breastfed within the preceding 12 mo and the mother is known to be infected with, or at risk for HIV, HBV or HCV infection

People who have injected drugs for nonmedical reasons in the preceding 12 mo

People who have been in lockup, jail, prison or a juvenile correctional facility for ≥ 72 consecutive hours in the preceding 12 h

People who have been newly diagnosed with, or have been treated for, syphilis, gonorrhea, Chlamydia or genital ulcers in the preceding 12 mo

People who have been on hemodialysis in the preceding 12 mo (HCV only)

HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus; MSM: Men who have sex with men.