Infectious Disease Transmission in Solid Organ Transplantation
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Review Infectious Disease Transmission in Solid Organ Transplantation: Donor Evaluation, Recipient Risk, and Outcomes of Transmission SarahL.White,PhD,1 William Rawlinson, FRACP, FRCPA, PhD,2,3 Peter Boan, FRACP, FRCPA,4,5 Vicky Sheppeard, FAFPHM,6 Germaine Wong, FRACP, PhD,7,8,9 Karen Waller, MBBS,1 Helen Opdam, FRACP, FCICM,10,11 John Kaldor, PhD,12 Michael Fink, MD, FRACS,10,13 Deborah Verran, MD, FRACS,14 Angela Webster, PhD, FRCP, FRACP,7,9 Kate Wyburn, FRACP, PhD,1,15 Lindsay Grayson, MD, FRACP, FAFPHM, FRCP, FIDSA,10,13 Allan Glanville, MD, FRACP,16 Nick Cross, MD, PhD,17 Ashley Irish, FRACP,18,19 Toby Coates, FRACP, PhD,20,21 Anthony Griffin, FRACS,22 Greg Snell, MD, FRACP,23 StephenI.Alexander,MD,FRACP,8 Scott Campbell, FRACP, PhD,24 Steven Chadban, FRACP, PhD,1,15 Peter Macdonald, MD, FRACP, PhD,25,26 Paul Manley, FRACP,27 Eva Mehakovic,11 Vidya Ramachandran, MBBS,2 Alicia Mitchell, PhD,16,28,29 and Michael Ison, MD30 Abstract. In 2016, the Transplantation Society of Australia and New Zealand, with the support of the Australian Government Or- gan and Tissue authority, commissioned a literature review on the topic of infectious disease transmission from deceased donors to recipients of solid organ transplants. The purpose of this review was to synthesize evidence on transmission risks, diagnostic test characteristics, and recipient management to inform best-practice clinical guidelines. The final review, presented as a special supplement in Transplantation Direct, collates case reports of transmission events and other peer-reviewed literature, and summa- rizes current (as of June 2017) international guidelines on donor screening and recipient management. Of particular interest at the time of writing was how to maximize utilization of donors at increased risk for transmission of human immunodeficiency virus, hep- atitis C virus, and hepatitis B virus, given the recent developments, including the availability of direct-acting antivirals for hepatitis C virus and improvements in donor screening technologies. The review also covers emerging risks associated with recent epidemics (eg, Zika virus) and the risk of transmission of nonendemic pathogens related to donor travel history or country of origin. Lastly, the implications for recipient consent of expanded utilization of donors at increased risk of blood-borne viral disease transmission are considered. (Transplantation Direct 2018;4: e416; doi: 10.1097/TXD.0000000000000852. Published online 20 December, 2018.) Received 13 August 2018. 11 The Organ and Tissue Authority, Australian Government, Canberra, Australia. Accepted 15 August 2018. 12 Kirby Institute, University of New South Wales, Sydney, Australia. 1 Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, 13 Department of Surgery, Melbourne Medical School, The University of Melbourne, Australia. Melbourne, Australia. 2 Serology and Virology Division, NSW Health Pathology Prince of Wales Hospital, 14 Transplantation Services, Royal Prince Alfred Hospital, Sydney, Australia. Sydney, Australia. 15 Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia. 3 Women's and Children's Health and Biotechnology and Biomolecular Sciences, 16 Department of Thoracic Medicine and Lung Transplantation, St Vincent's Hospi- University of New South Wales Schools of Medicine, Sydney, Australia. tal, Sydney, Australia. 4 Departments of Infectious Diseases and Microbiology, Fiona Stanley Hospital, 17 Department of Nephrology, Canterbury District Health Board, Christchurch Hos- Perth, Australia. pital, Christchurch, New Zealand. 5 PathWest Laboratory Medicine, Perth, Australia. 18 Department of Nephrology, Fiona Stanley Hospital, Perth, Australia. 6 Communicable Diseases Network Australia, New South Wales Health, Sydney, 19 Faculty of Health and Medical Sciences, UWA Medical School, The University of Australia. Western Australia, Crawley, Australia. 7 Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia. 20 Renal and Transplantation, Royal Adelaide Hospital, Adelaide, Australia. 8 Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, 21 Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia. Australia. 9 Sydney School of Public Health, The University of Sydney, Sydney, Australia. 22 Renal Transplantation, Princess Alexandra Hospital, Woolloongabba, Queensland, 10 Austin Health, Melbourne, Australia. Australia. Transplantation DIRECT ■ 2018 www.transplantationdirect.com 1 2 Transplantation DIRECT ■ 2018 www.transplantationdirect.com he unanticipated transmission of an infectious disease i. donor-derived infectious disease transmission events in re- Tfrom an organ donor to recipient(s) is a rare event; how- cipients of solid organs from deceased donors; ever, when it does occur, it is associated with significant morbid- ii. residual risk of bloodborne virus transmission under dif- ity and mortality.1 Therefore, it is the goal of organ donation ferent deceased donor scenarios; and transplantation programs to minimize such events while si- iii. the impact on recipient outcomes of the transmission of viral, bacterial, parasitic, fungal, and other infectious diseases; multaneously maximizing opportunities for transplantation. iv. diagnostic test availability, modality, and performance, and This goal relies on (i) rational donor screening policies based international guidelines for donor screening; on an understanding of the epidemiology of infectious diseases v. clinical practice strategies for minimizing transmission risk of interest and the performance characteristics of the tests used from increased-risk donors; to diagnose them, and (ii) evidence regarding patient outcomes vi. current international recommendations with respect to re- in the event of disease transmission, to facilitate informed de- cipient management posttransplant in the event of possible cision making with regard to the risk tradeoff between infectious disease transmission; accepting an organ with an increased risk of disease transmis- vii. vigilance and surveillance systems in organ donation sion versus remaining on the waiting list. and transplantation. This literature review summarizes case reports, peer- The potential to transmit bloodborne viruses (BBV)— reviewed literature, and international guidelines on the fol- human immunodeficiency virus (HIV), hepatitis C virus lowing topics: contributions to the conception and intellectual content of the review, provided 23 Lung Transplant, Alfred Health, Melbourne, Victoria, Australia. critical revision of drafts, and approved the final version for publication. K.W. made 24 Department of Renal Medicine, University of Queensland at Princess Alexandra substantial contributions to the conception and intellectual content of the review, Hospital, Woolloongabba, Queensland, Australia. provided critical revision of drafts, and approved the final version for publication. 25 M.L.G. made substantial contributions to the interpretation of evidence and to the Department of Cardiology, St Vincent's Hospital, Sydney, Australia. intellectual content of the review, provided critical revision of drafts, and approved 26 St Vincent's Hospital Victor Chang Cardiac Research Institute, University of New the final version for publication. A.G. made substantial contributions to the South Wales, Sydney, Australia. interpretation of evidence, reviewed the work for important intellectual content, and 27 Kidney Disorders, Auckland District Health Board, Auckland City Hospital, approved the final version for publication. N.C. made substantial contributions to Auckland, New Zealand. the acquisition of information, reviewed the work for important intellectual content, 28 and approved the final version for publication. A.I. made substantial contributions Woolcock Institute of Medical Research, Sydney, Australia. to the interpretation of evidence, reviewed the work for important intellectual 29 School of Medical and Molecular Biosciences, University of Technology, Sydney, content, and approved the final version for publication. T.C. made substantial Australia. contributions to the interpretation of evidence, reviewed the work for important 30 Divisions of Infectious Diseases and Organ Transplantation, Northwestern Univer- intellectual content, and approved the final version for publication. A.G. made sity Feinberg School of Medicine, Chicago, IL. substantial contributions to the interpretation of evidence, reviewed the work for important intellectual content, and approved the final version for publication. G.S. This literature review was funded by The Transplantation Society of Australia and made substantial contributions to the interpretation of evidence, reviewed the work New Zealand and the Australian Government Organ and Tissue Authority. for important intellectual content, and approved the final version for publication. None of the authors have any conflicts of interest to declare in relation to this work. S.A. made substantial contributions to the interpretation of evidence, reviewed the Disclaimer: The information contained in this document is for general information work for important intellectual content, and approved the final version for only. It is designed to be educational, and is not intended to be, and is not, a publication. S.Ca. made substantial contributions to the interpretation of evidence, complete or definitive statement on any area of medical practice or procedure. reviewed the work for important intellectual content,