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Should I Accept This Heart? Addressing Uncertainty Associated with Increased Risk Donor Organs


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Khadieja Khalid, MBBch, BAO
The Ohio State University
Columbus, OH, USA



A 28 year old woman with no known past medical history is found down on a train with drug paraphernalia on her person. She is taken to the local hospital but unfortunately progresses to brain death by hospital day 3. Due to active intravenous drug use, she is deemed an increased risk donor, and you are offered her heart. Pertinent laboratory testing of the donor includes undetectable human immunodeficiency virus (HIV) and hepatitis C virus (HCV) nucleic acid tests (NAT), negative hepatitis B surface antigen, and negative hepatitis B core antibody. Do you accept the organ for a 45 year old woman with non-ischemic cardiomyopathy currently listed as a 1A at your center?

Scenarios such as this are becoming increasingly common, and transplant infectious disease providers are frequently asked, "How much risk does 'increased risk' pose?"

Part of this answer lies in the definition of "increased risk." In 2013, the United States Public Health Service (PHS) published guidelines for reducing the transmission of HIV, hepatitis B virus (HBV), and HCV through organ transplantation. In contrast to the previous 1994 PHS guidelines, which addressed prevention of HIV transmission through transplantation, the updated guidelines were expanded to include factors associated with an increased likelihood of recent HIV, HBV, or HCV infection and to assist in identifying donors who may be at increased risk for transmitting these infections to transplant recipients. Factors associated with increased risk of HIV, HBV, or HCV infection currently include hemodilution of the donor blood specimen and/or any of the following within the preceding 12 months: sex with a person known or suspected to have HIV, HBV, or HCV, men who have had sex with men (MSM), women who have had sex with a man with a history of MSM, sex in exchange for money or drugs, sex with a person who has had sex in exchange for money or drugs, sex with a person who has injected drugs for nonmedical reasons, nonmedical injection drug use, residence in lockup, jail, prison, or a juvenile correctional facility for ?72 hours, and a new diagnosis or treatment for syphilis, gonorrhea, Chlamydia, or genital ulcers. The need for hemodialysis in the preceding 12 months is now considered a risk for HCV only. Among pediatric donors, increased risk includes birth to a mother known to be infected with or at increased risk for HIV, HBV, or HCV and breastfeeding from a mother known to be infected with or increased risk for HIV infection within the preceding 12 months [1].

Screening modalities for HIV, HBV, and HCV also play a significant role in conceptualizing the risk of disease transmission to the recipient. A shift from the use of enzyme immunoassays (EIAs) to nucleic acid tests (NATs) for identification of HIV and HCV infection, for example, has shortened the window period for detection of HIV from 22 days to 9 days [2] and from 66 days to 7 days for HCV [3]. For this reason, the 2013 PHS guidelines recommend that all potential organ donors should undergo NAT testing for HCV infection and that increased risk donors should be screened for HIV via HIV NAT [1].

The final question is whether the risk for disease transmission is the same among all increased risk donors with undetectable HIV and HCV NAT results. It ultimately appears that "increased risk" is variable and depends upon the underlying increased risk behavior. Kucirka and colleagues assessed pooled HIV and HCV incidence estimates from each category of increased risk behavior and calculated the risk of window period HIV and HCV infections. For HIV, the risk of window period infection ranged from 0.04-4.9 per 10,000 donors with NAT testing and was highest in injection drug users, followed by MSM, sex workers, incarcerated donors, donors exposed to HIV through blood, and individuals engaging in high-risk sexual encounters [2]. Similarly, the risk of window period HCV infection ranged from 0.027-32.4 per 10,000 donors by NAT testing and was highest in injection drug users, followed by commercial sex workers, individuals engaging in high-risk sexual behavior, MSM, incarcerated donors, and donors exposed to HIV-infected blood [3].

Overall, it appears that the risk of HIV, HBV, and HCV transmission from increased risk donors is relatively low (and significantly less than the 1 in 2000 risk of needing emergency treatment in the next year after being injured by a bed mattress or pillow, as reported by the British Medical Journal [4]). Nonetheless, the decision to use an increased risk donor organ requires informed consent from the recipient. Additionally, as the risk of infectious disease transmission is not zero, and rare transmissions have occurred, experts have recommended a modified recipient testing schedule at 1, 3, and 12 months post-transplant utilizing NAT testing for HIV and HCV as well as hepatitis B surface antigen testing [1]. ■

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. Seem DL, Lee I, Umscheid CA, et al. PHS Guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation. Public Health Rep 2013;128(4):247-344.
  2. Kucirka LM, Sarathy H, Govindan P, et al. Risk of window period HIV infection in high infectious risk donors: systematic review and meta-analysis. Am J Transplant 2011;11(6):1176-1187.
  3. Kucirka LM, Sarathy H, Govindan P, et al. Risk of window period hepatitis-C infection in high infectious risk donors: systematic review and meta-analysis. Am J Transplant 2011;11(6):1188-1200.
  4. Table of everyday risks. http://www.bmj.com/content/suppl/2003/09/25/327.7417.694.DC1



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