8.9.1 Infection
Statements of Recommendation
Infection screening is important to identify potential risk for the donor from previous or current infection and to assess potential risk of transmission to the recipient. (A1)
Active hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are contraindications to donation. HBV core antibody positive patients and
HCV antibody positive/HCV RNA negative patients can be considered as liver donors in exceptional circumstances. (A1)
Cytomegalovirus or Epstein Barr Virus positivity is not a contraindication to donation but counselling must be provided re the risk of primary infection and lymphoproliferative disorder. (A1)
Human immune deficiency virus or human T lymphotrophic virus infection is an absolute contraindication to donation. (A1)
Identification of current or previous infection in the prospective donor is an important component of donor evaluation. A number of infections may be transmitted at the time of organ transplantation.
Infections can be transmitted by organ donation during the incubation period of the offending organism and before a serological response has been mounted. Serology is therefore not a substitute for a detailed psychosexual and medical history. Routine testing for viral infection may, if positive, raise complex ethical problems.
Human Immune Deficiency Virus (HIV) or Human T Lymphotrophic Virus (HTLV) The presence of human immune deficiency virus (HIV) or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. HIV and HTLV serology must be performed in the prospective donor (26).
Hepatitis C Virus
Active hepatitis C virus (HCV) in the donor is a contraindication to living donation. The risk of HCV transmission from an HCV RNA positive donor approaches 100% if transplanted into a virus-naive recipient. All potential donors must have HCV antibody testing performed and, if positive, HCV RNA must be checked. If the antibody-positive donor is consistently RNA negative, then transplantation may be considered, even into a naive recipient. The risks must be carefully explained to both donor and recipient.
testing must be performed in prospective donors from endemic areas who are core antibody positive, those with possible mutant HBV, and those with abnormal liver tests or a past history of liver disease of unknown aetiology. Testing for HBV IgM core antibody is not required unless the donor is HBeAg positive and acute infection is queried.
Several studies of both liver and kidneys transplanted from HBsAg and HBV DNA negative but core antibody-positive deceased donors report a low risk of seroconversion and no excess risk of graft failure or short-term morbidity. In the context of living donation, donors with this virological profile may be considered providing the recipient has either been effectively immunised against HBV or will be administered maintenance antiviral therapy. Advice from a hepatologist must be sought under these circumstances and the donor and recipient kept fully informed (27).
Cytomegalovirus (CMV) Infection
CMV infection is the most common clinically significant viral infection after liver transplantation and may cause significant morbidity and mortality. It also increases the risk of chronic graft dysfunction and post-transplant lymphoproliferative disorder (PTLD) and opportunistic infection.
CMV disease may result from reactivation of latent infection or because of primary infection transmitted by liver or blood product transfusion from a CMV positive donor. Primary infection is generally more severe. Matching CMV seronegative recipients with CMV seronegative donors is an effective strategy for reducing the risk of CMV infection but is rarely practicable in the context of living donor transplantation. Either CMV prophylaxis or pre-emptive therapy with close monitoring of viral loads must be offered. Education of donor and recipient regarding this viral illness is recommended.
Epstein-Barr virus (EBV) infection
Primary EBV infection is most likely to occur in EBV-negative paediatric recipients who receive a liver from an EBV-positive donor. EBV infection increases the risk of PTLD several-fold and this risk is increased further if the recipient is given anti-lymphocyte antibody immunosuppressive therapy. Vigilance is required to detect PTLD as early as possible. Consideration must be given to the prophylactic use of antiviral agents in order to minimise viral load after transplantation, although the benefit of this approach is unclear (28).
Miscellaneous Infection
HHV8 may be transmitted by organ transplantation and is associated with an increased risk of Kaposi sarcoma (29,30). However, there is no evidence to support the screening of potential organ donors.
There must be active screening for Mycobacterium tuberculosis and atypical mycobacteria. A careful history and a chest X-ray is a satisfactory initial triage.
Transmission of syphilis has been reported in the UK to two recipients from a deceased organ donor with a past history of treated disease. If there is concern re potential transmission, discussion with specialist in genitourinary medicine is recommended.
Toxoplasmosis and malaria have been transmitted by living donor kidney transplantation in the developing world.
No screening test is currently available for the prion-associated diseases (CJD or vCJD). To date, transmission by living donor kidney or liver has not been reported. Relevant history would include recipients of human pituitary-derived (growth) hormones, dura mater, corneal and scleral grafts or a positive family history of prion- associated disease.