Transplantation of contaminated organs

A systematic review and disability-adjusted life years of Scedosporium/Lomentospora infection in patients after near-drowning

Scedosporium/Lomentospora species exist as saprophytic moulds that can potentially lead to serious infections in patients who have experienced near-drowning incidents. Scedosporium species are distributed across different regions of the world while Lomentospora prolificans has quite a restricted geographic distribution. We aimed to systematically review scedosporiosis cases after near-drowning, their clinical manifestations, underlying diseases, treatments, outcomes and its impact through disability-adjusted life years (DALYs). Five available sources were searched from 1 January 2007, to 20 April 2022. Thirty-eight studies, including 41 patients, were evaluated. Mean age was 33.6 ± 18.6 years (range 1-68), and 28 were male (68.3%). Central nervous system (CNS) dissemination predominated (36/41; 87.8%), presenting mainly as multiple brain abscesses (26/41; 63.4%), followed by lung involvement (22/41; 56.4%). Scedosporium apiospermum species complex was the most causative agent (38/41; 92.7%). Overall mortality was 51.2%. Half of the patients (18/37) were cured after receiving proper treatment, and in most cases, voriconazole alone or in combination with surgery or other antifungals caused survival. The mean survival time was 123 ± 27 days. Mean DALYs in 1980-2022 were 46.110 ± 3.318 (39.607-52.612). Time to diagnosis was estimated to be 120 days, and there was no association between time to diagnosis and outcome. Voriconazole is a potentially effective therapy, and combination of surgery and antifungal treatment may lead to more favourable outcome. Advances in early diagnosis and appropriate antifungal therapy may have contributed to reducing its mortality.

Scedosporium Infection in Recipients of Kidney Transplants from Deceased Near-Drowning Donor

Scedosporium aurianticum infection developed in 2 recipients of kidney transplants in India, acquired from the same deceased near-drowning donor. Given the substantial risk for death associated with Scedosporium infection among solid-organ transplant recipients, safety protocols for organ transplantation from nearly drowned donors should be thoroughly revaluated and refined.

Wide-spectrum antibiotic prophylaxis guarantees optimal outcomes in drowned donor kidney transplantation

BACKGROUND

Drowned victims possibly obtain various pathogens from drowning sites. Using drowned renal donors to expand the donor pool still lacks consensus due to the potential risk of disease transmission.

RESEARCH DESIGN AND METHODS

This retrospective study enrolled 38 drowned donor renal recipients in a large clinical center from August 2012 to February 2021. A 1:2 matched cohort was generated with donor demographics, including age, gender, BMI, and ICU durations. Donor microbiological results, recipient perioperative infections, and early post-transplant and first-year clinical outcomes were analyzed.

RESULTS

Compared to the control group, drowned donors had significantly increased positive fungal cultures (36.84% vs.13.15%, p = 0.039). Recipients in the drowned group had significantly higher rates of gram-negative bacteria (GNB) and multidrug-resistant GNB infections (23.68% vs.5.26%, 18.42% vs. 3.95%, both p < 0.05). Other colonization and infections were also numerically more frequent in the drowned group. Drowned donor recipients receiving inadequate antibiotic prophylaxis had more perioperative bloodstream infections, higher DGF incidences, and more first-year respiratory tract infections and recipient loss than those receiving adequate prophylaxis (all p < 0.05). Clinical outcomes were similar between the adequate group and the control group.

CONCLUSIONS

Drowned donors could be suitable options under wide-spectrum and adequate antimicrobial prophylaxis.

Trends in pediatric liver transplant donors and deceased donor circumstance of death in the United States, 2002-2015

While much of the discussion regarding expanding the donor pool for pediatric liver transplantation has surrounded the use of technical variant grafts, little attention has been directed toward changes in the deceased donor population. The aim of this study was to investigate trends in the circumstance of the death of deceased donors used for pediatric liver transplantation. All pediatric liver transplant recipients transplanted between 2002 and 2015 were identified in the UNOS database and were categorized based on the donor circumstance of death. There was no significant correlation between year of transplantation and number of pediatric liver transplants performed, pediatric donors, split livers, or living donors. There was a significant downward trend in donors from motor vehicle fatalities and an upward trend in suicide, non-MVA, and death due to natural causes. There was also an upward trend in drowning, one of the most common mechanisms of death among non-MVA in 2015. While the number of donors who died in MVA has fallen, the number of deceased donors who died from suicide, natural causes, and non-MVA, especially drowning, has increased, maintaining the overall number of pediatric deceased donor livers transplanted.

Are drowned donors marginal donors? A single pediatric center experience

Drowning, a common cause of death in the pediatric population, is a potentially large donor pool for OLT. Anecdotally, transplant centers have deemed these organs high risk over concerns for infection and graft dysfunction. We theorized drowned donor liver allografts do not portend worse outcomes and therefore should not be excluded from the donation pool. We reviewed our single-center experience of pediatric OLTs between 1988 and 2015 and identified 33 drowned donor recipients. These OLTs were matched 1:2 to head trauma donor OLTs from our center. A chart review assessed postoperative peak AST and ALT, incidence of HAT, graft and recipient survival. Recipient survival at one year between patients with drowned donor vs head trauma donor allografts was not statistically significant (94% vs 97%, P=.63). HAT incidence was 6.1% in the drowned donor group vs 7.6% in the control group (P=.78). Mean postoperative peak AST and ALT was 683 U/L and 450 U/L for drowned donors vs 1119 U/L and 828 U/L in the matched cohort. These results suggest drowned donor liver allografts do not portend worse outcomes in comparison with those procured from head trauma donors.

Confirmed Transmission of Bacterial or Fungal Infection to Kidney Transplant Recipients from Donated After Cardiac Death (DCD) Donors in China: A Single-Center Analysis

Background

We aimed to investigate blood and urine cultures of donated after cardiac death (DCD) donors and report the cases of confirmed (proven/probable) transmission of bacterial or fungal infection from donors to kidney recipients.

Material/Methods

Seventy-eight DCD donors between 2010 and 2016 were included. Sixty-one DCD donors underwent blood cultures and 22 episodes of bacteremias developed in 18 donors. Forty-three donors underwent urine cultures and 14 donors experienced 17 episodes of urinary infections.

Results

Seven of 154 (4.5%) kidney recipients developed confirmed donor-derived bacterial or fungal infections. Inappropriate use of antibiotics in donor was a risk factor for donor-derived infection (p=0.048). The use of FK506 was more frequent in recipients without donor-derived infection than those with donor-derived infection (p=0.033). Recipients with donor-derived infection were associated with higher mortality and graft loss (42.9% and 28.6%, respectively), when compared with those without donor-derived infection (4.8% each). Three kidney recipients with donor-derived infection died; one death was due to multi-organ failure caused by Candida albicans, and two were related to rupture of the renal artery; two of them did not receive appropriate antimicrobial therapy after infection.

Conclusions

Our kidney recipients showed high occurrence rates of donor-derived infection. Recipients with donor-derived infection were associated with higher mortality and graft loss than those without donor-derived infection. The majority of recipients with donor-derived infection who died did not receive appropriate antimicrobial therapy after infection.

Respiratory Failure due to Possible Donor-Derived Sporothrix schenckii Infection in a Lung Transplant Recipient

Background. De novo and donor-derived invasive fungal infections (IFIs) contribute to morbidity and mortality in solid organ transplant (SOT) recipients. Reporting of donor-derived IFIs (DDIFIs) to the Organ Procurement Transplant Network has been mandated since 2005. Prior to that time no systematic monitoring of DDIFIs occurred in the United States. Case Presentation. We report a case of primary graft dysfunction in a 49-year-old male lung transplant recipient with diffuse patchy bilateral infiltrates likely related to pulmonary Sporothrix schenckii infection. The organism was isolated from a bronchoalveolar lavage on the second day after transplantation. Clinical and radiographic responses occurred after initiation of amphotericin B lipid formulation. Conclusion. We believe that this was likely a donor-derived infection given the early timing of the Sporothrix isolation after transplant in a bilateral single lung transplant recipient. This is the first case report of sporotrichosis in a lung transplant recipient. Our patient responded well to amphotericin induction therapy followed by maintenance therapy with itraconazole. The implications of donor-derived fungal infections and Sporothrix in transplant recipients are reviewed. Early recognition and management of these fungi are essential in improving outcomes.

Fatal scedosporiosis in multiple solid organ allografts transmitted from a nearly-drowned donor

Scedosporium spp. is the most common mold infection in pneumonia resulting from near-drowning. Three fatal scedosporiosis cases developed after solid organ transplantation, probably transmitted from the nearly-drowned donor. One heart transplant recipient and two kidney transplant recipients developed fatal scedosporiosis following deceased donor transplantation from the same donor, a nearly-drowned victim of a suicide attempt. Genotypically, indistinguishable strains of Scedosporium auratiacum were recovered from the three recipients. Two liver transplant recipients from the same donor received prophylactic voriconazole without any subsequent signs of infection. To determine the safety of donation from nearly-drowned donors, a national traceback investigation was also performed of the causes of deaths in all transplant recipients who received organs from drowned donors between 2001 and 2013. Over 13 years, 2600 deceased donor transplants were performed in Korea. Among these 2600 deceased donor transplants, 27 (1%) victims of drowning donated their organs. From these 27 donors, 84 patients received organ transplants and 18 died, including the above three. We found no microbiologic evidence of invasive mold transmission from the nearly-drowned donors to the other 15 recipients. Although disseminated infection in the donor could not be demonstrated by culture, undiagnosed disseminated donor infection and transmission of Scedosporium spp. should be considered in near-drowning events.

Quality of life, risk assessment, and safety research in liver transplantation: new frontiers in health services and outcomes research

PURPOSE OF REVIEW

In this review, we briefly summarize three fruitful, emerging areas in liver transplantation research, quality of life; risk assessment; and patient safety. Our goal is to highlight recent findings in these areas, with a call for increased integration of social scientists and transplant clinicians to address how best to shape policy and improve outcomes.

RECENT FINDINGS

After liver transplantation, recipients generally experience clinically significant, sustained improvement in their physical, social and emotional well being. However, a sizeable minority of patients do experience excess morbidity that may benefit from ongoing surveillance and/or intervention. There is growing body of research that describes risks associated with liver transplantation, which can be useful aids to better inform decision making by patients, clinicians, payers, and policy makers. In contrast, there has been a relative lack of empirical data on transplant patient safety vulnerabilities, placing the field of surgery in stark contrast to other high-risk industries, wherein such assessments inform continuous process improvement.

SUMMARY

Health services and outcomes research has grown in importance in the liver transplantation literature, but several important questions remain unanswered that merit programmatic, interdisciplinary research.

Donor-derived fungal infections in organ transplant recipients: guidelines of the American Society of Transplantation, infectious diseases community of practice

Donor-derived fungal infections can be associated with serious complications in transplant recipients. Most cases of donor-derived candidiasis have occurred in kidney transplant recipients in whom contaminated preservation fluid is a commonly proposed source. Donors with cryptococcal disease, including those with unrecognized cryptococcal meningoencephalitis may transmit the infection with the allograft. Active histoplasmosis or undiagnosed and presumably asymptomatic infection in the donor that had not resolved by the time of death can result in donor-derived histoplasmosis in the recipient. Potential donors from an endemic area with either active or occult infection can also transmit coccidioidomycosis. Rare instances of aspergillosis and other mycoses, including agents of mucormycosis may also be transmitted from infected donors. Appropriate diagnostic evaluation and prompt initiation of appropriate antifungal therapy are warranted if donor-derived fungal infections are a consideration. This document discusses the characteristics, evaluation and approach to the management of donor-derived fungal infections in organ transplant recipients.

Invasive fungal infections in solid organ transplant recipients

Invasive fungal infections are a major problem in solid organ transplant (SOT) recipients. Overall, the most common fungal infection in SOT is candidiasis, followed by aspergillosis and cryptococcosis, except in lung transplant recipients, where aspergillosis is most common. Development of invasive disease hinges on the interplay between host factors (e.g., integrity of anatomical barriers, innate and acquired immunity) and fungal factors (e.g., exposure, virulence and resistance to prophylaxis). In this article, we describe the epidemiology and clinical features of the most common fungal infections in organ transplantation. Within this context, we review recent advances in diagnostic modalities and antifungal chemotherapy, and their impact on evolving prophylaxis and treatment paradigms.

Scedosporium apiospermum infection after near-drowning

Scedosporium apiospermum and its teleomorph (sexual form) Pseudallescheria boydii are ubiquitous saprophytic fungi, which under specific conditions, such as near-drowning, may cause therapy-refractory and life-threatening infections. We reviewed 22 cases (eight children and 14 adults) of S. apiospermum infection after near-drowning reported in the literature including an additional paediatric case from our institution. Scedosporiosis after near-drowning was associated with high mortality (16/23, 70%) even in immunocompetent hosts. It affected mainly young (mean age 24 years) and immunocompetent (83% with no apparent immune defect) males (male to female ratio 2.5 : 1). Scedosporiosis after near-drowning was a slow progressive disease (mean survival time 87 days) involving virtually all body organs. However, central nervous system (CNS) dissemination predominated (21/23, 91%) presenting mainly as multiple brain abscesses (15/23, 65%). All 23 patients showed preceding clinical and/or radiological evidence of lung disease indicating the mode of invasion. Diagnosis was delayed (median time to diagnosis 28 days) and was made by culture (16/23, 69.5%) or culture and tissue examination (7/23, 30.5%). The majority of the patients (20/23, 87%) received antifungal treatment and underwent neurosurgery. While the optimal treatment remains undefined, the most recent reports indicated voriconazole as a potentially effective option. Better knowledge of scedosporiosis after near-drowning could lead to improved intervention and ultimately to more favourable outcome.

Arterial anastomosis disrupton in two kidney recipients of contaminated grafts from a donor with Gorham's syndrome

Transmission of donor infections to immunosuppressed recipients may produce serious complications. Here, we report two cases of ruptured renal artery pseudoaneurysm within a few months after renal transplantation from a donor with Gorham's syndrome, a rare disease characterized by proliferation of vascular and lymphatic channels associated with extensive bony destruction. The donor had died of respiratory failure, sepsis, and anoxic brain death due to difficult airway control secondary to a maxillofacial deformity.

Donor-related coccidioidomycosis in organ transplant recipients

Most cases of coccidioidomycosis in organ transplant recipients arise from either primary infection with Coccidioides immitis after environmental exposure or from reactivation of latent infection. Herein, we report 2 cases of rapidly fatal, disseminated coccidioidomycosis that occurred in organ transplant recipients who had never lived in or visited an area where C. immitis is endemic. Both subjects had received a transplanted organ from the same donor, an individual with unrecognized active coccidioidomycosis at the time of his death.

Cardiac Transplantation: Pre-transplant Infectious Diseases Evaluation and Post-transplant Prophylaxis

Screening of recipients and donors of cardiac allografts for infectious pathogens, and the use of appropriate immunization and antimicrobial prophylaxis strategies, remain important for the control of infection following heart transplantation. However, the risk of infectious complications in a particular patient must often be weighed against the risk of delaying or denying allograft transplantation. In addition, the ongoing degree of immunosuppression and its contribution to the risk for infectious complications should also be considered to guide the length of prophylactic antimicrobial therapy and provide optimal patient care.

Infections in solid-organ transplant recipients

Solid-organ transplantation is a therapeutic option for many human diseases. Infections are a major complication of solid-organ transplantation. All candidates should undergo a thorough infectious-disease screening prior to transplantation. There are three time frames, influenced by surgical factors, the level of immunosuppression, and environmental exposures, during which infections of specific types most frequently occur posttransplantation. Most infections during the first month are related to surgical complications. Opportunistic infections typically occur from the second to the sixth month. During the late posttransplant period (beyond 6 months), transplantation recipients suffer from the same infections seen in the general community. Opportunistic bacterial infections seen in transplant recipients include those caused by Legionella spp., Nocardia spp., Salmonella spp., and Listeria monocytogenes. Cytomegalovirus is the most common cause of viral infections. Herpes simplex virus, varicella-zoster virus, Epstein-Barr virus and others are also significant pathogens. Fungal infections, caused by both yeasts and mycelial fungi, are associated with the highest mortality rates. Mycobacterial, pneumocystis, and parasitic diseases may also occur.

Transmission of invasive aspergillosis from a subclinically infected donor to three different organ transplant recipients

OBJECTIVE

To describe a cluster of donor-transmitted cases of invasive aspergillosis.

DESIGN

Case series of epidemiologically linked cases of invasive aspergillosis.

SETTING

Two tertiary care centers with solid-organ transplant programs.

PATIENTS

Two kidney recipients, one heart recipient, and the single donor.

MEASUREMENTS

Routine clinical, microbiological, and pathologic investigation as dictated for patient care. Epidemiologic analysis to establish linkage among cases.

RESULTS

Three allografts (two kidneys and a heart) from a single donor transmitted invasive aspergillosis to the recipients. Three weeks after transplantation, the two kidney recipients had fever and urine cultures positive for Aspergillus fumigatus. The infected kidneys had multiple Aspergillus abscesses and had to be removed to cure the patients. The heart recipient had a negative workup when a diagnosis of aspergillosis was made for the kidney recipients but presented three months later with aspergillus endocarditis with hematogenous spread to the eyes and to the skin. Treatment included eye surgery, aortic valve replacement, and antifungal therapy; control of infection ensued. The donor was intensely immunosuppressed (17 days post-liver transplantation with death from intracerebral bleeding) but had no clinical or autopsy evidence of aspergillosis. Donor tracheal secretions obtained at the time of organ harvest later grew A fumigatus.

CONCLUSION

Expanded criteria for organ donation have to be balanced against infectious risk to organ recipients. A fumigatus can be transmitted from a subclinically infected donor to solid-organ transplant recipients.

Fever in the solid organ transplant patient

Fever is common in the solid organ transplant patient and may be produced by a variety of processes. The approach to the febrile transplant patient must include an extensive search for infection, which may be aided by considering the organ transplanted, time after transplantation, and the patient's immunosuppressed state. In addition, a number of noninfectious causes of fever exist in this population, including allograft rejection, drug fever, and thromboembolic disease. A review of the pathogens commonly noted in posttransplant patients is presented, emphasizing risk factors for disease, typical time of presentation, and particular organ groups affected. In addition, the authors review the noninfectious causes of fever in the solid organ transplant patient.

Donor-related secondary haemorrhage complicating renal transplantation

We report two cases of secondary haemorrhage in renal transplant recipients that would appear to relate to their common donor. Our experience confirms the inadequacy of arterial repair in this setting. One patient, a middle aged diabetic male, required excision of his external iliac artery, but recovered without reconstructive surgery. In the second case nephrectomy was performed on day 8 because of accelerated rejection. This was followed by recurrent sepsis due to E. coli, which was implicated in the previous case. Haemorrhage from the donor aortic wall patch occurred 3 weeks later. We now recommend that if secondary haemorrhage occurs, recipients of other organs from the donor should be carefully monitored for evidence of infection. If this is found and a similar organism cultured, consideration to transplant nephrectomy should be made with removal of all donor tissue to avoid the risk of subsequent secondary haemorrhage.

Postmortem bacteriology of cadaver tissue donors: an evaluation of blood cultures as an index of tissue sterility

Microbiological cultures were performed on the blood and bone marrow of 239 cadaver bone donors and 58 "beating heart cadaver" organ donors who had been asymptomatic of sepsis. The incidence of positive blood cultures was significantly lower among the "beating heart cadaver" donors (8.6%) as compared to other donors from whom tissues were excised up to 30 hr postmortem (38%). Microorganisms were isolated from the bones of 82 of 148 (55.4%) bone donors as well as from 36 of 53 (67.9%) "beating heart cadaver" donors who had negative blood cultures. The majority of microbial species recovered from the blood and bone marrow belonged to species normal to the skin microflora (coagulase-negative staphylococci, Bacillus and Propionibacterium species). Species of Clostridium were the second most common organisms isolated from the blood. Blood cultures alone were not useful as indicators of sepsis in cadaver tissue donors or as an index of the sterility of the tissues excised for transplantation.

Invasive pulmonary aspergillosis after near-drowning

After near-drowning following a car accident, a 27-year-old man developed severe ARDS. Six days later Aspergillus fumigatus was isolated in his sputum, and invasive pulmonary aspergillosis developed thereafter. Aspergillus titre increased, and chest tomograms revealed cavities in both lungs. The treatment consisted essentially of Amphotericin B and 5 fluorocytosine, intravenously and by inhalation, intensive postural drainage and mechanical ventilation with PEEP. After 41 days he was cured and discharged from the ICU. Six months later he returned to his job and clinical examination was normal.

Safe removal of failed transplanted kidneys

The surgical removal of a transplanted kidney following rejection or failure can be hazardous. A total of 110 grafts were removed consecutively in 84 patients (in 21 cases a second graft and in 5 cases a third graft was removed). Two surgical techniques were applied: extracapsular and intracapsular removal. The extracapsular technique was associated with complications in 11 out of 69 cases (16 per cent) and the intracapsular technique, in 3 out of 36 cases (8 per cent). In 5 cases the operative technique could not be determined from the records. In the 14 cases developing complications, wound infection was observed in 7 cases, wound haematoma in 4 and mycotic aneurysm, pulmonary embolism and clotting in the bladder each in 1 case. One patient (1.2 per cent) died due to late complications after allograft nephrectomy following rupture of a mycotic aortic aneurysm. The technique of kidney transplant removal by either the intra- or extra-capsular route of the exact timing of the operation are important features for safe treatment of patients with end-stage graft failure.

Experiences with cadaver renal allograft contamination before transplantation

Microbial contamination occurred in 23 (13 per cent) of 177 cadaver donor kidneys prior to renal transplantation. In 16 cases there were no complications directly attributable to the organisms recovered from the preservation media. Three patients developed perinephric infections associated with renal artery anastomotic disruption and required emergency transplant nephrectomy. A fourth patient developed renal artery stenosis and a hypogastric artery aneurysm that required correction 6 months later with preservation of renal allograft function. In 3 cases no follow-up information was available. None of the 154 uncontaminated kidneys developed arterial disruption or aneurysm. Candida albicans and Pseudomonas aeruginosa infections were responsible for the nearly disastrous arterial disruptions and possibly the hypogastric arterial aneurysm. These findings demonstrate the importance of bacteriological surveillance of perfusion media to detect nosocomial infection, to guide antibiotic chemotherapy and to direct surgical management of septic complications. In our experience contamination was not necessarily incompatible with long term satisfactory results; however, when complications did occur they were serious. It is likely that the size of the microbial inoculum, the patient's immune competence and the protective effect of antibiotic therapy administered to the donor and recipient affected the eventual outcome.