Organ and tissue safety workshop 2007: advances and challenges

Pathological features and outcomes of incidental renal cell carcinoma in candidate solid organ donors

Background

We report the findings of a single Italian center in the evaluation of renal lesions in deceased donors from 2001 to 2017. In risk evaluation, we applied the current Italian guidelines, which include donors with small (< 4 cm, stage pT1a) renal carcinomas in the category of non-standard donors with a negligible risk of cancer transmission.

Methods

From the revision of our registries, 2,406 donors were considered in the Emilia Romagna region of Italy; organs were accepted from 1,321 individuals for a total of 3,406 organs.

Results

The evaluation of donor safety required frozen section analysis for 51 donors, in which a renal suspicious lesion was detected by ultrasound. Thirty-two primary renal tumors were finally diagnosed 26 identified by frozen sections and 6 in discarded kidneys. The 32 tumors included 13 clear cell renal cell carcinomas (RCCs), 6 papillary RCCs, 6 angiomyolipomas, 5 oncocytomas, 1 chromophobe RCC, and 1 papillary adenoma. No cases of tumor transmission were recorded in follow-up of the recipients.

Conclusion

Donors with small RCCs can be accepted to increase the donor pool. Collaboration in a multidisciplinary setting is fundamental to accurately evaluate donor candidate risk assessment and to improve standardized protocols for surgeons and pathologists.

Biovigilance: A Global Perspective

A biological is a substance which either comprises, contains, or is derived from human cells or human tissues. The use of biological products is associated with the risk of infection transmission, allergic reactions, and other adverse events (AEs). The science and activities relating to the detection, assessment, understanding, and prevention of AEs or any other problems related to biological products (blood, cells, tissues, organs, and vaccine in international perspective) are termed as biovigilance. With more and more biologicals being marketed and the rapid revolutionary changes in transplant-related services, the importance of biovigilance is increasing day by day. Although specific types of vigilance systems (pharmacovigilance and materiovigilance) exist, activities related to “biovigilance” are still in an infancy stage. Many developed countries such as the USA, Europe, and Australia have implemented nationwide biovigilance programs. In India, the National Institute of Biologicals, in collaboration with the Indian Pharmacopoeia Commission, has launched the Biovigilance Programme of India. In this article, the biovigilance systems of different countries across the globe have been reviewed along with highlights of the current biovigilance needs.

Tissue banking, biovigilance and the notify library

This issue is dedicated to the contributions of Professor Glyn O. Phillips to the field of tissue banking and the advancement of science in general. The use of ionizing radiation to sterilize medical products drew the interest of the International Atomic Energy Agency (IAEA). A meeting in 1976 in Athens Greece to present work on the effects of sterilizing radiation doses upon the antigenic properties of proteins and biologic tissues was my first introduction of Professor Phillips and the role that he was to play in Tissue Banking (Friedlaender, in Phillips GO, Tallentine AN (eds) Radiation sterilization. Irradiated tissues and their potential clinical use. The North E. Wales Institute, Clwyd, p 128, 1978). The IAEA sponsored subsequent meetings in the Republic of Korea, Czechoslovakia and Rangoon, the later including a visit to the tissue bank by Professor Phillips. His advocacy resulted in multiple workshops and teaching opportunities in a variety of countries, one of which led to the establishment of the Asia Pacific Surgical Tissue Banking Association in 1989 (Phillips and Strong, in Phillips GO, Strong DM, von Versen R, Nather A (eds) Advances in tissue banking, vol 3. World Scientific, Singapore, pp 403-417, 1999).

Non-injected illicit drug use and infectious disease risk of donor tissue: a single institution retrospective review

This study assessed the relationship of non-injected illicit drug use and infectious disease seropositivity for human immunodeficiency virus (HIV-1), hepatitis B virus (HBV), hepatitis C virus (HCV), and Syphilis. In a retrospective review of 986 donor charts recovered from 2009 to 2011 at a single tissue bank, the absence of reported non-injected illicit drug use corresponded with seropositivity in 6.61 %, of recovered donors while reported illicit drug use in the medical and social history corresponded with seropositivity in 11.25 %, representing a 70 % increased risk. There was no significant difference noted for overall seropositivity rates between types on noninjected illicit drugs, although donors that used cocaine had a higher incidence of HIV, while marijuana use was associated with a higher rate of HBV, HCV, and syphilis positivity. Toxicology screening results were not an accurate predictor of seropositivity (PPV = 3.77 %; NPV = 91.56 %). Further, the degree of relationship between the donor and the next of kin had no bearing on the veracity of actual drug use when comparing the response of the medical-social history and the toxicology screen.

Characterization and risk of blood-borne virus transmission in organ transplantation: what are the priorities?

ABSTRACT 

Blood-borne virus transmission through organ transplantation, although rare, has been associated with severe complications in recipients. There are few data available to ascertain the risk of infection in organ transplantation for known and emerging pathogens, as most information comes from events of transmission, which are rare and not always well characterized. The balance between quality of life through organ transplantation and the risks of donor-derived infection can be improved through advances in donor screening, enhanced monitoring and a multidisciplinary approach to improving donor assessment and recipient biosurveillance. The involvement of investigators with clinical, laboratory, surveillance and policy expertise is critical to bridge research knowledge and clinical practice.

Donor-derived infection--the challenge for transplant safety

Unusual clinical syndromes or clusters of infections in recipients of organs from the same donor suggest donor-derived infection as a possible source of transmission

The incidence of transmission of unexpected infection by organ allografts is low, but precise data are lacking

Screening of donors for common pathogens involves both epidemiologic history and microbiological assays, and is highly effective for preventing the transmission of HIV and hepatitis B and C viruses

Donor screening for uncommon pathogens must be guided by knowledge of changes in the local epidemiology of infection

The key element in the detection of donor-derived infection is suspicion on the part of the clinicians caring for organ recipients

Application of newer microbiological techniques will increase the speed of donor screening and enhance transplant safety

Each year, over 70,000 organs are transplanted worldwide. The degree of risk of transmission of infection from transplanted organs to the recipient is largely unknown and is difficult to assess for specific organs. Here, Jay A. Fishman and Paolo A. Grossi describe the major risk factors for organ donor-derived transmission of infection and discuss opportunities to reduce the incidence of such events.

Organ transplantation, including of the heart, lung, kidney, liver, pancreas, and small bowel, is considered the therapy of choice for end-stage organ failure. Each year, over 70,000 organs are implanted worldwide. One donor may provide multiple organs, as well as corneas and other tissues, for multiple recipients. The degree of risk for transmission of infection carried with grafts, notably of viruses, is largely unknown and, for a specific organ, difficult to assess. The approach to microbiological screening of organ donors varies with national and regional regulations and with the availability and performance of microbiological assays used for potential donors. Transmission of both expected or common, and unexpected infections has been observed in organ transplants, generally recognized after development of clusters of infections among recipients of organs from a common donor. Other than for unusual or catastrophic events, few data exist that define the incidence and manifestations of donor-derived infections or the ideal assays to use in screening to prevent such transmissions. Absolute prevention of the transmission of donor-derived infections in organ transplantation is not possible. However, improvements in screening technologies will enhance the safety of transplantation in the future.

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

Selection of the appropriate donor is essential to a successful allograft recipient outcome for solid organ transplantation. Multiple infectious diseases have been transmitted from the donor to the recipient via transplantation. Donor-transmitted infections cause increased morbidity and mortality to the recipient. In recent years, a series of high-profile transmissions of infections have occurred in organ recipients prompting increased attention on the process of improving the selection of an appropriate donor that balances the shortage of needed allografts with an approach that mitigates the risk of donor-transmitted infection to the recipient. Important advances focused on improving donor screening diagnostics, using previously excluded high-risk donors, and individualizing the selection of allografts to recipients based on their prior infection history are serving to increase the donor pool and improve outcomes after transplant. This article serves to review the relevant literature surrounding this topic and to provide a suggested approach to the selection of an appropriate solid organ transplant donor.

Opportunistic infections--coming to the limits of immunosuppression?

Possible etiologies of infection in the solid organ recipient are diverse, ranging from common bacterial and viral pathogens to opportunistic pathogens that cause invasive disease only in immunocompromised hosts. The recognition of infectious syndromes in this population is limited by alterations in the clinical manifestations by immunosuppression. The risk of serious infections in the organ transplant patient is determined by the interaction between the patients' recent and distant epidemiological exposures and all factors that contribute to the patient's net state of immune suppression. This risk is altered by antimicrobial prophylaxis and changes in immunosuppressive therapies. In addition to the direct effects of infection, opportunistic infections, and the microbiome may adversely shape the host immune responses with diminished graft and patient survivals. Antimicrobial therapies are more complex than in the normal host with a significant incidence of drug toxicity and a propensity for drug interactions with the immunosuppressive agents used to maintain graft function. Rapid and specific microbiologic diagnosis is essential. Newer microbiologic assays have improved the diagnosis and management of opportunistic infections. These tools coupled with assays that assess immune responses to infection and to graft antigens may allow optimization of management for graft recipients in the future.

Assessment of tissue allograft safety monitoring with administrative healthcare databases: a pilot project using Medicare data

Assess whether Medicare data are useful for monitoring tissue allograft safety and utilization. We used health care claims (billing) data from 2007 for 35 million fee-for-service Medicare beneficiaries, a predominantly elderly population. Using search terms for transplant-related procedures, we generated lists of ICD-9-CM and CPT(®) codes and assessed the frequency of selected allograft procedures. Step 1 used inpatient data and ICD-9-CM procedure codes. Step 2 added non-institutional provider (e.g., physician) claims, outpatient institutional claims, and CPT codes. We assembled preliminary lists of diagnosis codes for infections after selected allograft procedures. Many ICD-9-CM codes were ambiguous as to whether the procedure involved an allograft. Among 1.3 million persons with a procedure ascertained using the list of ICD-9-CM codes, only 1,886 claims clearly involved an allograft. CPT codes enabled better ascertainment of some allograft procedures (over 17,000 persons had corneal transplants and over 2,700 had allograft skin transplants). For spinal fusion procedures, CPT codes improved specificity for allografts; of nearly 100,000 patients with ICD-9-CM codes for spinal fusions, more than 34,000 had CPT codes indicating allograft use. Monitoring infrequent events (infections) after infrequent exposures (tissue allografts) requires large study populations. A strength of the large Medicare databases is the substantial number of certain allograft procedures. Limitations include lack of clinical detail and donor information. Medicare data can potentially augment passive reporting systems and may be useful for monitoring tissue allograft safety and utilization where codes clearly identify allograft use and coding algorithms can effectively screen for infections.

Infectious disease transmission during organ and tissue transplantation

Transplantation of organs and tissues (bone, tendon, skin, cornea) will always be associated with some risk for transmission of infectious diseases from donor to recipient. Understanding and minimizing this risk is difficult for many reasons: donor screening processes vary, screening for every infectious organism is not possible, and assessment of recipient health after transplantation to determine possibility of disease transmission is often not adequate. In May 2010, the US Food and Drug Administration held a meeting to address these challenges and establish a research agenda for minimizing these transplant transmission risks. Attendees agreed that the focus should be on standardizing donor screening, compiling disease transmissibility data, monitoring of transplant recipients’ health, and assessing effectiveness of measures to minimize disease transmission. Collaboration and sharing of perspectives, experiences, and resources of all stakeholders in the transplantation process (government, private industry, and health care providers) can improve the safety of organ and tissue transplantation.

Infectious disease transmission through organ and tissue transplantation has been associated with severe complications in recipients. Determination of donor-derived infectious risk associated with organ and tissue transplantation is challenging and limited by availability and performance characteristics of current donor epidemiologic screening (e.g., questionnaire) and laboratory testing tools. Common methods and standards for evaluating potential donors of organs and tissues are needed to facilitate effective data collection for assessing the risk for infectious disease transmission. Research programs can use advanced microbiological technologies to define infectious risks posed by pathogens that are known to be transplant transmissible and provide insights into transmission potential of emerging infectious diseases for which transmission characteristics are unknown. Key research needs are explored. Stakeholder collaboration for surveillance and research infrastructure is required to enhance transplant safety.

Transmission of infection with human allografts: essential considerations in donor screening

Transmission of infection via transplantation of allografts including solid organs, eyes, and tissues are uncommon but potentially life-threatening events. Donor-derived infections have been documented following organ, tissue, and ocular transplants. Each year, more than 70 000 organs, 100 000 corneas, and 2 million human tissue allografts are implanted worldwide. Single donors may provide allografts for >100 organ and tissue recipients; each allograft carries some, largely unquantifiable, risk of disease transmission. Protocols for screening of organ or tissue donors for infectious risk are nonuniform, varying with the type of allograft, national standards, and availability of screening assays. In the absence of routine, active surveillance, coupled with the common failure to recognize or report transmission events, few data are available on the incidence of allograft-associated disease transmission. Research is needed to define the optimal screening assays and the transmissibility of infection with allografts. Approaches are reviewed that may contribute to safety in allograft transplantation.

Uniform definitions for donor-derived infectious disease transmissions in solid organ transplantation

High-profile cases of infectious diseases transmitted from organ donors to transplant recipients, such as the transmission of human immunodeficiency virus, have driven policy globally. Many nations have or are developing regulations requiring reporting and investigation of such disease transmissions as part of broader biovigilance programs for all substances of human origin. A group of experts (see Acknowledgments) developed definitions for proven, probable, possible, unlikely, excluded, intervened upon without documented transmission, and positive assay without apparent disease transmission events that should be used, as a starting point, to standardize nomenclature and facilitate global tracking and study of such infectious disease transmissions.

Xenotransplantation-associated infectious risk: a WHO consultation

Xenotransplantation carries the potential risk of the transmission of infection with the cells or tissues of the graft. The degree of risk is unknown in the absence of clinical trials. The clinical application of xenotransplantation has important implications for infectious disease surveillance, both at the national and international levels. Preclinical data indicate that infectious disease events associated with clinical xenotransplantation from swine, should they occur, will be rare; data in human trials are limited but have demonstrated no transmission of porcine microorganisms including porcine endogenous retrovirus. Xenotransplantation will necessitate the development of surveillance programs to detect known infectious agents and, potentially, previously unknown or unexpected pathogens. The development of surveillance and safety programs for clinical trials in xenotransplantation is guided by a "Precautionary Principle," with the deployment of appropriate screening procedures and assays for source animals and xenograft recipients even in the absence of data suggesting infectious risk. All assays require training, standardization and validation, and sharing of laboratory methods and expertise to optimize the quality of the surveillance and diagnostic testing. Investigation of suspected xenogeneic infection events (xenosis, xenozoonosis) should be performed in collaboration with an expert data safety review panel and the appropriate public health and competent authorities. It should be considered an obligation of performance of xenotransplantation trials to report outcomes, including any infectious disease transmissions, in the scientific literature. Repositories of samples from source animals and from recipients prior to, and following xenograft transplantation are essential to the investigation of possible infectious disease events. Concerns over any potential hazards associated with xenotransplantation may overshadow potential benefits. Careful microbiological screening of source animals used as xenotransplant donors may enhance the safety of transplantation beyond that of allotransplant procedures. Xenogeneic tissues may be relatively resistant to infection by some human pathogens. Moreover, xenotransplantation may be made available at the time when patients require organ replacement on a clinical basis. Insights gained in studies of the microbiology and immunology of xenotransplantation will benefit transplant recipients in the future. This document summarizes approaches to disease surveillance in individual recipients of nonhuman tissues.

Transmission of human immunodeficiency virus and hepatitis C virus from an organ donor to four transplant recipients

In 2007, a previously uninfected kidney transplant recipient tested positive for human immunodeficiency virus type 1 (HIV) and hepatitis C virus (HCV) infection. Clinical information of the organ donor and the recipients was collected by medical record review. Sera from recipients and donor were tested for serologic and nucleic acid-based markers of HIV and HCV infection, and isolates were compared for genetic relatedness. Routine donor serologic screening for HIV and HCV infection was negative; the donor's only known risk factor for HIV was having sex with another man. Four organs (two kidneys, liver and heart) were transplanted to four recipients. Nucleic acid testing (NAT) of donor sera and posttransplant sera from all recipients were positive for HIV and HCV. HIV nucleotide sequences were indistinguishable between the donor and four recipients, and HCV subgenomic sequences clustered closely together. Two patients subsequently died and the transplanted organs failed in the other two patients. This is the first recognized cotransmission of HIV and HCV from an organ donor to transplant recipients. Routine posttransplant HIV and HCV serological testing and NAT of recipients of organs from donors with suspected risk factors should be considered as routine practice.

An update on donor-derived disease transmission in organ transplantation

Several recent donor-to-recipient disease transmissions have highlighted the importance of this rare complication of solid organ transplantation. The epidemiology of donor-derived disease transmissions in the United States has been described through reports to the Organ Procurement and Transplant Network (OPTN); these reports are reviewed and categorized by the ad hoc Disease Transmission Advisory Committee (DTAC); additional data comes through the published literature. From these reports, it is possible to estimate that donor-derived disease transmission complicates less than 1% of all transplant procedures but when a transmission occurs, significant morbidity and mortality can result. Only through continued presentation of the available data can continuous quality improvements be made. As the epidemiology of donor-derived disease transmission has become better understood, several groups have been working on methods to further mitigate this risk.

Coding and traceability for cells, tissues and organs for transplantation

Modern transplantation of cells, tissues and organs has been practiced within the last century achieving both life saving and enhancing results. Associated risks have been recognized including infectious disease transmission, malignancy, immune mediated disease and graft failure. This has resulted in establishment of government regulation, professional standard setting and establishment of vigilance and surveillance systems for early detection and prevention and to improve patient safety. The increased transportation of grafts across national boundaries has made traceability difficult and sometimes impossible. Experience during the first Gulf War with mis-identification of blood units coming from multiple countries without standardized coding and labeling has led international organizations to develop standardized nomenclature and coding for blood. Following this example, cell therapy and tissue transplant practitioners have also moved to standardization of coding systems. Establishment of an international coding system has progressed rapidly and implementation for blood has demonstrated multiple advantages. WHO has held two global consultations on human cells and tissues for transplantation, which recognized the global circulation of cells and tissues and growing commercialization and the need for means of coding to identify tissues and cells used in transplantation, are essential for full traceability. There is currently a wide diversity in the identification and coding of tissue and cell products. For tissues, with a few exceptions, product terminology has not been standardized even at the national level. Progress has been made in blood and cell therapies with a slow and steady trend towards implementation of the international code ISBT 128. Across all fields, there are now 3,700 licensed facilities in 66 countries. Efforts are necessary to encourage the introduction of a standardized international coding system for donation identification numbers, such as ISBT 128, for all donated biologic products.

Traceability

The importance of effective and timely traceability in both the recall of substances of human origin (blood, cells, tissues and organs) implicated in infectious transmission, and in the prevention of inappropriate use of substances of human origin is now well recognised. However, traceability remains poorly understood and inadequately controlled in many cases. In particular there is: a lack of appreciation of the complexity of the traceability pathway; a fragmented approach to traceability; and, an assumption that traceability data is static. The traceability path for a single tissue donor may involve dozens or even hundreds of different organizations, each responsible for one segment of the path. Whilst responsibility within each organization may be clearly defined, responsibility for maintaining the interfaces between organizations is often less clear. Traceability is seldom regarded in a holistic manner, the assumption being made that if each segment of the pathway is correctly maintained then the full path will be intact. End to end traceability audits are not routinely performed, and the only true test of the trail occurs when recall is required-often with inadequate results.

Fatal Apophysomyces elegans infection transmitted by deceased donor renal allografts

Two patients developed renal mucormycosis following transplantation of kidneys from the same donor, a near-drowning victim in a motor vehicle crash. Genotypically, indistinguishable strains of Apophysomyces elegans were recovered from both recipients. We investigated the source of the infection including review of medical records, environmental sampling at possible locations of contamination and query for additional cases at other centers. Histopathology of the explanted kidneys revealed extensive vascular invasion by aseptate, fungal hyphae with relative sparing of the renal capsules suggesting a vascular route of contamination. Disseminated infection in the donor could not be definitively established. A. elegans was not recovered from the same lots of reagents used for organ recovery or environmental samples and no other organ transplant-related cases were identified. This investigation suggests either isolated contamination of the organs during recovery or undiagnosed disseminated donor infection following a near-drowning event. Although no changes to current organ recovery or transplant procedures are recommended, public health officials and transplant physicians should consider the possibility of mucormycosis transmitted via organs in the future, particularly for near-drowning events. Attention to aseptic technique during organ recovery and processing is re-emphasized.

Development of a transplantation transmission sentinel network to improve safety and traceability of organ and tissues

The US lags behind other developed countries in creating a system to monitor disease transmission and other complications from human allograft use, despite a pressing need. The risks of transmission are amplified in transplantation, since at least 8 organs and more than 100 tissues can be recovered from a single common organ and tissue donor. Moreover, since many allografts collected in the US are distributed internationally, tissue safety is a global concern. In June 2005, participants of a US government-sponsored workshop concluded that a communication network for the tracking and reporting of disease transmissions for tissues and organs was critically needed. The United Network for Organ Sharing (UNOS) entered into a cooperative agreement with the Centers for Disease Control and Prevention (CDC) in 2006 to develop a system prototype. Over the following 3 years, the Transplantation Transmission Sentinel Network (TTSN) was developed and piloted with the participation of organ procurement organizations, tissue banks and transplant centers. The prototype centered around three elements of data entry: (1) donation, (2) tissue implantation, and (3) adverse event. The pilot proved that a system can be built and operated successfully, but also suggested that users may be hesitant to report adverse events. CDC has requested further input on scope and cost to build a transplant surveillance infrastructure for a fully functional national system. For tissues however, in contrast to organs, tracking from recovery to implantation will be necessary before a system is operable, requiring common identifiers and nomenclature. Until a US sentinel network is operational, future transmission events that are preventable may result nationally and globally due to its absence.

The epidemiology and prevention of donor-derived infections

Donor-derived infectious diseases are infections that are present in an organ donor and have the potential to be transmitted to at least 1 transplant recipient. Several recent transmissions have been covered by the lay media and in the medical literature, including a recent transmission of HIV and hepatitis C virus from 1 donor to 4 recipients. These reports have highlighted the importance and clinical impact of this rare complication of organ transplantation. Donor-derived infectious diseases appear to complicate less than 1% of all transplant procedures, but, when a transmission occurs, significant morbidity and mortality can occur. A number of guidelines and policies define the optimal screening of organ donors to prevent the transmission of infectious diseases. Unfortunately, there are significant limitations in our screening methods, and only some pathogens are screened for routinely. The regulatory framework related to and the epidemiology, identification, and management of donor-derived infectious disease transmission shall be reviewed.