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White SL, Rawlinson W, Boan P, Sheppeard V, Wong G, Waller K, Opdam H, Kaldor J, Fink M, Verran D, Webster A, Wyburn K, Grayson L, Glanville A, Cross N, Irish A, Coates T, Griffin A, Snell G, Alexander SI, Campbell S, Chadban S, Macdonald P, Manley P, Mehakovic E, Ramachandran V, Mitchell A, Ison M. Infectious Disease Transmission in Solid Organ Transplantation: Donor Evaluation, Recipient Risk, and Outcomes of Transmission. Transplant Direct 2019; 5:e416. [PMID: 30656214 PMCID: PMC6324914 DOI: 10.1097/txd.0000000000000852] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/15/2018] [Indexed: 12/11/2022] Open
Abstract
In 2016, the Transplantation Society of Australia and New Zealand, with the support of the Australian Government Organ 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 summarizes 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, hepatitis 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.
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Affiliation(s)
- Sarah L White
- Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - William Rawlinson
- Serology and Virology Division, NSW Health Pathology Prince of Wales Hospital, Sydney, Australia
- Women's and Children's Health and Biotechnology and Biomolecular Sciences, University of New South Wales Schools of Medicine, Sydney, Australia
| | - Peter Boan
- Departments of Infectious Diseases and Microbiology, Fiona Stanley Hospital, Perth, Australia
- PathWest Laboratory Medicine, Perth, Australia
| | - Vicky Sheppeard
- Communicable Diseases Network Australia, New South Wales Health, Sydney, Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Karen Waller
- Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Helen Opdam
- Austin Health, Melbourne, Australia
- The Organ and Tissue Authority, Australian Government, Canberra, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Michael Fink
- Austin Health, Melbourne, Australia
- Department of Surgery, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Deborah Verran
- Transplantation Services, Royal Prince Alfred Hospital, Sydney, Australia
| | - Angela Webster
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Kate Wyburn
- Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Lindsay Grayson
- Austin Health, Melbourne, Australia
- Department of Surgery, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Allan Glanville
- Department of Thoracic Medicine and Lung Transplantation, St Vincent's Hospital, Sydney, Australia
| | - Nick Cross
- Department of Nephrology, Canterbury District Health Board, Christchurch Hospital, Christchurch, New Zealand
| | - Ashley Irish
- Department of Nephrology, Fiona Stanley Hospital, Perth, Australia
- Faculty of Health and Medical Sciences, UWA Medical School, The University of Western Australia, Crawley, Australia
| | - Toby Coates
- Renal and Transplantation, Royal Adelaide Hospital, Adelaide, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Anthony Griffin
- Renal Transplantation, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Greg Snell
- Lung Transplant, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen I Alexander
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Scott Campbell
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Steven Chadban
- Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter Macdonald
- Department of Cardiology, St Vincent's Hospital, Sydney, Australia
- St Vincent's Hospital Victor Chang Cardiac Research Institute, University of New South Wales, Sydney, Australia
| | - Paul Manley
- Kidney Disorders, Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand
| | - Eva Mehakovic
- The Organ and Tissue Authority, Australian Government, Canberra, Australia
| | - Vidya Ramachandran
- Serology and Virology Division, NSW Health Pathology Prince of Wales Hospital, Sydney, Australia
| | - Alicia Mitchell
- Department of Thoracic Medicine and Lung Transplantation, St Vincent's Hospital, Sydney, Australia
- Woolcock Institute of Medical Research, Sydney, Australia
- School of Medical and Molecular Biosciences, University of Technology, Sydney, Australia
| | - Michael Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL
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Eastlund T. Infectious Disease Transmission through Cell, Tissue, and Organ Transplantation: Reducing the Risk through Donor Selection. Cell Transplant 2017; 4:455-77. [PMID: 8520830 DOI: 10.1177/096368979500400507] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The incidence of cell transplant-transmitted infection is unknown and can only be inferred from prospective studies–that have not yet been performed and reported. The possibility of donor-to-recipient disease transmission through cell transplant therapy can be considered by reviewing the risk associated with other transplanted tissues and organs. Viral, bacterial, and fungal infections have been transmitted via transplantation of organs, tissue allografts such as bone, skin, cornea, and heart valves, and cells such as islets, hematopoietic stem cells, and semen. Several types of protozoan and worm parasites have been transferred via organ transplants. Bone allografts have transmitted hepatitis, tuberculosis, and human immunodeficiency virus (HIV-1). Corneas have transmitted rabies, Creutzfeldt-Jakob disease (CJD), hepatitis B (HBV), cytomegalovirus (CMV), herpes simplex virus (HSV), bacteria, and fungi. Heart valves have been implicated in transmitting tuberculosis and hepatitis B. HIV-1 and CMV seroconversion has been reported in patients receiving skin from seropositive donors. CJD has been transmitted by dura and pericardium transplants. Over the past several years, improvements in donor screening criteria, such as excluding potential donors with infection and those with behaviors risky for HIV-1 and hepatitis infection, and introduction of new donor blood tests have greatly reduced the risk of HIV-1 and hepatitis and may have nearly eliminated the risk of tuberculosis and CJD. Prior to use, many tissues are exposed to antibiotics, disinfectants, and sterilants, which further reduce or remove the risk of transmitted disease. Because organs, cells, and some tissue grafts cannot be subjected to sterilization steps, the risk of infectious disease transmission remains and thorough donor screening and testing is especially important.
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Affiliation(s)
- T Eastlund
- American Red Cross, North Central Tissue Services, St. Paul, MN 55107, USA
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Abstract
Assessment, prevention, and treatment of bacterial infection in donors are critically important to the welfare of grafts and recipients after transplantation. Transmission of bacterial, viral, fungal, and protozoan infections from a donor to recipient(s) has been documented to have serious or fatal consequences. This article reviews issues of bacterial infection only. The organ procurement coordinator, supported by guidelines developed and prospectively modified by the organ procurement organization, must assess the donor for the presence and severity of bacterial tissue invasion and administer appropriate antimicrobial agents during donor care. Continuation of infection control measures, obtaining serial or surveillance samples for culture, review of antibiotic sensitivity data, initiation of empiric treatment, and modification of medications or their dosing are components of this important responsibility during donor care.
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Affiliation(s)
- David J. Powner
- University of Texas Health Science Center at Houston (DJP), Memorial Hermann Texas Medical Center Hospital (TAA), Houston, Texas
| | - Teresa A. Allison
- University of Texas Health Science Center at Houston (DJP), Memorial Hermann Texas Medical Center Hospital (TAA), Houston, Texas
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Surgical Treatment of Advanced Heart Failure. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gupta P, Blanco C, Madigan M, Dodgen A, Hanson M, Frazier EA, Bhutta AT, Fiser WP. Solid organ donation in a child after extracorporeal membrane oxygenation, orthotopic heart transplantation, and ventricular assist device support. Pediatr Transplant 2012; 16:E368-71. [PMID: 22594304 DOI: 10.1111/j.1399-3046.2012.01720.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Use of high-risk or marginal donors is the most viable short-term means to boost the organ supply and bridge the widening gap between the number of patients on the waiting list for organ transplantation and the insufficient numbers of organ donors. Expansion of the donor pool requires an understanding of the impact on survival likely to result from extending one or more high risk factors. Use of extended donor pool results in shorter waiting list times and limits the morbidity and mortality associated with long-term mechanical support needed to support diseased organs. In this report, we present one such example of expanding donor pool in which a pediatric patient donated a solid organ after two heart transplants and successful use of ECMO and VAD.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas Medical Center, Little Rock, Arkansas, USA.
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Colvara Mattana AM, Marra AR, de Oliveira Machado AM, Lopes Filho GDJ, Salzedas Netto AA, Gonzalez AM. Evaluation of the presence of microorganisms in solid-organ preservation solution. Braz J Infect Dis 2011. [DOI: 10.1016/s1413-8670(11)70246-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Use of hearts transplanted from donors with severe sepsis and infectious deaths. J Heart Lung Transplant 2009; 28:260-5. [PMID: 19285618 DOI: 10.1016/j.healun.2008.11.911] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 09/12/2008] [Accepted: 11/19/2008] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The reluctance to use organs from donors who have died from severe infections is based on the potential transmission of an infectious agent to the recipient and on the uncertainty about allograft function in the setting of severe donor sepsis. METHODS From 1999 to 2007, donor hospital records were reviewed which focused on microbiology cultures and sensitivity results; type and duration of antimicrobial therapy; hemodynamic data, results of echocardiogram, and imaging studies. Preliminary positive and negative results from pre-harvest blood, respiratory, urine, and cerebrospinal fluid cultures were verified with the procurement agency. The harvesting surgeon performed gross inspection of donor valvular structures. RESULTS Nine donor hearts were transplanted from patients who expired from community onset infections with severe septic shock, meningitis, and/or pneumonia caused by Streptococcus pneumoniae (n = 4), Streptococcus milleri (n = 2), Neisseria meningitidis (n = 2), and unidentified gram- positive cocci (n = 1). Four donors had probable infection-induced intracranial hemorrhage, and all donors were vasopressor-dependent before organ procurement. No evidence of donor-transmitted infection, sepsis, or rejection was observed, and long-term function remained excellent; allograft dysfunction in three patients resolved after transplant. Our series of nine donors represents approximately 1.3% of successfully transplanted cardiac allografts during the respective period of review. CONCLUSIONS Patients succumbing to severe infections (meningitis, pneumonia, and septic shock) should not be arbitrarily excluded for possible heart donation. Assessing the suitability of donors with severe infections requires flawless communication between the donor and transplant facility, including a comprehensive evaluation of donor infection and pathogen(s), severity of sepsis, adequacy of antimicrobial treatment, and the degree of sepsis-induced myocardial dysfunction.
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Sözen H, Fidan K, Mahli A, Singin E, Buyan N, Sindel S, Söylemezoğlu O, Arinsoy T, Dalgic A. Successful solid organ transplantation from septicemic cadaveric donors: case report. Transplant Proc 2008; 40:299-301. [PMID: 18261610 DOI: 10.1016/j.transproceed.2007.11.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Systemic donor infections especially with gram-negative organisms are regarded as an absolute contraindication to cadaveric organ donation for transplantation. This is largely due to fear of transmitting the pathogenic organisms to the immunosuppressed recipient. However, due to the current shortage of organs available for transplantation, clinicians are faced with the option to use organs from infected donors. Between 1996 to January 2006, we collected 44 solid organs. Two out of nine donors had microorganisms from blood cultured. Case 1 was of 23-year old woman whose cause of brain death was intracerebral bleeding due to a traffic accident. The donor had stayed 9 days in the intensive care unit prior to brain death. Two kidneys, two livers (split), and or heart were used. Klebsiella was the organism on blood culture. Case 2 was of 35-year-old man; cause of brain death was cerebral hematoma due to traffic accident. The donor had stayed 6 days prior to brain death onset. The liver and two kidneys were used. Acinetobacter baumannii was yielded upon blood culture. All donors were treated with appropriate antibiotics for at least 48 hours prior to organ procurement with consequent negative blood cultures, while the recipients received the same culture-specific antibiotics for 10 days following transplantation. One donor (case 1) heart and both donor corneas were not used due to infection. All patients are alive with excellent graft function at a median of 90 days following transplantation. In conclusion, our results suggested that bacteremic donors with severe sepsis under proper treatment can be considered for transplantation.
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Affiliation(s)
- H Sözen
- Department of General Surgery, Gazi University Medical Faculty, Ankara, Turkey.
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Vasanthan A, Dallal N. Periodontal treatment considerations for cell transplant and organ transplant patients. Periodontol 2000 2007; 44:82-102. [PMID: 17474927 DOI: 10.1111/j.1600-0757.2006.00198.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Asvin Vasanthan
- Department of Periodontics, School of Dentistry, University of Missouri-Kansas City, USA
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12
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Frazier OH, Gregoric ID, Cohn WE. Surgical Treatment of Advanced Heart Failure. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Caballero F, Lopez-Navidad A, Perea M, Cabrer C, Guirado L, Solà R. Successful liver and kidney transplantation from cadaveric donors with left-sided bacterial endocarditis. Am J Transplant 2005; 5:781-7. [PMID: 15760402 DOI: 10.1111/j.1600-6143.2005.00773.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Bacterial infections are frequent in cadaveric organ donors and can be transmitted to the transplantation recipient, which could have devastating consequences for the recipients if adequate preventive measures are not adopted. From the 355 consecutive brain dead cadaveric organ donors procured at our center in the last four years, 2000-2003, four of them (1.1%) had bacterial endocarditis as cause of death. The bacteria responsible for the endocarditis were Staphylococcus epidermidis, coagulase-negative Staphylococcus, Staphylococcus hominis and Streptococcus viridans, respectively. We performed five kidney and two liver transplantations on seven recipients. All donors and recipients received antibiotic treatment against the germ causing the respective endocarditis. Infection by the bacteria responsible for the endocarditis in the respective donors was not transmitted to any of the recipients. Six of the seven recipients were alive with normal-functioning grafts after between 13 and 24 months' follow-up. Transplantectomy was performed on one kidney recipient due to thrombosis of the renal vein of the graft not related to the endocarditis. Liver and kidney transplantation from donors dying from bacterial endocarditis can be performed without causing the transmission of infection to the recipient or the dysfunction of the graft.
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Affiliation(s)
- Francisco Caballero
- Hospital de la Santa Creu i Sant Pau, Organ and Tissue Procurement for Transplantation, Barcelona, Spain.
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López-Navidad A, Caballero F. Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool. Clin Transplant 2003; 17:308-24. [PMID: 12868987 DOI: 10.1034/j.1399-0012.2003.00119.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The terms extended donor or expanded donor mean changes in donor acceptability criteria. In almost all cases, the negative connotations of these terms cannot be justified. Factors considered to affect donor or organ acceptability have changed with time, after showing that they did not negatively affect graft or patient survival per se or when the adequate measures had been adopted. There is no age limit to be an organ donor. Kidney and liver transplantation from donors older than 65 years can have excellent graft and patient actuarial survival and graft function. Using these donors can be from an epidemiological point of view the most important factor to esablish the final number of cadaveric liver and kidney transplantations. Organs with broad structural parenchyma lesion with preserved functional reserve and organs with reversible functional impairment can be safely transplanted. Bacterial and fungal donor infection with the adequate antibiotic treatment of donor and/or recipient prevents infection in the latter. The organs, including the liver, from donors with infection by the hepatitis B and C viruses can be safely transplanted to recipients with infection by the same viruses, respectively. Poisoned donors and non-heart-beating donors, grafts from transplant recipients, reuse of grafts, domino transplant and splitting of one liver for two recipients can be an important and safe source of organs for transplantation.
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Affiliation(s)
- Antonio López-Navidad
- Department of Organ & Tissue Procurement for Transplantation, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Kavarana MN, Sinha P, Naka Y, Oz MC, Edwards NM. Mechanical support for the failing cardiac allograft: a single-center experience. J Heart Lung Transplant 2003; 22:542-7. [PMID: 12742416 DOI: 10.1016/s1053-2498(02)00654-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Mechanical support for pre-transplant stabilization is established, but its use in peri-operative graft failure (PGF) has not been well documented. With liberal acceptance criteria being used to enlarge the donor pool, an increased incidence of graft failure might be expected. We evaluated the incidence and outcome of PGF at our institution. METHODS A retrospective review of 462 consecutive adult heart transplants performed between January 1993 and December 1999 revealed 20 cases of PGF. Donor-, surgery- and device-related variables were evaluated for association with operative mortality, survival and successful device weaning. RESULTS Transplant recipients included 17 men and 3 women, median age 56.5 years (20 to 66 years). PGF etiology included primary graft failure (n = 9); right heart failure (RHF) secondary to pulmonary hypertension, coagulopathy/intra-operative hemorrhage or sepsis (n = 9); and hyperacute rejection (n = 2). Device types included RVAD (n = 11), LVAD (n = 4), BIVAD (n = 3) and IABP (n = 2). The wean rate was 45%. Duration of device support ranged from 2 to 965 hours. Early ventricular recovery (within 96 hours) was associated with significantly better 30-day and 2-year survival. Weaned patients had an 88% 30-day and 67% 2-year survival, whereas the overall survival rate was 79% at 2 years (p = not significant). CONCLUSIONS Early ventricular recovery is an important predictor of successful weaning and survival. In view of the prohibitive mortality associated with PGF and the dismal prognosis with re-transplantation, we advocate aggressive use of mechanical assistance for PGF, with an acceptable survival benefit.
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Affiliation(s)
- Minoo N Kavarana
- Department of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA.
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Keay S. Cardiac Transplantation: Pre-transplant Infectious Diseases Evaluation and Post-transplant Prophylaxis. Curr Infect Dis Rep 2002; 4:285-292. [PMID: 12126604 DOI: 10.1007/s11908-002-0019-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Susan Keay
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine and Medical Service, VA Maryland Health Care System, Baltimore, MD 21201, USA. E-mail
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Stoica SC, Satchithananda DK, Charman S, Sharples L, King R, Rozario C, Dunning J, Tsui SS, Wallwork J, Large SR. Swan-Ganz catheter assessment of donor hearts: outcome of organs with borderline hemodynamics. J Heart Lung Transplant 2002; 21:615-22. [PMID: 12057693 DOI: 10.1016/s1053-2498(02)00380-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND High-dosage inotrope use or periods of hypotension may cause rejection of donor hearts for transplantation. At our institution, we do not refuse potential donor organs based on these criteria alone before Swan-Ganz catheter (SGC) assessment. In this study, we evaluate the role of the SGC in donor heart resuscitation and selection and assess the outcome of using borderline organs. METHODS We retrospectively analyzed 129 donors assessed between 1996 and 1999, all with complete hemodynamic data. Two sets of SGC measurements were analyzed: one set from the initial assessments, and one set from assessments made just before organ harvesting. The physiologic targets were mean blood pressure >60 mm Hg, central venous pressure <12 mm Hg, pulmonary capillary wedge pressure <12 mm Hg, left ventricular stroke work index >15 x g.m/m(2), and use of only one inotrope. A poorly functioning heart was defined as an organ failing on 2 or more of these criteria. Hemodynamic categories were defined as A, good function throughout assessment; B, sub-optimal function and then improvement; and C, decreasing or poor function throughout. We have a policy to avoid allocating sub-optimal organs to high-risk recipients. RESULTS One hundred fourteen donor hearts went on to be transplanted: 75 as orthotopic hearts and 39 as heart-lungs (5 of these were heart, lung, and liver transplantations, not reported further here). Of the 75 donor hearts used for heart transplantations, 53 were from Category A, 9 were from Category B, and 13 were from Category C. Of the donor hearts used for the 34 heart-lung transplantations 16 were from Category A, 10 were from Category B, and 8 were from Category C. Three patients died of donor organ failure: 1 of the corresponding hearts was from Category B, and 2 were from Category C. When comparing separately the outcome of the 2 procedures, we found no significant difference in duration of stay in the intensive care unit, requirement for mechanical support, 30-day mortality, or 1-year survival among patients with hearts from Categories A, B, and C. Ischemic time was the only significant risk factor for death (p = 0.006). CONCLUSIONS Use of organs from Categories B and C permitted expansion of the donor pool without compromising short-term outcome. However, these organs should be used with caution in combination with other risk factors, in particular long ischemic time.
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Affiliation(s)
- Serban C Stoica
- Transplant Unit, Papworth Hospital, Papworth Everard, Cambridge, United Kingdom
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Schaffner A. Pretransplant evaluation for infections in donors and recipients of solid organs. Clin Infect Dis 2001; 33 Suppl 1:S9-14. [PMID: 11389516 DOI: 10.1086/320898] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The risk of infectious disease reactivation in recipients of and transmission by solid-organ transplants remains, and thorough screening and testing of recipient and donor is especially important. In conceiving screening strategies, it is crucial to consider the sensitivity and specificity of individual diagnostic tests in the context of their use. Furthermore, recognition of special risks for infectious complications of transplantation will help to guide preventive, diagnostic, and therapeutic steps in the control of infectious complications in individual patients. The acceptability of risks for infectious complications after transplantation depends also on the urgency of transplantation of a vital organ as well as the availability of organs. Although these principals are well accepted, standards for the extent of screening and criteria for inappropriate donors and exclusion of unfit recipients remain controversial to some extent.
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Affiliation(s)
- A Schaffner
- Department of Internal Medicine, University Hospital, Zurich, Switzerland.
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Abstract
In addition to the net state of immunosuppression, the risk of infection after transplantation is largely determined by the transplant recipient's epidemiologic exposures. Potential sources of infection in the transplant recipient include the environment and the recipient's endogenous flora. This article presents aspects of prevention of infection after solid-organ transplantation such as avoidance of epidemiologic exposures, antibacterial prophylaxis, prophylaxis for tuberculin-positive transplant recipients, and prophylaxis against infections with Pneumocystis carinii and Toxoplasma gondii.
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Affiliation(s)
- R Soave
- Division of Infectious Diseases, Weill Medical College of Cornell University, New York, NY 10021, USA.
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Zibari GB, Lipka J, Zizzi H, Abreo KD, Jacobbi L, McDonald JC. The use of contaminated donor organs in transplantation. Clin Transplant 2000; 14:397-400. [PMID: 10946778 DOI: 10.1034/j.1399-0012.2000.14040702.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Organ transplantation has become an accepted means of treating end-stage organ disease in recent years with acceptable patient and graft survival. Transplant recipients have an increased risk of infectious complications due to multiple factors including decreased host resistance from chronic end-stage organ failure as well as from the immunosuppression required to prevent graft rejection. HYPOTHESIS Therefore, the use of contaminated allografts could result in life-threatening infections in organ recipients. METHOD In this study, transplant patients receiving organs from donors with positive blood or urine cultures, from 1993 to 1997, were retrospectively reviewed. RESULTS There was a total of 599 organ donors in our state. Forty-six (7.5%) had positive blood cultures and 25 (4.5%) had positive urine cultures. A total of 179 patients received organs from these contaminated donors, 36 of which were transplanted at our center. In this group, there were 16 kidney, 9 liver, and 11 heart transplants. Both donors and recipients received prophylactic broad-spectrum antibiotics, which were adjusted based on culture and sensitivity results. The most common organisms isolated from the blood were staphylococci followed by streptococci and Gram-negative organisms. Three of the 9 liver transplant patients in the series died with a mortality of 33%. Two of the 3 patients who died had sepsis but the responsible organisms were different from those recovered from the donor. The rest (66%) did well and have acceptable liver function. None of the 16 renal transplant recipients developed an infection and all survived. One patient developed acute irreversible rejection requiring transplant nephrectomy. There was one death in the heart transplant group resulting in a mortality of 9%. This death was not attributed to infectious processes. Three of 11 heart transplant patients grew organisms in the post-operative period that were similar to those found in the corresponding donors. However, no patient suffered significant morbidity or mortality from these infections and all recovered. The recipients of contaminated organs had levels of organ function similar to those of randomly chosen recipients of non-contaminated organs, and both groups had similar lengths of hospital stay. CONCLUSION Only 3 of 36 organ recipients had infections caused by organisms found in the contaminated donor organs for a rate of 8%. Contaminated donor organs seem to fare as well as non-contaminated donor organs and there was no increase in morbidity or mortality. Contamination of organs should not be an absolute contraindication to the use of these organs in transplantation.
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Affiliation(s)
- G B Zibari
- Department of Surgery, Louisiana State University Health Sciences Center, Shreveport 71130, USA.
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22
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Perreas K, Milano C, Tsui S, Wallwork J. Donor management tactics for cardiothoracic transplantation. Transplant Rev (Orlando) 2000. [DOI: 10.1053/tr.2000.4652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Despite improvements in survival rates, infection remains an important cause of morbidity and mortality following solid organ transplantation. Prevention of infection and, failing this, prompt diagnosis and treatment remain the cornerstones of management. During the peri-operative admission, when the level of immunosuppression is at its height, nosocomial infection accounts for the majority of infective morbidity. Although the measures taken to prevent nosocomial infection may vary, centres undertaking such procedures must ensure that strategies are in place to protect patients. The importance of basic infection control measures cannot be over-emphasised. In addition, appropriate prophylactic agents, rapid diagnostic techniques and the early institution of appropriate therapy are essential. As developments in this field advance, the epidemiology of infection will continue to change, demanding an ongoing assessment of preventative, diagnostic and therapeutic strategies.
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Affiliation(s)
- O M Murphy
- Department of Microbiology, Newcastle NHS Trust, Freeman Hospital, Newcastle upon Tyne
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Burket JS, Chenoweth CE, Meyer TL, Barg NL. Donor-to-recipient transmission of bacteria as an unusual cause of mediastinitis in a heart transplant recipient. Infect Control Hosp Epidemiol 1999; 20:132-3. [PMID: 10064219 DOI: 10.1086/501603] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We present a 54-year-old male heart transplant recipient who developed mediastinitis caused by Klebsiella oxytoca and Veillonella species. Culture of the donor's bronchus also grew K. oxytoca and a Veillonella species. Pulsed-field gel electrophoresis revealed that the K. oxytoca isolates had identical banding patterns. This case illustrates transmission of pathogenic bacteria via a contaminated organ.
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Affiliation(s)
- J S Burket
- Department of Internal Medicine, Ann Arbor Veterans' Administration Medical Center, University of Michigan Health System, USA
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Affiliation(s)
- J A Fishman
- Program in Transplantation Infectious Disease, Massachusetts General Hospital, Boston 02114, USA
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Mossad SB, Avery RK, Goormastic M, Hobbs RE, Stewart RW. Significance of positive cultures from donor left atrium and postpreservation fluid in heart transplantation. Transplantation 1997; 64:1209-10. [PMID: 9355844 DOI: 10.1097/00007890-199710270-00024] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The significance of positive perioperative cultures routinely obtained from the donor left atrium and postpreservation fluid during heart transplantation is unknown. METHODS A retrospective chart review of 128 heart transplant recipients was done. RESULTS A total of 106 of 128 patients had left atrial and/or postpreservation fluid cultures performed; 61 (57.5%) of them were positive. Forty-one positive left atrial or postpreservation cultures grew indolent organisms and 20 grew virulent organisms. Six donors had positive blood cultures, and five of the six did not have left atrial or postpreservation fluid cultures positive for the same organism. Seven recipients had positive blood cultures with organisms different from their corresponding left atrial or postpreservation fluid cultures. Three patients had sternal wound infections with organisms different from their donors' left atrial or postpreservation fluid cultures. Seven patients received additional antibiotics after heart transplantation specifically directed at a positive left atrial or postpreservation fluid culture for 5 to 7 days; none of them developed infection with these organisms. CONCLUSIONS We found no evidence that positive donor left atrium or postpreservation fluid cultures increase the recipients' risk of infection. Nevertheless, we cannot refute that the small group of patients who received additional antibiotics might have developed an infection if they had not been treated. We recommend that the left atrial and postpreservation fluid cultures growing indolent organisms be discounted. However, if they grow more virulent organisms, consideration could be given to a brief course of specific therapy while awaiting recipient cultures.
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Affiliation(s)
- S B Mossad
- Department of Infectious Diseases, Cleveland Clinic Foundation, Ohio 44195-5066, USA.
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27
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Keating MR, Guerrero MA, Daly RC, Walker RC, Davies SF. Transmission of invasive aspergillosis from a subclinically infected donor to three different organ transplant recipients. Chest 1996; 109:1119-24. [PMID: 8635345 DOI: 10.1378/chest.109.4.1119] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- M R Keating
- Division of Infectious Diseases, Mayo Medical Center, Rochester, Minn., USA
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Abstract
Infection remains a major cause of morbidity and mortality after cardiac transplantation. Most infections occur during the first few months after transplantation. Although late infection does occur, the risk of infection during maintenance immunosuppression is low in the absence of recurrent rejection that necessitates augmentation of suppression of the immune response. Before cardiac transplantation, the risk factors for infectious disease in potential candidates should be assessed. A detailed history of past infections should be elicited, and patients should be screened for the presence of active indolent infection. In addition, potential donors must be thoroughly assessed for organ-transmittable infection. Many common infections that may occur after cardiac transplantation can be prevented with the use of appropriate prophylactic regimens directed toward cytomegalovirus, Toxoplasma gondii, Pneumocystis carinii, and herpes simplex virus. Periodic surveillance serologic tests and cultures after cardiac transplantation facilitate early diagnosis and prompt institution of appropriate therapy.
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Affiliation(s)
- M R Keating
- Division of Infectious Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905
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Emery RW, Eales F, Joyce LD, Von Rueden TJ, King RM, Jorgensen CR, Pritzker MR, Johnson KE, Lake KD, Arom KV. Mechanical circulatory assistance after heart transplantation. Ann Thorac Surg 1991; 51:43-7. [PMID: 1985572 DOI: 10.1016/0003-4975(91)90445-v] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
From October 1985 through December 1989, 92 heart transplant procedures were performed in 89 patients. Nine patients (aged 19 to 66 years; 7 male, 2 female) required mechanical circulatory support after transplantation because of primary idiopathic organ failure (n = 2), implant difficulty (2), poor organ quality (2), or acute right heart failure (3). Devices used included the intraaortic balloon pump (6), centrifugal right ventricular assist device (2), left ventricular assist (1), biventricular assists (2), and total artificial heart (1). Two patients required multiple devices. One patient underwent retransplantation. Implant time ranged from 1 to 18 days. One early death occurred owing to right heart failure 6 days after transplantation, 7 hours after removal of a right ventricular assist device, for an overall mortality of 11%. The remaining 8 patients are alive 4 months to 28 months after transplantation. The actuarial 1-year survival of 89% +/- 10% compares well with the survival of 87% +/- 4% for the entire transplant group. All surviving patients are in functional class I. Echocardiographic examination in all patients revealed left ventricular ejection fraction to be normal in 7 and depressed in 1. Extending the criteria for organ donors or difficulty with the implant procedure can lead to early organ failure, which may be reversible with circulatory assistance allowing excellent survival.
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Affiliation(s)
- R W Emery
- Division of Cardiothoracic Transplantation, Minneapolis Heart Institute/Abbott Northwestern Hospital, Minnesota
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