Receiving the Unwanted Gift: Infection Transmission through Organ Transplantation

Effects of preservative fluid associated possible donor-derived carbapenem-resistant Klebsiella Pneumoniae infection on kidney transplantation recipients

BACKGROUND

Infections remain a major cause of morbidity and mortality in kidney transplant (KT) recipients. This study aimed to investigate the preservation fluid (PF) samples from deceased donors and report the impacts of possible donor-derived carbapenem-resistant Klebsiella pneumoniae (pdd-CRKP) infections on KT recipients.

METHODS

A retrospective study was performed that included all recipients who received kidney transplantation from deceased donors in our hospital between December 2018 and December 2020. A total of 212 patients received kidney transplantation from deceased donors, a total of 206 PF samples were collected, and 20 recipients had a CRKP-positive culture. Both donors and recipients with CRKP-positive PF cultures were divided into two groups, and continuous variables between the two groups were compared using independent-sample t tests and Mann-Whitney tests. Categorical variables were compared using the chi-square test or Fisher's exact test. The significance level of p values was set at 0.05.

RESULTS

A total of 337 recipients underwent kidney transplantation, including 212 recipients of organs from deceased donors and 110 corresponding deceased donors. A total of 206 PF samples were collected, and 20 recipients had CRKP-positive PF cultures. The donors' length of ICU stay was a potential risk factor for CRKP positivity in the PF culture (P < 0.05). Fifteen recipients were infected with pdd-CRKP, and the incidence of pdd-CRKP infection was 7.3% (15/206). The use of antibiotics, including ceftazidime-avibactam (CAZ-AVI), was a potential protective factor against death and graft loss in recipients with a CRKP-positive PF culture (P < 0.05).

CONCLUSIONS

This study shows that the incidence of pdd-CRKP is high in our centre, recipients with pdd-CRKP infection can still achieve a good prognosis with the use of antimicrobial agents including CAZ-AVI.

Donor-Derived Human Parvovirus B19 Infection in Kidney Transplantation

Background

Donor-derived human parvovirus B19 (B19V) infections are rarely reported. Thus, its incidence in kidney transplantation is still unknown due to lack of surveillance studies. Similarly, whether the donor needs to be routinely screened for B19V and whether the kidneys from those with B19V DNAemia could be accepted also remain unknown.

Methods

This retrospective study aims to evaluate the donor-derived B19V infections occurring in 823 living and 1,225 deceased donor kidney transplantations from January 2016 to December 2020. The serum viral load of living donors and their corresponding recipients was evaluated before and after transplantation. Meanwhile, for the deceased donor kidney transplantation, the serum viral load of recipients was only tested after transplantation; if recipients of a deceased donor subsequently developed B19V infection, the serum viral load of recipients and their corresponding donors before transplantation would then be further traced.

Results

A total of 15 living donors were B19V DNAemia positive before the donation, of which B19V DNAemia occurred in three corresponding recipients. In deceased donor kidney transplantation, DNAemia occurred simultaneously in 18 recipients and their corresponding nine donors. A progressive decline in hemoglobin and reticulocyte count could be observed in one living donor recipient and other 11 deceased donor recipients, which were all well controlled by treatment eventually.

Conclusion

The incidence of donor-derived B19V infection was 0.4% and 1.5% in living and deceased kidney transplantations, respectively. B19V was seemingly unnecessary to be routinely screened for the donor. Moreover, kidneys of the donors with B19V infection were acceptable.

Clinical Impacts and Outcomes With Possible Donor-Derived Infection in Infected Donor Liver Transplantation: A Single-Center Retrospective Study in China

BACKGROUND

Information on possible donor-derived transmission events in China is limited. We evaluated the impacts of liver transplantation from infected deceased-donors, analyzed possible donor-derived bacterial or fungal infection events in recipients, and evaluated the etiologic agents' characteristics and cases outcomes.

METHODS

A single-center observational study was performed from January 2015 to March 2017 to retrospectively collect data from deceased-donors diagnosed with infection. Clinical data were recorded for each culture-positive donor and the matched liver recipient. The microorganisms were isolated and identified, and antibiotic sensitivity testing was performed. The pathogens distribution and incidence of possible donor-derived infection (P-DDI) events were analyzed and evaluated.

RESULTS

Information from 211 donors was collected. Of these, 82 donors were infected and classified as the donation after brain death category. Overall, 149 and 138 pathogens were isolated from 82 infected donors and 82 matched liver recipients, respectively. Gram-positive bacteria, Gram-negative bacteria, and fungi accounted for 42.3% (63 of 149), 46.3% (69 of 149), and 11.4% (17 of 149) of pathogens in infected donors. The incidence of multidrug-resistant bacteria was high and Acinetobacter baumannii was the most concerning species. Infections occurred within the first 2 weeks after liver transplantation with an organ from an infected donor. Compared with the noninfection recipient group, the infection recipient group experienced a longer mechanical ventilation time (P = .004) and intensive care unit stay (P = .003), a higher incidence of renal dysfunction (P = .026) and renal replacement therapy (P = .001), and higher hospital mortality (P = .015). Possible donor-derived infection was observed in 14.6% of cases. Recipients with acute-on-chronic liver failure were more prone to have P-DDI than recipients with other diseases (P = .007; odds ratio = 0.114; 95% confidence interval, .025-.529).

CONCLUSIONS

When a liver recipient receives a graft from an infected deceased-donor, the postoperative incidence of infection is high and the infection interval is short. In addition, when a possible donor-derived, drug-resistant bacterial infection occurs, recipients may have serious complications and poor outcomes.

Moving from the HIV Organ Policy Equity Act to HIV Organ Policy Equity in action: changing practice and challenging stigma

PURPOSE OF REVIEW

The HIV Organ Policy Equity (HOPE) Act, signed in 2013, reversed the federal ban on HIV-to-HIV transplantation. In this review, we examine the progress in HOPE implementation, the current status of HIV-to-HIV transplantation, and remaining challenges.

RECENT FINDINGS

Pursuant to the HOPE Act, the Department of Health and Human Services revised federal regulations to allow HIV-to-HIV transplants under research protocols adherent to criteria published by the National Institutes of Health. The first HIV-to-HIV kidney and liver transplants were performed at Johns Hopkins in March of 2016. Legal and practical challenges remain. Further efforts are needed to educate potential HIV+ donors and to support Organ Procurement Organizations. As of November 2017, there are 22 transplant centers approved to perform HIV-to-HIV transplants in 10 United Network for Organ Sharing regions. To date, 16 Organ Procurement Organizations in 22 states have evaluated HIV+ donors. The National Institutes of Health-funded HOPE in Action: A Multicenter Clinical Trial of HIV-to-HIV Deceased Donor (HIVDD) Kidney Transplantation Kidney Trial will launch at 19 transplant centers in December of 2017. A HOPE in Action Multicenter HIVDD Liver Trial is in development.

SUMMARY

Significant progress toward full HOPE implementation has been made though barriers remain. Some challenges are unique to HIV-HIV transplantation, whereas others are amplifications of issues across the current transplant system. In addition to a public health benefit for all transplant candidates in the United States, partnership on the HOPE Act has the potential to address systemic challenges to national donation and transplantation.

Postmortem microbiology sampling following death in hospital: an ESGFOR task force consensus statement

Postmortem microbiology (PMM) is a valuable tool in the identification of the cause of death and of factors contributory to death where death has been caused by infection. The value of PMM is dependent on careful autopsy planning, appropriate sampling, minimisation of postmortem bacterial translocation and avoidance of sample contamination. Interpretation of PMM results requires careful consideration in light of the clinical history, macroscopic findings and the histological appearances of the tissues. This consensus statement aims to highlight the importance of PMM in the hospital setting and to give microbiological and pathological advice on sampling in deaths occurring in hospital.

Organ donation: reducing the risk of health care-associated infection

Health care-associated infection is a real and relative risk within the realm of organ donation. Despite detailed guidance from the Advisory Committee on the Safety of Blood, Tissues and Organs on the microbiological safety of human organs, tissues and cells used in transplantation, the topic has received limited exposure in the literature. This paper will give a context to the Safety of Blood, Tissues and Organs guidance, outline the key recommendations for mandatory/recommended screening and provide a summary of infections that may be present at the time of donation that require careful risk assessment. This does not detract from national guidelines and cannot replace expert advice but will raise awareness and complement safe and effective care delivery.

Rabies virus transmission via solid organs or tissue allotransplantation

BACKGROUND

Rabies, for which the mortality rate is almost 100%, is a zoonotic viral disease that can be transmitted via solid organs or tissue allotransplantation. Dozens of deaths from rabies via solid organs or tissues allotransplantation (ROTA) have been documented during the last decades. In 2015 and 2016, two cases of rabies virus transmission via solid organs or tissue allotransplantation were reported in China, which further underscore the risk and importance of this special type of rabies for organ transplant recipients.

MAIN TEXT

From 1978 to 2017, at least 13 cases of ROTA, causing dozens of deaths, have been reported worldwide, whether in the high-risk or low-risk countries of rabies. The reported incubation period of ROTA ranges from 11 days to more than 17 months, while the historical incubation period of rabies is generally considered to range from ~ 1 week to several years. The pathogenesis of ROTA is not clear, but the use of post-exposure prophylaxis (PEP) can play a protective role in the transplant recipients. We also summarize reports about ROTA in China, combined with the actual situation regarding work on rabies surveillance and elimination, and suggest countermeasures for the prevention and control of ROTA in the future.

CONCLUSIONS

Understanding the significance of ROTA, screening the suspected organs, assessing the risk and protecting the related population will be effective way to prevent and control further occurrence of ROTA.

Evaluation of early and late-term infections after renal transplantation: Clinical experiences of Sanko University Medical Faculty Transplantation Center

OBJECTIVE

Infections play an important part in post-transplantation causes of morbidity and mortality. The purpose of this study is to evaluate short-, and long-term infections encountered in after renal transplantations.

MATERIAL AND METHODS

Two hundred and thirteen cases that consisted of both living and cadaver donors, who suffered from late period renal insufficiency and had renal transplant between June 2011 and January 2016 at the Transplantation Center of Sanko University School of Medicine were included in the study. In this study the short-, and long-term infections seen in post renal transplantation were examined retrospectively. Infection types, frequency and periods of infection, infection agents and predisposing factors were determined as the examination parameters.

RESULTS

Of the 213 patients who received renal transplant, 139 were males (65.3%) and 74 were women (34.75%) and the mean age was 42±11,8 (range, 14-70) years. Twelve (5.6%) patients exited after renal transplantation. Post-transplant infections were seen in 49 patients (23.1%) within 1-6 months; in 13 patients (6.1%) within 6-12 months; and in 5 patients (2.4%) after the 12^th month. The most common infections after renal transplantation were associated with urinary tract (70 patients, 34.3%). The most frequently isolated agents were E. coli (n=66; 30.9%), Kebsiella spp. (n=18; 8.4%) and Enterococci (n=18; 8.4%) respectively. The renal transplants from the cadavers were observed to contract infections 1.78 times more frequently compared to the living donors (OR=1.78, 95% CI=1.03-3.09).

CONCLUSION

The most common complication after renal transplantation are infections. The majority of the infections are seen within the first year especially between 1-6 months. Post-transplant infections are often related to urinary system. E.coli is the most frequently isolated agent and it may be responsible for urosepsis in renal transplant patients. Infection more often seen in renal transplantations from cadavers.

Donor-derived infections among Chinese donation after cardiac death liver recipients

AIM

To investigate blood cultures of deceased donors and report the confirmed transmission of bacterial infection from donors to liver recipients.

METHODS

We retrospectively studied the results of blood cultures among our donation after cardiac death (DCD) donors and calculated the donor-derived bacterial infection rates among liver recipients. Study participants underwent liver transplantation between January 1, 2010 and February 1, 2017. The study involved a total of 67 recipients of liver grafts from 67 DCD donors. We extracted the data of donors’ and patients’ characteristics, culture results and clinical outcomes, especially the post-transplant complications in liver recipients, from electronic medical records. We analyzed the characteristics of the donors and the corresponding liver recipients with emphasis put on donor-derived infections.

RESULTS

Head trauma was the most common origin of death among our 67 DCD donors (46.3%). Blood taken prior to the procurement operation was cultured for 53 of the donors, with 17 episodes of bloodstream infections developing from 13 donors. The predominant organism isolated from the blood of donors was Gram-positive bacteria (70.6%). Only three (4.5%) of 67 liver recipients developed confirmed donor-derived bacterial infections, with two isolates of multidrug-resistant Klebsiella pneumoniae and one isolate of multidrug-resistant Enterobacter aerogenes. The liver recipients with donor-derived infections showed relation to higher crude mortality and graft loss rates (33.3% each) within 3 mo post transplantation, as compared to those without donor-derived infections (9.4% and 4.7%, respectively). All three liver recipients received appropriate antimicrobial therapy.

CONCLUSION

Liver recipients have high occurrence of donor-derived infections. The liver recipients with donor-derived multidrug-resistant Enterobacteriaceae infections can have good outcome if appropriate antimicrobial therapy is given.

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.

Emerging infectious disease agents and blood safety in Australia: spotlight on Zika virus

Emerging infectious diseases (EIDs) are infectious diseases whose incidence has increased in humans in the past 20 years or could increase in the near future. EID agents may represent a threat to blood safety if they infect humans, cause a clinically significant illness, include an asymptomatic blood phase in the course of infection, and are transmissible by transfusion. EID agents are typically not well characterised, but there is a consensus that we can expect ongoing outbreaks. Strategies to manage the risk to blood safety from EIDs include ongoing surveillance, regular risk assessments, modelling transfusion transmission risk, and deferral of donors with a recent travel history to outbreak areas. The 2015-16 Zika virus (ZIKV) outbreak in the Americas is the largest reported ZIKV outbreak to date, and it highlights the unpredictable nature of EID outbreaks and how quickly they can become a major public health problem. This ZIKV outbreak has provided evidence of a causal link between the virus and microcephaly in newborns. In assessing the potential risk of ZIKV to blood safety in Australia, it should be noted that a relatively small number of imported ZIKV infections have been reported in Australia, there have been no reported cases of local ZIKV transmission, and the geographical distribution of the potential ZIKV mosquito vector in Australia (Aedes aegypti) is limited to northern Queensland. Moreover, reported transfusion-transmitted ZIKV cases worldwide are rare. At present, ZIKV represents a low risk to blood safety in Australia.