Risk of Transmission of H1N1 Influenza by Solid Organ Transplantation in the United Kingdom

Impact of Respiratory Viral Infections in Transplant Recipients

Respiratory viral infections (RVIs) are among the leading cause of morbidity and mortality in pediatric hematopoietic stem cell transplant (HCT) and solid organ transplant (SOT) recipients. Transplant recipients remain at high risk for super imposed bacterial and fungal pneumonia, chronic graft dysfunction, and graft failure as a result of RVIs. Recent multicenter retrospective studies and prospective studies utilizing contemporary molecular diagnostic techniques have better delineated the epidemiology and outcomes of RVIs in pediatric transplant recipients and have advanced the development of preventative vaccines and treatment interventions in this population. In this review, we will define the epidemiology and outcomes of RVIs in SOT and HSCT recipients, describe the available assays for diagnosing a suspected RVI, highlight evolving management and vaccination strategies, review the risk of donor derived RVI in SOT recipients, and discuss considerations for delaying transplantation in the presence of an RVI.

Approach to suspected donor-derived infections

Prevention of donor-derived disease among pediatric solid organ transplant recipients requires judicious risk-benefit assessment. Comprehensive guidelines outline specific donor risk factors and post-transplant monitoring strategies to prevent and mitigate transmission of HIV, hepatitis B, and hepatitis C. However, elimination of unanticipated donor-derived infections remains challenging. The objectives of this review are to (1) define risk of anticipated vs. unanticipated disease transmission events in pediatric solid organ transplant recipients; (2) discuss donor presentations that confer greater risk of unanticipated disease transmission; (3) develop a matrix for consideration of donor acceptance; and (4) discuss limitations and future directions for donor screening. Although solid organ transplant confers inherent risk of infection transmission, the risk of significant disease transmission events may be mitigated by a comprehensive approach including donor assessment, consideration of recipient need, post-transplant monitoring, and early intervention.

Kidney transplantation from a SARS-CoV-2-positive donor for the recipients with immunity after COVID-19

The coronavirus (COVID‐19) pandemic is evolving very quickly and has affected healthcare systems worldwide. Many uncertainties remain about transplantation from a SARS‐CoV‐2‐positive donor as only a few cases have been reported. Here, we present the successful transplantation of 2 kidneys from a 52‐year‐old male donor with active (2 weeks of COVID‐19‐like symptoms and positive nasopharyngeal swab SARS‐CoV‐2 polymerase chain reaction on the day of organ recovery) SARS‐CoV‐2 disease. The immediate postoperative course of both recipients was uneventful. This case emphasizes that patients with SARS‐CoV‐2 may be safe organ donors.

Heart transplantation in the era of the SARS-CoV-2 pandemic: Is it safe and feasible?

As the SARS‐CoV‐2–pandemic continues to unfold, the number of heart transplants completed in the United States has been declining steadily. The current case series examines the immediate short‐term outcomes of seven heart transplant recipients transplanted during the SARS‐CoV‐2 pandemic. We hope to illustrate that with proper preparation, planning, and testing, heart transplantation can be continued during a pandemic. We assessed 7 patients transplanted from March 4, 2020, to April 15, 2020. The following endpoints were noted: in‐hospital survival, in‐hospital freedom from rejection, in‐hospital nonfatal major cardiac adverse events (NF‐MACE), severe primary graft dysfunction, hospital length of stay, and ICU length of stay. There were no expirations throughout the hospital admission. In addition, there were no patients with NF‐MACE or treated rejection, and 1 patient developed severe primary graft dysfunction. Average length of stay was 17.2 days with a standard deviation of 5.9 days. ICU length of stay was 7.7 days with a standard deviation of 2.3 days. Despite the decreasing trend in completed heart transplants due to SARS‐CoV‐2, heart transplantation appears to be feasible in the immediate short term. Further follow‐up is needed, however, to assess the impact of SARS‐CoV‐2 on post–heart transplant outcomes months after transplantation.

Use of SARS-CoV-2-infected deceased organ donors: Should we always "just say no?"

In the context of a rapidly evolving pandemic, multiple organizations have released guidelines stating that all organs from potential deceased donors with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection should be deferred, including from otherwise medically eligible donors found to have mild or asymptomatic SARS-CoV-2 discovered on routine donor screening. In this article, we critically examine the available data on the risk of transmission of SARS-CoV-2 through organ transplantation. The isolation of SARS-CoV-2 from nonlung clinical specimens, the detection of SARS-CoV-2 in autopsy specimens, previous experience with the related coronaviruses SARS-CoV and MERS-CoV, and the vast experience with other common RNA respiratory viruses are all addressed. Taken together, these data provide little evidence to suggest the presence of intact transmissible SARS-CoV in organs that can potentially be transplanted, specifically liver and heart. Other considerations including ethical, financial, societal, and logistical concerns are also addressed. We conclude that, for selected patients with high waitlist mortality, transplant programs should consider accepting heart or liver transplants from deceased donors with SARS-CoV-2 infection.

Effects of donor cause of death, ischemia time, inotrope exposure, troponin values, cardiopulmonary resuscitation, electrocardiographic and echocardiographic data on recipient outcomes: A review of the literature

BACKGROUND

Heart transplantation has become standard of care for pediatric patients with either end-stage heart failure or inoperable congenital heart defects. Despite increasing surgical complexity and overall volume, however, annual transplant rates remain largely unchanged. Data demonstrating pediatric donor heart refusal rates of 50% suggest optimizing donor utilization is critical. This review evaluated the impact of donor characteristics surrounding the time of death on pediatric heart transplant recipient outcomes.

METHODS

An extensive literature review was performed to identify articles focused on donor characteristics surrounding the time of death and their impact on pediatric heart transplant recipient outcomes.

RESULTS

Potential pediatric heart transplant recipient institutions commonly receive data from seven different donor death-related categories with which to determine organ acceptance: cause of death, need for CPR, serum troponin, inotrope exposure, projected donor ischemia time, electrocardiographic, and echocardiographic results. Although DITs up to 8 hours have been reported with comparable recipient outcomes, most data support minimizing this period to <4 hours. CVA as a cause of death may be associated with decreased recipient survival but is rare in the pediatric population. Otherwise, however, in the setting of an acceptable donor heart with a normal echocardiogram, none of the other data categories surrounding donor death negatively impact pediatric heart transplant recipient survival.

CONCLUSIONS

Echocardiographic evaluation is the most important donor clinical information following declaration of brain death provided to potential recipient institutions. Considering its relative importance, every effort should be made to allow direct image visualization.

ISHLT consensus statement on donor organ acceptability and management in pediatric heart transplantation

The number of potential pediatric heart transplant recipients continues to exceed the number of donors, and consequently the waitlist mortality remains significant. Despite this, around 40% of all donated organs are not used and are discarded. This document (62 authors from 53 institutions in 17 countries) evaluates factors responsible for discarding donor hearts and makes recommendations regarding donor heart acceptance. The aim of this statement is to ensure that no usable donor heart is discarded, waitlist mortality is reduced, and post-transplant survival is not adversely impacted.

Pediatric heart transplant from an incompletely treated influenza A-positive donor

There is a shortage of pediatric donor hearts for waitlisted children, and yet nearly 50% of organs offered are not transplanted. Donor quality is often cited as a reason for declining organs offered from donors infected with influenza, presumably due to concern about disease transmission at transplant leading to severe disease. We previously described an excellent outcome after heart transplant from a donor infected with influenza B that had been treated with a complete course of oseltamivir. In this report, we describe a similar outcome after transplantation of an organ from an influenza A-positive donor with symptomatic disease incompletely treated with oseltamivir. Due to the availability of effective antiviral treatment, we suggest that influenza A is also a manageable donor infection that need not preclude heart placement.

Pediatric heart transplantation from an influenza B-positive donor

As heart transplantation demand is increasing without subsequent growth of the donor pool, need for expansion of acceptance criteria is paramount, particularly when considering critically ill, highly sensitized patients. We present a case report of a pediatric heart transplant recipient of an organ refused by 197 prior potential recipients due to the donor being infected with influenza virus. We perform a literature review of recent solid organ transplant cases from influenza-positive donors and conclude that the donor pool may be expandable by allowing donors with treatable infections to be included.

Infections in pediatric solid-organ transplant recipients

Solid-organ transplantation in pediatrics can be a life-saving procedure, but it cannot be accomplished without risk of infection-related morbidity and mortality. Evaluation of the recipient during candidacy and donor during evaluation can assist with identification of risk. Further, risk of infection from the surgical procedure can be mitigated through careful planning and attention to infection prevention processes. Finally, early recognition of infection posttransplant can limit the impact of these events.

Use of organs from donors with bloodstream infection, pneumonia, and influenza: Results of a survey of infectious diseases practitioners

BACKGROUND

Potential organ donors may be admitted with an infection to an intensive care unit, or contract a nosocomial infection during their stay, increasing the risk of potential transmission to the recipient. Because of a lack of practice guidelines and large-scale data on this topic, we undertook a survey to assess the willingness of transplant infectious diseases (ID) physicians to accept such organs.

METHODS

We performed a 10-question survey of ID providers from the American Society of Transplantation Infectious Disease Community of Practice to determine the scope of practice regarding acceptance of organs from donors with bloodstream infection, pneumonia, and influenza prior to organ procurement, as well as management of such infections following transplantation.

RESULTS

Among 60 respondents to our survey, a majority indicated that organs would be accepted from donors bacteremic with streptococci (76%) or Enterobacteriaceae (73%) without evidence of drug resistance. Acceptance rates varied based on infecting organism, type of organ, and center size. Ten percent of respondents would accept an organ from a donor bacteremic with a carbapenem-resistant organism. Over 90% of respondents would accept an organ other than a lung from a donor with influenza on treatment, compared with 52% that would accept a lung in the same setting.

CONCLUSIONS

This study is the first to our knowledge to survey transplant ID providers regarding acceptance of organs based on specific infections in the donor. These decisions are often based on limited published data and experience. Better characterization of the outcomes from donors with specific types of infection could lead to liberalization of organ acceptance practices across centers.

Influenza prevention and treatment in transplant recipients and immunocompromised hosts

The host immune response is critical for the control and clearance of influenza virus after initial infection. Unfortunately, key components of the innate and adaptive responses to influenza are compromised in solid organ and hematopoietic stem cell transplant recipients. As a result, influenza in these key patient populations is associated with prolonged viral shedding, more frequent complications, including bacterial and fungal superinfections and rejection, and increased mortality. While vaccine is the critical prophylaxis strategy in other populations, response rates are diminished, particularly early post-transplant, among immunocompromised patients. Prospective data suggest that antiviral prophylaxis represents an effective and safe alternative to vaccine in patients who would be predicted to have poor responses to influenza vaccine. While there have not been randomized, controlled studies of antiviral therapy completed in solid organ or hematopoietic stem cell patient populations, observational data suggest that early therapy is associated with reduced rates of progression to lower airway involvement, morbidity, and mortality. Further studies are needed to define the optimal regimen, dose, duration, and endpoint to define successful treatment.

The impact of influenza A(H1N1)pdm09 infection on immunosuppressed patients

Before the advent of the influenza A(H1N1)pdm virus in 2009, the information available about the clinical manifestations and prognosis of influenza in immunosuppressed patients was scarce. With the 2009 pandemic, knowledge of the behavior, severity and importance of antiviral therapy for influenza A infection in immunocompromised hosts has increased considerably. The aim of the present manuscript is to review the main challenges of influenza in the most representative immunosuppressed populations such as solid organ transplant recipients, hematopoietic stem cell transplant recipients, patients with solid and hematological cancer and human immunodeficiency virus infected patients.

Management of influenza infection in solid-organ transplant recipients: consensus statement of the Group for the Study of Infection in Transplant Recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Network for Research in Infectious Diseases (REIPI)

BACKGROUND

Solid organ transplant (SOT) recipients are at greater risk than the general population for complications and mortality from influenza infection.

METHODS

Researchers and clinicians with experience in SOT infections have developed this consensus document in collaboration with several Spanish scientific societies and study networks related to transplant management. We conducted a systematic review to assess the management and prevention of influenza infection in SOT recipients. Evidence levels based on the available literature are given for each recommendation. This article was written in accordance with international recommendations on consensus statements and the recommendations of the Appraisal of Guidelines for Research and Evaluation II (AGREE II).

RESULTS

Recommendations are provided on the procurement of organs from donors with suspected or confirmed influenza infection. We highlight the importance of the possibility of influenza infection in any SOT recipient presenting upper or lower respiratory symptoms, including pneumonia. The importance of early antiviral treatment of SOT recipients with suspected or confirmed influenza infection and the necessity of annual influenza vaccination are emphasized. The microbiological techniques for diagnosis of influenza infection are reviewed. Guidelines for the use of antiviral prophylaxis in inpatients and outpatients are provided. Recommendations for household contacts of SOT recipients with influenza infection and health care workers in close contact with transplant patients are also included. Finally antiviral dose adjustment guidelines are presented for cases of impaired renal function and for pediatric populations.

CONCLUSIONS

The latest scientific information available regarding influenza infection in the context of SOT is incorporated into this document.