Donor-Transmitted Diseases

On Friday, April 27, I represented AST at a Northwestern/ASTS/AST sponsored consensus conference on donor-transmitted diseases, specifically HIV, HCV, and HBV. These are the infections addressed in the recent draft Public Health Service guidelines now undergoing comprehensive revision. The discussion was vibrant, and the topic important. However, between 2007-11, a five-year period during which organs from over 39,000 donors were utilized, there were 20 proven or probable transmissions from 9 deceased donors in the United States! Transmission from living donors is even rarer (a potential living donor is more likely to die intraoperatively [risk 0.0003] than to transmit one of these diseases!), with at least one of the recently publicized cases clearly due to human error.

It became obvious during the consensus conference that we were trying to develop a set of recommendations for a "high-risk" issue that in scope remains relatively small compared to dozens of other risks inherent in the transplantation process. Trying to build each element into the informed consent process is a daunting challenge just for these three viruses, not to mention all the other variables each of us knows is more important to both donor and recipient.

Our responsibility is to make sure the organ supply is as safe as possible, no question, and that all involved are adequately informed. However, I am reminded of a story that the safest way to spend one's life is in bed, alone. Not much life, though.

How do we deal with this issue and appropriately communicate with potential donors and recipients?

Robert S. Gaston

Comments

Submitted by egibney on Mon, 2012-04-30 11:15

I agree that this is a difficult subject. I'm sure you've also had the experience of a recipient that was shocked that they developed CMV from the kidney, which we hardly think about because it is so commonplace, but the recipient can develop a life-threatening or very morbid illness from an important infection. It's not a reason to avoid the transplant, but we have to continue to remember that things we are familar/comfortable with can still be scary and deadly to others. It's a challenge to have perspective about these more feared diseases (HIV, HepC, HepB, malignancies), especially in light of the risk/benefit of transplant. Enjoy the blog posts! Eric

Submitted by smossad on Mon, 2012-04-30 11:43

Thank you, Dr. Gaston for representing AST & leading the discussion on this important topic. I agree; we should continue to strive to decrease the 0.02% chance you quoted for transmission from deceased donors, while at the same time trying to increase the donor pool. I recently came accross the following paper that may help in this regard: Organ donor screening using parallel nucleic acid testing allows assessment of transmission risk and assay results in real time. Baleriola, C.; Tu, E.; Johal, H.; Gillis,J.; Ison,M.G.; Law,M.; Coghlan,P.; Rawlinson,W.D. Transplant Infectious Disease, 2012, http://onlinelibrary.wiley.com/doi/10.1111/j.1399-3062.2012.00734.x/pdf Best Regards, Sherif Mossad

Submitted by mison on Mon, 2012-04-30 13:19

Thank you and all of the attendees for engaging in the meeting last week. I think the discussion was highly productive and will lead to a manuscript which we hope to submit in the near future. We will be posting the final slides and other materials in the DropBox for those who attended and on the meeting website (http://www.feinberg.northwestern.edu/transplant/Increased%20Risk%20Conse...) for the public to see. This is the begining of hopefully a continuing discussion about these important issues. Michael G. Ison, MD MS Associate Professor, Divisions of Infectious Diseases and Organ Transplantation Northwestern University Feinberg School of Medicine Medical Director, Transplant & Immunocompromised Host Infectious Diseases Service Northwestern University Comprehensive Transplant Center

Submitted by rgaston on Mon, 2012-04-30 18:14

Just to reiterate: the numbers I quoted in the original blog refer only to proven and probable transmission of HCV, HBV, and HIV. Thanks for all the interesting comments, and to Michael Ison for organizing and chairing the meeting.

Submitted by mgreen on Tue, 2012-05-01 08:00

Bob, thanks for your thoughtful comments and efforts to put this in perspective. The challenge we face is that while unintended transmission of HCV and HBV as well as any transmission of HIV is rare, the impact of transmission is magniified by the attention (especially to HIV) given to these rare events. Thus, a single event brings not only discussion but also likely a loud call for changes in processes which may or may not lead to a change in frequency of these rare events. while it is important to work towards assessing practices and policies and optimize the safety of our organ donation system, this work needs to be careful, evidence based (where evidence is available) and feasible within the confines of the donation infrastructure, Balancing the desire to achieve "zero risk" with impact on donor pool and candidate outcome is challenging but must be done. Determining who will make the final decision and how the process of decision making will be carried out has been the source of much concern over the last few years. No transplant is without risk, infectious or otherwise. Informing ourselves and our patients and their families is a major task for our transplant community. Doing this well is clearly as big of a challenge as choosing the "right" immune suppression for an individual patient. Mike Green

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