Timing is everything. Routine screening of organ donors for human immunodeficiency virus (HIV) infection has made transmission of HIV through organ transplantation rare in the United States. This week, the Center for Disease Control and Prevention (CDC) has released its commentary on the events reported recently regarding the discovery that a person that received a kidney transplant, contracted HIV from the donor. However, HIV screening was not done as close to the procedure as it could, or should have been.
Twelve days before receiving a much needed kidney transplant in 2009, a recipient was screened for HIV and tested negative. The post transplant clinical course was complicated however, including multiple hospitalizations for febrile illness, episodes of renal insufficiency, and evaluation for possible rejection of the transplanted kidney. One year after the transplant the recipient tested positive for HIV.
The recipient did not have any history of sexually transmitted infections, injection drug use, sex with injection drug users, or other high-risk sexual activity. The recipient received blood transfusions in 2006, but none previously.
During the year after kidney transplantation, the recipient did not engage in any behaviors that would increase the risk for acquiring HIV. One year after transplant, the recipient was hospitalized with refractory oral and esophageal candidiasis; screening for HIV infection by EIA was positive, and HIV infection was confirmed with a positive Western blot (a widely used analytical technique used to detect specific proteins in the given sample of tissue homogenate or extract).
The donor was an adult male who underwent evaluation as a potential living donor for kidney transplantation at a participating hospital in 2009. The donor had a previous diagnosis of syphilis and a history of sex with male partners. He reported unprotected sex with one male partner during the first year before the transplant, including the time between his initial evaluation and organ recovery. He did not know his partner’s HIV status. He did not report any history of injection drug use, tattoos, or blood transfusions.
Laboratory testing conducted during the initial evaluation 79 days before transplant showed no evidence of infection with HIV, so the donor’s kidney was removed without complication and without the need for any blood transfusions during the procedure.
The transplant team learned of the living donor’s new HIV diagnosis during his follow up visit one year after the transplant. A public health investigation ensured.
Transmission of HIV can be an uncommon complication of organ transplantation, but is a public health concern. In 2010, the New York City Department of Health and Mental Hygiene was notified of a potential transplant-related HIV infection.
Here are the new CDC Guidelines:
- First, to reduce the risk for transmission of HIV through living-donor organ transplantation, transplant centers should screen living donors for HIV as close to the time of organ recovery and transplantation as possible.
- Second, clinicians should inform transplant candidates of the potential risks for disease transmission and advise donors during evaluation of their obligation to avoid behaviors that would put them at risk for acquiring HIV before organ donation.
How did this happen though?
Time is of the essence in these types of cases and all organ transplants.
Yes, the donor and recipient were interviewed in person using a standardized case interview form. Medical records were reviewed, focusing on relevant medical history before and after kidney transplantation, history of HIV testing and evidence of infection, pretransplant evaluation, post transplant course, blood product transfusion history, other past medical history, history of substance use, sexual history, and other risk factors for HIV infection.
Yes, the recipient’s transplant coordinator, nephrologist, and HIV physician were interviewed separately to review the transplant evaluation and medical course and the donor’s primary-care physician and transplant nephrologist also were interviewed.
It is standard procedure to have donated organs and tissues screened for infectious diseases such as hepatitis and HIV/AIDS. If an HIV test is positive, the deceased donor’s family could possibly be informed of the results. In this case, the screening was too far removed from the procedure.
It is a crime in some states to try to donate organs or tissues if you know you are HIV positive and that the virus may be transmitted by a donation. If an HIV positive individual wants to donate organs or tissues for purposes such as research and education, specific arrangements should be made for such a donation with a medical research or educational facility.
Organ donations are often referred to as “anatomical gifts.” All fifty states have passed some version of the Uniform Anatomical Gift Act. This act allows a person to make a gift of organs and tissues during his or her lifetime with the gift to take effect upon death.
Living organ donation dates back to 1954, when a kidney from one twin was successfully transplanted into his identical brother. Today, the number of living organ donors is more than 6,000 per year. And one in four of these donors aren’t biologically related to the recipient.
By offering a kidney, lobe of a lung, portion of the liver, pancreas, or intestine, living donors offer their loved one or friend an alternative to waiting on the national transplant waiting list for an organ from a deceased donor.
Living donors make up 44% of the total donor pool while deceased donors are the other 56%.
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Written by Sy Kraft, B.A.