CONTRAINDICATIONS

FOR ORGAN DONATION

Dr Divyesh Engineer
Associate Professor Nephrology
IKDRC-ITS

18/01/2020
Contraindications for organ donation
• General to all organs
- Donor Infections
Donor Derived Diseases
- Donor malignancies

• Organ specific
 Donor derived diseases
• Data: OPTN date: less than 0.2 %
RESITRA study : 1.7%
• May have serious and /or fatal outcome
• Most donor infections independently are not contraindications to
transplantation
• Considering donor organ scarcity, selected donors with infection can
be used with informed consent and proper plan of recipient
management
 Pathogens documented to be transmitted in SOT
Bacteria Fungi Viruses
Staphylococcus aureus Aspergillus species Cytomegalovirus
Klebsiella species Candida species Epstein‐Barr virus
Bacteroides fragilis Coccidioides immitis Herpes simplex virus
Pseudomonas aeruginosa Cryptococcus neoformans Varicella‐zoster virus*
Escherichia coli Histoplasma capsulatum Human herpesvirus‐6
Salmonella species Scedosporium apiospermum Human herpesvirus‐7
Yersinia enterocolitica Prototheca species Human herpesvirus‐8
Plasmodium species Zygomycetes Hepatitis B, D
Treponema pallidum Hepatitis C
Brucella species Mycobacteria HIV
Enterobacter species Mycobacterium tuberculosis Parvovirus B19
Acinetobacter species Non-TB mycobacteria Rabies
Legionella species Lymphocytic choriomeningitis v
Nocardia species Parasites/Protozoa West Nile virus
Listeria monocytogenes Toxoplasma gondii BK virus
Strongyloides stercoralis HTLV‐ 1/2
Plasmodium species
Trypanosoma cruzi
Pneumocystis jirovecii
Document Donor Derived Malignancy
Adenocarcinoma*
Basaloid CA*
Cholangiocarcinoma*
Leukemia*
Liver CA*
Lung CA*
Lymphoma*
Melanoma*
Mesothelioma*
Neuroendocrine CA*
Oncocytoma*
Ovarian CA*
Renal Cell Carcinoma*
Small Bowel CA*
Small Cell CA*
 Infectious contraindications
• Active Fungal, Parasitic, Viral and Bacterial Meningitis/ Encephalitis
• Bacterial: TB
Gangrenous bowel/Perforated bowel/ Intraabdominal sepsis
Uncontrolled bacterial sepsis
• Viral: Active Hepatitis B/C
Rabies
Retroviral infections HIV, HTLV I/II
Active Herpes simplex, EBV,CMV or varicella viremia or pneumonia
West nile virus
 Infectious contraindications
• Fungal: Active Cryptococus, Aspergillus, Histoplasma, Coccidioides
Active candidemia/ Invasive yeast
• Parasitic: Active infection with T.Cruzi, Leishmania, Strongyloides or
Plasmodium
• Prion: Creutzfeldt–Jakob disease
COMMON CLINICAL SCENARIOS OF
DONOR WITH
CONFIRMED/SUSPECTED INFECTION
 Donor Bacteremia
• Approx 5% donor are bacteremic
• May have catastrophic outcomes:
- Mycotic aneurysm of anastomotic site
- Graft loss
- Sepsis
• Risk of transmission and impact of such infection depends on type of bacteria
-GPC CONS ------- Low risk of transmission
-GNB ------- Greater risk of transmission and poor outcome
• Greatest concern: MDR bacteria
-MRSA
-VRE
-MDR GNB (Pseudomonas, Klebsiella, Acinetobacter)
 Do Bacteremic Donors Can Donate?
• Emerging data suggest that bacteremic donors may be utilized
in certain circumstances
• Targeted antimicrobial treatment for at least 24-48 hours
• Some degree of clinical response:
- Improved white blood cell count
- Improved hemodynamics
- Defervescence
• Informed consent from recipient
• Recipient is treated with a 7- to 14-day course of antibiotics targeted to
the organism isolated from the donor
 What about MDR Bacteremia?
• Currently prevalent:
- ESBL-producing enterobacteriaceae
- Carbapenem-resistant Acinetobacter baumannii (CRAB)
- Carbapenem-resistant Klebsiella pneumoniae (CR-KP)
- Other Carbapenem-resistant enterobacteriaceae (CRE)

• Extremely problematic bacteria:

- Extended multidrug resistant phenotype
- Sensitive to only few antibiotics
- Limited antibiotics options for MDR GNB

• Transplant of any organ should not be considered, because outcomes in such

circumstances are still unknown
 Donor with Bacterial Meningitis
• Patients with culture-proven bacterial meningitis can be used safely
as an organ donor if:
-Donor was treated for 24-48 hours with culture appropriate antibiotic
- Appropriate clinical response to therapy

• Recipient receives a complete treatment course (typically 14 days)

directed against the cultured pathogen
 Donor with Bacterial Meningitis
• Meningitis caused by highly virulent or intracellular organisms such
as Listeria species or tuberculosis is still considered a contraindication
to donation

• Documentation of bacterial meningitis is essential –Should be definitive and

not presumed bacterial meningitis

• Culture negative presumed bacterial meningitis- Contraindication

 Donor with Encephalitis
• Donors with encephalitis should not be used especially when etiology
is non known
• Encephalitis, particularly with fever, without a documented source is
frequently associated with disease transmission
• Transmission of rabies, parasitic infections, lymphomas, and
leukemias have occurred when donors with encephalitis without a
proven cause were accepted as organ donors
 Donor with Encephalitis
• The two exceptions:
- Donors with proven bacterial encephalitis
- Donors with proven Naegleria fowlerii meningoencephalitis.
• Naegleria infection is generally limited to the CNS
• Even when there is molecular evidence of the parasite outside the
CNS, transmission has not been documented.
• If the donor has proven N fowlerii meningoencephalitis, the organs
can be utilized with a low risk of transmission, as long as the
recipients are informed of the risk and monitored closely
 Donor Pneumonia
• Fungal pneumonia is a contraindication to transplantation
• Candida species positive respiratory cultures typically represent upper
airway colonization
• Pneumonia without bacteremia: All other organs can be used
• Presence of pneumonia is typically a contraindication to lung
transplantation; lungs that have completed a course of active
antibacterial therapy may considered on a case-by-case basis
 Donor with Influenza(
Seasonal/Pandemic)
• Seasonal: Mostly limited to respiratory tract without viremia
• Lung donation: contraindicated unless completed standard course of
therapy
• Other organs: consideration on case to case basis
• Atypical presentation post Tx- Fever may be only symptom and
typical respiratory features may be absent
• All recipients of organ from confirmed Influenza should receive
empirical treatment( Not prophylaxis)
• Pandemic-Non novel virus: In immunocompetent patients no risk of
transmission via blood- Non lung organ donation can be done
• Pandemia-Novel virus: Contraindication
 Donor with UTI
• Presence of UTI is not a contraindication for donation
• Exclude MDR bacterial infection
• In uncomplicated UTI/Bacteuria- Kidneys can be used
• Donor with pyelonephritis-High risk of transmission of infection-
requires discussion
• Kidney transplant recipient: 3-7 days of culture appropriate antibiotics
• Other organ recipients: No treatment unless bacteremia/fungemia
Donor with positive syphilis screen
• Not a contraindication
• Do confirmative testing with FTA-ABS
• All such recipient to be treated on line of therapy for syphilis of
unclear duration
 Donor with TB
• Active TB/ Disseminated TB is contraindication
 Hepatitis C positive donor
• Traditionally: HCV Pos to Pos
• HCV NAT positive donor for HCV negative recipients:
- Recently been considered due to efficacy of DAA
- The experience with such HCV D+/R− transplant is limited
- Done with use of DAA at time of or early after Tx
- Should be done with informed consent under IRB approved
protocols
- Be careful of Genotype 3 – Less response rated and less Rx options
Hepatits B positive Donor
 HIV positive donors
• HIV to HIV transplant legalized in US and other countries
 Donor with Chikungunya Virus
• Viremia persist 4 days to 3 week after mosquito bite
• Diagnosis: NAT
• Infection in SOT have been rare and does not appear to be more
serious
• Organs may be used with consultation with Tx ID expert
 Donor with Dengue Infection
• Viremia may persist upto 21 days after bite
• Limited reports of transmission by transplant
• Case report show increased graft complication but no mortality
• Organs can be used with caution with informed consent
 Measures to reduce risk of donor derived
infections
• Prevention is best: Standard intensive care unit policies for the
prevention of hospital-acquired infections
- Pneumonia
- Central line-associated blood stream infections
- Urinary tract infections
• Early diagnosis and treatment of donor infections
• Risk Stratification from the Donor Medical and Social History
• Careful Clinical assessment of the Donor and the Donor Organs
• Laboratory Screening of the Donor for Infection
 Infectious Diseases Screening Recommended For Donors

• HIV 1/2 antibody or HIV antigen/antibody combination test

• Cytomegalovirus (CMV) antibody
• Hepatitis B surface antigen (HBsAg)
• Hepatitis B core antibody (HBcAb)
• Hepatitis C antibody
• Hepatitis C NAT
• Syphilis test
• Epstein–Barr virus (EBV) antibody
• Blood and urine cultures
• Sputum gram stain (lung transplant donors only)
• Toxoplasma antibody test result or appropriate donor sample to be tested at
transplant hospital (heart donors only)
Infectious Diseases Screening Recommended
For Donors- Special situation
• Coccidioidomycosis serology
• Strongyloides
• TB screening (PPD or interferon-γ release assay)
• West Nile virus testing
Beware of window period
 Risk grading for Donor derived
infections
• Unacceptable risk : Absolute contraindication
• Increased but acceptable risk: Clinical condition of recipient justifies Tx
• Calculated risk:
-recipients with the same disease or with
-protective serological status
-broad-spectrum antibiotic therapy of a minimum duration (24 h) and
those with documented bacteremia who have started targeted antibiotic
therapy.
• Not assessable risk includes
• Standard risk
Len O :1Clin Microbiol Infect. 2014;20(Suppl 7):10–8.
Donor with Malignancy
Malignancy contraindicating donation
• A recent history of or an active malignant neoplasm
Except: low risk of transmission or localized tumors
- Skin basal cell carcinoma
- Cervical carcinoma in situ
- Primary CNS tumors (excluding high grade medulloblastoma,
glioblastoma and astrocytoma)
• Kidney tumors accepted when
size is ≤ 4cm
Fuhrman grade I-II
Margins are free
Malignancy contraindicating donation
• The donation of organs is contraindicated for donors with a past history
of
- Breast cancer
- Melanoma
- Soft tissue sarcoma
- Blood cancers
- Metastatic cancers
(independent from the time elapsed since the onset of disease)
• Donors with a history of other types of neoplasms with a disease-free
period of 3, 5 or even 10 years without tumor relapse might be accepted
 Take Home Message
• Donor with infection/malignancy is not an absolute no to donation
• Careful screening of donors through history, physical examination,
microbiologic ,serologic and molecular testing is must
• Impossible to screen for all pathogens, so donor derived infection should
be always a differential diagnosis for all early infections or Atypical post
transplant course
• Reporting of all suspected/proven donor derived infections/malignancy
should be mandatory in Transplant law
• Informed consent is must when using such organs
THANK YOU