Quantifying the risk of undetected HIV, hepatitis B virus, or hepatitis C virus infection in Public Health Service increased risk donors

Organ Nonutilization Following Revision to the Public Health Service Donor Risk Criteria for HIV, HCV, or HBV Transmission

BACKGROUND

Organs from Public Health Service criteria (PHSC) donors, previously referred to as PHS infectious-risk donors, have historically been recovered but not used, traditionally referred to as "discard," at higher rates despite negligible risk to recipients. On March 1, 2021, the definition of PHSC donors narrowed to include only the subset of donors deemed to have meaningfully elevated risk in the current era of improved infectious disease testing.

METHODS

Using Scientific Registry of Transplant Recipients data from May 1, 2019, to December 31, 2022, we compared rates of PHSC classification and nonutilization of PHSC organs before versus after the March 1, 2021, policy change among recovered decedents using the χ2 tests. We performed an adjusted interrupted time series analysis to examine kidney and liver recovery/nonuse (traditionally termed "discard") and kidney, liver, lung, and heart nonutilization (nonrecovery or recovery/nonuse) prepolicy versus postpolicy.

RESULTS

PHSC classification dropped sharply from 24.5% prepolicy to 15.4% postpolicy (P < 0.001). Before the policy change, PHSC kidney recovery/nonuse, liver nonuse, lung nonuse, and heart nonuse were comparable to non-PHSC estimates (adjusted odds ratio: kidney = 0.981.061.14, P = 0.14; liver = 0.850.921.01, P = 0.07; lung = 0.910.991.08, P = 0.83; heart = 0.890.971.05, P = 0.47); following the policy change, PHSC kidney recovery/nonuse, liver nonuse, lung nonuse, and heart nonuse were lower than non-PHSC estimates (adjusted odds ratio: kidney = 0.770.840.91, P < 0.001; liver = 0.770.840.92, P < 0.001; lung = 0.740.810.90, P < 0.001; heart = 0.610.670.73, P < 0.001).

CONCLUSIONS

Even though PHSC donors under the new definition are a narrower and theoretically riskier subpopulation than under the previous classification, PHSC status appears to be associated with a reduced risk of kidney and liver recovery/nonuse and nonutilization of all organs. Although historically PHSC organs have been underused, our findings demonstrate a notable shift toward increased PHSC organ utilization.

Sexual and gender minority relevant policies in Canadian and United States organ and tissue donation and transplantation systems: An opportunity to improve equity and safety

Current policies in organ and tissue donation and transplantation (OTDT) systems in Canada and the United States unnecessarily restrict access to donation for sexual and gender minorities (SGMs) and pose safety risks to transplant recipients. We compare SGM-relevant policies between the Canadian and United States systems. Policy domains include the risk assessment of living and deceased organ and tissue donors, physical examination considerations, viral testing recommendations, and informed consent and communication. Identified gaps between current evidence and existing OTDT policies along with differences in SGM-relevant policies between systems, represent an opportunity for improvement. Specific recommendations for OTDT system policy revisions to achieve these goals include the development of behavior-based, gender-neutral risk assessment criteria, a reduction in current SGM no-sexual contact period requirements pending development of inclusive criteria, and destigmatization of sexual contact with people living with human immunodeficiency virus. OTDT systems should avoid rectal examinations to screen for evidence of receptive anal sex without consent and mandate routine nucleic acid amplification test screening for all donors. Transplant recipients must receive enhanced risk-to-benefit discussions regarding decisions to accept or decline an offer of an organ classified as increased risk. These recommendations will expand the donor pool, enhance equity for SGM people, and improve safety and outcomes for transplant recipients.

Transfusion-Transmitted Disorders 2023 with Special Attention to Bone Marrow Transplant Patients

Transfusion medicine is traditionally a strong/fundamental part of clinical practice, saving hundreds of millions of lives. However, blood-borne or transmitted infections are a well-known and feared possibility, a risk we relentlessly mitigate. Pathogens are continuously and rather quickly changing, so during the last decade, many, sometimes exotic, new pathogens and diseases were recorded and analyzed, and some of them were proved to be transmitted with transfusions. Blood or blood component transfusions are carried out after cautious preparative screening and inactivation maneuvers, but in some instances, newly recognized agents might escape from standard screening and inactivation procedures. Here, we try to focus on some of these proven or potentially pathogenic transfusion-transmitted agents, especially in immunocompromised patients or bone marrow transplantation settings. These pathogens are sometimes new challenges for preparative procedures, and there is a need for more recent, occasionally advanced, screening and inactivation methods to recognize and eliminate the threat a new or well-known pathogen can pose. Pathogen transmission is probably even more critical in hemophiliacs or bone marrow transplant recipients, who receive plasma-derived factor preparations or blood component transfusions regularly and in large quantities, sometimes in severely immunosuppressed conditions. Moreover, it may not be emphasized enough that transfusions and plasma-derived product administrations are essential to medical care. Therefore, blood-borne transmission needs continued alertness and efforts to attain optimal benefits with minimized hazards.

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

Increased Risk Donors Utilized in Lung Transplantation At A Single Center

Introduction: In 2013, the US Public Health Service (PHS) updated guidelines for high-risk donor organs and renamed the category increased risk. Project Aims: We compared survival of patients who received increased risk or non-increased risk donor lungs to determine if PHS designated increased risk donor lungs were an underutilized resource. Design: This retrospective cohort analysis compared survival and utilization rates of increased-risk and non-increased-risk donor lungs used in lung transplantation at a single institution over a period of 8 years (Feb-2012 through Mar-2020). Survival was assessed using Kaplan-Meier analysis and compared by log-rank test. Cox proportional hazards modeling was used to analyze impact on survival of variables significantly associated with risk status, including recipient ethnicity, lung allocation score (LAS), donor age, year of transplant procedure, and lung transplant type. Results: Of 744 lung transplant recipients from February 2012 through March 2020, there were 192 (26%) recipients of increased risk designated lungs. In 2012 and 2013, 6% and 0% respectively of the lungs transplanted were increased risk labeled. After the PHS guidelines were nationally implemented in February 2014, the proportion of increased risk lung transplants rose to 7% (2014), 21% (2015), 27% (2016), 35% (2017), 28% (2018), 27% (2019), and 40% (January-March 2020). Kaplan-Meier analysis and log-rank test comparison showed no significant difference in survival between patients that received increased risk versus non-increased risk labeled lungs (P = 0.47). Conclusions: Our analysis suggested the 2013 PHS increased risk designation threatened underutilization of viable donor lungs, providing further support for the 2020 PHS changes.

Consent to organ offers from public health service “Increased Risk” donors decreases time to transplant and waitlist mortality

Background

The Public Health Service Increased Risk designation identified organ donors at increased risk of transmitting hepatitis B, hepatitis C, and human immunodeficiency virus. Despite clear data demonstrating a low absolute risk of disease transmission from these donors, patients are hesitant to consent to receiving organs from these donors. We hypothesize that patients who consent to receiving offers from these donors have decreased time to transplant and decreased waitlist mortality.

Methods

We performed a single-center retrospective review of all-comers waitlisted for liver transplant from 2013 to 2019. The three competing risk events (transplant, death, and removal from transplant list) were analyzed. 1603 patients were included, of which 1244 (77.6%) consented to offers from increased risk donors.

Results

Compared to those who did not consent, those who did had 2.3 times the rate of transplant (SHR 2.29, 95% CI 1.88–2.79, p < 0.0001), with a median time to transplant of 11 months versus 14 months (p < 0.0001), as well as a 44% decrease in the rate of death on the waitlist (SHR 0.56, 95% CI 0.42–0.74, p < 0.0001). All findings remained significant after controlling for the recipient age, race, gender, blood type, and MELD. Of those who did not consent, 63/359 (17.5%) received a transplant, all of which were from standard criteria donors, and of those who did consent, 615/1244 (49.4%) received a transplant, of which 183/615 (29.8%) were from increased risk donors.

Conclusions

The findings of decreased rates of transplantation and increased risk of death on the waiting list by patients who were unwilling to accept risks of viral transmission of 1/300–1/1000 in the worst case scenarios suggests that this consent process may be harmful especially when involving “trigger” words such as HIV. The rigor of the consent process for the use of these organs was recently changed but a broader discussion about informed consent in similar situations is important.

Use of Hepatitis B Virus-Positive Organs in Organ Transplantation

The significant morbidity and mortality of people with end-stage renal, liver, heart, and lung diseases in need of transplantation provides rationale for use of organs from donors who are hepatitis B positive. The recipient's hepatitis B status plays a key role in defining the prophylactic strategy. The availability of safe and effective therapies (hepatitis B antivirals and hepatitis B immune globulin) has contributed to the safety of using hepatitis B-positive donors. The outcomes in both liver and nonliver solid organ transplant recipients given hepatitis B-positive organs have been excellent if appropriate prophylactic therapies provided.

Successful Implementation of an Increased Viral Risk Donor Waiting List for Preconsented Kidney Transplant Candidates in Victoria, Australia

Supplemental Digital Content is available in the text.

Increased viral risk donors (IVRDs) with increased risk behaviors for blood-borne virus infection and negative nucleic acid testing have a low absolute risk of “window period” infection. Utilization and allocation of IVRD organs differ between jurisdictions.

Guidance regarding gamete and embryo donation

This document provides the latest recommendations for the evaluation of potential sperm, oocyte, and embryo donors as well as their recipients, incorporating recent information about optimal screening and testing for sexually transmitted infections, genetic diseases, and psychological assessments. This revised document incorporates recent information from the US Centers for Disease Control and Prevention, US Food and Drug Administration, and American Association of Tissue Banks, which all programs offering gamete and embryo donation services must be thoroughly familiar with, and replaces the document titled "Recommendations for gamete and embryo donation: a committee opinion," last published in 2013.

Assessing Solid Organ Donors and Monitoring Transplant Recipients for Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infection - U.S. Public Health Service Guideline, 2020

The recommendations in this report supersede the U.S Public Health Service (PHS) guideline recommendations for reducing transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through organ transplantation (Seem DL, Lee I, Umscheid CA, Kuehnert MJ. PHS guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation. Public Health Rep 2013;128:247-343), hereafter referred to as the 2013 PHS guideline. PHS evaluated and revised the 2013 PHS guideline because of several advances in solid organ transplantation, including universal implementation of nucleic acid testing of solid organ donors for HIV, HBV, and HCV; improved understanding of risk factors for undetected organ donor infection with these viruses; and the availability of highly effective treatments for infection with these viruses. PHS solicited feedback from its relevant agencies, subject-matter experts, additional stakeholders, and the public to develop revised guideline recommendations for identification of risk factors for these infections among solid organ donors, implementation of laboratory screening of solid organ donors, and monitoring of solid organ transplant recipients. Recommendations that have changed since the 2013 PHS guideline include updated criteria for identifying donors at risk for undetected donor HIV, HBV, or HCV infection; the removal of any specific term to characterize donors with HIV, HBV, or HCV infection risk factors; universal organ donor HIV, HBV, and HCV nucleic acid testing; and universal posttransplant monitoring of transplant recipients for HIV, HBV, and HCV infections. The recommendations are to be used by organ procurement organization and transplant programs and are intended to apply only to solid organ donors and recipients and not to donors or recipients of other medical products of human origin (e.g., blood products, tissues, corneas, and breast milk). The recommendations pertain to transplantation of solid organs procured from donors without laboratory evidence of HIV, HBV, or HCV infection. Additional considerations when transplanting solid organs procured from donors with laboratory evidence of HCV infection are included but are not required to be incorporated into Organ Procurement and Transplantation Network policy. Transplant centers that transplant organs from HCV-positive donors should develop protocols for obtaining informed consent, testing and treating recipients for HCV, ensuring reimbursement, and reporting new infections to public health authorities.

Current status of liver transplantation in North America

Liver transplantation is continuing to grow and evolve in North America. Changes in organ availability, recipient selection, indications and progressive approaches to oncologic treatment have occurred in the last five years. Despite increased activity in deceased and living donation in North America, there continues to be a high mortality on the waitlist as the recipient indications have changed over time which has led to new approaches to help patients with end-stage liver disease.

The impact of change in definition of increased-risk donors on survival after lung transplant

OBJECTIVES

To study the impact of using the US Public Health Service broadened definition of "increased-risk" donors (2013) in comparison with "high-risk" (1994) and standard infectious risk donors on lung transplant recipient outcomes.

METHODS

Patients who underwent lung transplant between January 1, 2006, and May 31, 2017, in the Scientific Registry of Transplant Recipients were divided into 2 cohorts, recipients of: (1) high-risk donors: January 1, 2006, to October 1, 2013, and (2) increased-risk donors: January 1, 2014, to May 31, 2017, and compared with matched recipients who received standard-risk donors. Risks for acute rejection, patient, and graft survival using propensity score matched cohorts, multivariable logistic, and Cox models were examined.

RESULTS

In total, 18,490 lung transplant recipients were analyzed with 36% transplanted during the increased-risk donor definition period. The proportion of donors classified as nonstandard infectious risk increased with the definition change (8% high-risk donors vs 22% increased-risk donors; P < .001). In both cohorts, male patients with a lower forced expiratory volume in 1 second and greater creatinine were more likely to receive an organ from increased risk donors. Neither graft nor patient survival differed by donor type in either period. Acute treated rejection within 1 year did not differ by period for recipients of increased risk donors (odds ratio, 0.87; P = .23) or recipients of high-risk donors (odds ratio, 1.2; P = .27).

CONCLUSIONS

The 2013 broadened definition of donor risk increased the proportion of nonstandard infectious risk donors. Recipients of increased/high-risk donors had similar graft and patient survival compared with standard-risk donors.