Screening of donor and candidate prior to solid organ transplantation—Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

Vaccination strategies for solid organ transplant candidates and recipients: insights and recommendations

INTRODUCTION

Vaccines save lives. They are integral to reducing the morbidity and mortality of vaccine-preventable infections in solid organ transplant recipients. Pre-transplant vaccination provides a unique opportunity for administration of live, viral vaccines, and enhanced vaccine efficacy, compared to the post-transplant period with decreased vaccine response due to immunosuppression.

AREAS COVERED

We discuss a general approach to pre- and post-transplant vaccination in solid organ transplant candidates and recipients. We then review guideline statements and recent literature related to individual vaccines, including the recently developed respiratory syncytial virus vaccine. Travel and occupation-related vaccines are also discussed.

EXPERT OPINION

The challenge of vaccination for immunocompromised patients expands as the prevalence of immunocompromised adults rises, and immunocompromised patients are frequently excluded from vaccine trials. In an age of vaccine hesitancy and reemerging vaccine-preventable infections, well-powered, prospective studies are needed to evaluate the clinical effectiveness of vaccines in solid organ transplant candidates and recipients.

Evaluation of the analytical performances of the Alinity-i HSV-1 IgG and HSV-2 IgG chemiluminescent immunoassays

BACKGROUND

The landscape of diagnostic assays for detecting herpes simplex virus type 1 and 2 (HSV-1 and HSV-2) antibodies (IgG) has evolved over time. This study aims to evaluate the analytical performance of Alinity-i chemiluminescence immunoassays in detecting specific anti-HSV-1 and HSV-2 IgG.

METHODS

A retrospective analysis was conducted on 157 serum samples collected from 155 patients between June 2023 and July 2024. Three assays were compared: Alinity® HSV-1 and HSV-2 IgG (Abbott), Liaison® HSV-1 and HSV-2 Type Specific IgG (Diasorin), and BioPlex® 2200 HSV-1 & HSV-2 IgG (Bio-Rad). Results were interpreted based on index values. The Anti-HSV-1/HSV-2-gG2 EUROLINE Western blot was used to provide definitive conclusions in cases of discordant results.

RESULTS

The sensitivities and specificities of the Alinity-i assays were respectively 98 % and 100 % for HSV-1 IgG and 92 % and 98 % for HSV-2 IgG. The interpretation concordance among the three assays was high with Cohen's kappa values ranging from 0.82 to 0.90. Of the 27 discordant samples, Western-blot analysis identified false negatives as follows: 2 and 14 for Liaison, 3 and 5 for Alinity-i, and 2 and 0 for BioPlex, for HSV-1 and HSV-2 IgG respectively. Additionally, Western Blot revealed false positives in 3 Liaison and 1 BioPlex sample for HSV-1, and in 1 Liaison and 2 Alinity-i samples for HSV-2.

CONCLUSION

The Alinity-i HSV-1 and HSV-2 IgG serology demonstrated excellent sensitivities and specificities compared to Liaison and BioPlex assays. These findings underline the efficacy of Alinity-i in clinical diagnostics, suggesting it as a reliable tool for HSV-1 and HSV-2 antibody detection in diverse patient populations.

Expression Profile of Human Cytomegalovirus UL111A cmvIL-10 and LAcmvIL-10 Transcripts in Primary Cells and Cells from Renal Transplant Recipients

Human cytomegalovirus (HCMV) is a high-risk pathogen in immunocompromised individuals, especially in transplant recipients. HCMV viremia must be monitored, and frequently, patients are treated with antiviral agents. HCMV has a variety of strategies to modulate host antiviral responses, and one important player is a viral homolog of the cellular interleukin-10 (cIL-10). The viral UL111A gene produces several HCMV IL-10 transcripts and protein isoforms through alternative splicing. The cmvIL-10 (isoform A) has similar properties to cIL-10, while LAcmvIL-10 (isoform B) has more restricted biological properties. Other isoforms are produced (C to H) but have unknown functions. Here, we investigated the expression of the most abundant transcripts, cmvIL-10 and LAcmvIL-10, in productively and latently infected cells and in peripheral blood mononuclear cells from renal transplant recipients up to 60 days post-transplantation. This study investigated HCMV cmvIL-10 and LAcmvIL-10 transcription profiles in vitro, in productive and latent infection, and in vivo, in peripheral blood mononuclear cells (PBMCs) of renal transplant patients. In vitro, both cmvIL-10 and LAcmvIL-10 transcripts were detected in both types at high levels and low levels in MRC-5 and latent infected (CD14+). When PBMCs from transplant patients were analyzed, LAcmvIL-10 was detected mostly sporadically and in only a few patients, while cmvIL-10 was found in all patients at all time points. Furthermore, it was observed in PBMCs that expression of cmvIL-10 was positively associated with an increase in viral DNA detection in the subsequently collected sample, indicating that expression of cmvIL-10 might precede viral DNA replication. These results contribute to the understanding of HCMV biology in different phases of infection. In addition, our initial analysis suggests that monitoring cmvIL-10, along with viral DNA, could improve early detection of HCMV reactivation in transplant recipients.

Serological Profile of Anti-Toxoplasma gondii Antibodies in Liver Transplant Recipients

Toxoplasma gondii (T. gondii), a globally distributed obligatory intracellular opportunistic parasite that has infected one third of the world population, has different transmission routes including via organ transplantation. The liver has emerged as a frequent transplanted organ in which the transmission of T. gondii can occur between seropositive donors and seronegative recipients. Allied with immunosuppressive therapy, the presence of latent infection in recipients elevates the risk of severe toxoplasmosis. The goal of this study was to evaluate the demographic, clinical, epidemiological, and anti-T. gondii antibody profiles in liver transplant recipients. All demographic, clinical, epidemiological, and serological data were obtained from the electronic medical records of liver transplant recipients from the Liver Transplantation Service of the Hospital de Base in São José do Rio Preto, Brazil, from 2008 to 2018. Data from 48 eligible recipients (females: n = 17; males: n = 31) were evaluated. The recipients were grouped according to their T. gondii serological profiles (G1: IgM-/IgG-; G2: IgM-/IgG+; G3: IgM+/IgG+; G4: IgM+/IgG-). The overall mean age was 55.3 (±15.3) years; the age difference between women (42.7 ± 17 years) and men (62.2 ± 10.9 years) was statistically significant (p-value > 0.0001). The percentages of the serological profiles were 20 (n = 41.7%), 26 (n = 54.1%), and 2 (n = 4.2%) for G1, G2, and G3, respectively. No recipient had a serological profile for G4. Hepatosplenomegaly (47.9%), fever (35.4%), encephalopathy (20.8%), and headache (16.7%) were commonly observed symptoms. No statistically significant differences were observed between the serological group and clinical data (p-value = 0.953). The percentages of coinfection by T. gondii with hepatitis A, B, and C were 47.9%, 20.8%, and 12.5%, respectively. About 41.7% of the recipients later died. The data demonstrate that infection by T. gondii is common in liver transplant recipients, and it is not associated with the analyzed demographic, clinical, and epidemiological data.

Presentation and Outcomes of Histoplasmosis in Transplant Recipients: A Retrospective Single-Centre Cohort Study

BACKGROUND

Histoplasmosis is an important infection among transplant recipients. Few studies have described its epidemiology and outcomes in the modern era.

METHODS

We conducted a retrospective analysis using medical records from a single center in the United States. We included patients 18 years or older with histoplasmosis. We divided the cohort into transplant recipients and immunocompetent groups to assess the outcomes in both groups. We utilized Cox hazard models to assess 90-day all-cause mortality.

RESULTS

The study included 137 patients; with 28 (20%) transplant recipients. After the first year post-transplant, patients with lung transplant (30%) had a diagnosis of histoplasmosis. Transplant recipients exhibited a significantly higher incidence of disseminated histoplasmosis than immunocompetent patients (64% vs. 34%, p = 0.001), higher admission to ICU (39% vs. 16%; p = 0.01) and higher but not significant 90-day crude all-cause mortality (14% vs. 11%, p = 0.71). Patients with transplants had a higher, but not significant hazard of all-cause mortality at 90 days (hazard ratio: 1.5; 95% confidence interval: 0.4-3.9) when compared to immunocompetent patients.

CONCLUSION

Transplant recipients were more commonly diagnosed with histoplasmosis after the first year post-transplantation, and although they exhibited a higher hazard for death at 90 days, this increase was not statistically significant.

Understanding the Public's Viewpoint on Organ Donation Among Adults in Bangladesh: An Exploratory Cross-Sectional Study

Background and Aims

Organ donation is the last option for patients with end-stage organ failure, but the number of people in need of transplantation outweighs the supply of donor organs. A thorough analysis of public understanding is required to design educational programs that increase public commitment to organ donation. Therefore, the present study aimed to explore Bangladeshi adults' understanding, attitudes, and willingness towards organ donation, while also investigating the sources of information, gender-specific knowledge, intentions, and the factors influencing their decisions.

Methods

A cross-sectional survey was conducted between October 15 and November 25, 2021, using a non-probability convenience sampling technique. Data were analysed using both descriptive and inferential statistics.

Results

Among 592 participants, only 35.8% were knowledgeable about organ donation. Internet/online sources were the most reported source of knowledge (37.8%), followed by social media (36%). Despite having limited knowledge, 63.7% had a positive attitude, with females demonstrating a more positive attitude than males (β = 0.09, p = 0.024). Males were significantly more likely than females to follow Bangladesh's specific organ donation laws (29.3% vs. 25%, p = 0.004). Besides, 48.6% of females, compared to 40.4% of males, believe that the health service related to organ donation in Bangladesh is ineffective (p = 0.016). More than one-third (35.1%) of the participants indicated a willingness to donate their organs after death. The participants' significant barriers to organ donation were found to be family objections (40.4%), health complications (34.4%), fear of disfigurement (31.1%), and religious barriers (26.8%).

Conclusion

Although Bangladeshi adults have a positive attitude regarding organ donation, they lack adequate knowledge, which renders them unlikely to be eager to donate organs. Therefore, it is crucial to update policy within a sociocultural framework to boost organ donation for transplantation. National education campaigns and awareness-raising events should be held in Bangladesh to increase public knowledge of organ donation and transplants.

Prevention and management of infectious and tropical diseases in kidney transplant recipients residing in European outermost and overseas territories

BACKGROUND

The European Union encompasses 30 outermost and overseas countries and territories (OCTs). Despite a recent increasing activity of renal transplantation in these territories, many patients still undergo transplantation in continental Europe, with follow-up care coordinated between health professionals from both their transplant center and their home region. Each territory has its unique infectious epidemiology which must be known to ensure appropriate care for kidney transplant recipients (KTRs).

AIMS

This paper proposes a pragmatic approach to optimize pre-transplant check-up and to provide an overview of the specific epidemiological features of each region. It offers practical algorithms to help practitioners in managing infected KTR living in these territories. This work advocates for increased collaborative research among European OCTs.

Interpreting and managing preservation fluids positive for Gram-negative bacteria

PURPOSE OF REVIEW

Culturing preservation fluids of solid organs before transplantation is not a standardized procedure. In this review, we aim to describe the state-of-the-art of literature evidence in this debated setting with a special focus on Gram-negative bacteria (GNB).

RECENT FINDINGS

Contamination of preservation fluids is frequent, but preservation fluids related infections are rare and most commonly caused by high-risk pathogens, including GNB. GNB preservation fluids related infections are characterized by high morbidity and mortality. Recent studies showed improved outcomes in solid organ transplant recipients receiving antibiotic therapy tailored according to preservation fluids cultures especially when multidrug-resistant GNB are found. A robust procurement network is needed to alert recipients' centers in cases of positivity and the support of transplant infectious diseases specialists is essential to choose the best therapy.

SUMMARY

Culturing preservation fluids is a further step into preventing donor-derived infections. Interpreting and managing GNB positivity require a multidisciplinary team with specific skills. Standardized randomized trials are needed for insight into the real utility of preservation fluids cultures, the role of preservation fluids positivity, and the impact of antimicrobial therapy.

Donor-derived dengue infections - A review of screening protocol and outcomes in an endemic country

BACKGROUND

Donor-derived dengue infections present significant challenges to organ transplantation, particularly in endemic regions like Singapore. Although primarily transmitted by Aedes mosquitoes, dengue can also be transmitted through organ transplantation, occasionally with fatal outcomes. This study aims to evaluate the outcomes and evolution of dengue screening protocols for potential deceased donors in Singapore from 2006 to 2022.

METHODS

Initially, screening was done via dengue immunoglobulin M (IgM), targeting donors with specific clinical criteria (thrombocytopenia, drop in platelet count, prolonged prothrombin time/partial thromboplastin time, and discretion of the transplant team), later transitioning to blood dengue reverse transcription-polymerase chain reaction (RT-PCR) in 2007 with similar criteria, and subsequently universal screening in 2016. In 2021, urine dengue RT-PCR was added following a case of donor-derived dengue infection from an aviremic but viruric donor.

RESULTS

Out of 431 potential deceased donors, 395 (91.6%) underwent dengue screening, with six (1.5%) testing positive for dengue. In 2006, three positive screens were identified: two through dengue IgM and one via blood dengue RT-PCR; subsequent years saw one positive screen each in 2007, 2008, and 2019 via blood dengue RT-PCR. Potential deceased donors with a positive blood dengue screen were rejected as solid organ and tissue donors. Those with negative blood dengue RT-PCR but positive urine dengue RT-PCR would be rejected as kidney donors, but the use of other organs and tissues was at the discretion of the transplantation team.

CONCLUSION

The optimal screening protocol remains uncertain, but our findings suggest that a universal screening strategy utilizing both blood and urine dengue RT-PCR could be considered in dengue-endemic countries.

Donor-derived infections-Insights from Singapore, Japan, and Thailand

BACKGROUND

Solid organ transplantation (SOT) has expanded significantly in Asia over past few decades. Donor-derived infections (DDIs) remain a significant concern as they may adversely impact transplant outcomes. We aim to review the existing regulatory frameworks, screening protocols, and management practices for DDIs in Asia.

METHODS

We reached out to transplant infectious diseases experts in Asia to provide standardized data on annual SOT numbers, incidence of DDIs, regulatory frameworks, donor and recipient screening protocols, and DDI surveillance measures. We present the data from Singapore, Japan, and Thailand.

RESULTS

Donor screening for HIV, hepatitis B, hepatitis C, and syphilis is mandatory in all countries. Additionally, Japan screens for HTLV-1 antibody due to its endemicity. We also reviewed the protocols for screening and prevention of endemic infections in Asia. Singapore is the only country implementing universal screening for all donors for dengue, Zika, and chikungunya via blood and urine RT-PCR. Strongyloidiasis screening is not routinely done, although some transplant centers empirically give ivermectin prophylaxis to organ recipients. Tuberculosis screening with a donor questionnaire and chest radiograph is common for deceased donors, and some centers do Interferon Gamma Release Assay test for living donors. We also found a significant gap in the surveillance and reporting of potential DDIs in Asia and the overall incidence of DDIs in Asia is unknown and likely underreported.

CONCLUSION

The experiences of Singapore, Japan, and Thailand offer valuable insights into current practices and the unmet needs regarding a DDI registry and call for coordinated efforts to address this critical issue in the region.

Risk and benefits of expanded donor screening: A viewpoint from Germany

This review describes the risks and benefits of expanding screening for transmissible pathogens in deceased organ donors. The focus is on the experience and procedure in Germany to make a decision on how to proceed with a possible donor. Three issues are of interest in how screening policies impact the process with the aim of mitigating unexpected transmission risks: (1) Should we add universal or targeted nucleic acid testing to serological tests for common blood-borne viruses (BBVs; HIV, HBV, and HCV)? (2) Which tests should be added for screening in a geographically restricted region beyond testing for these BBVs? (3) Being faced with changes (e.g., climate and population) in the own geographically restricted region, what strategies are needed before implementing new tests, and which considerations apply for proper indication to do this? Testing may only be effective when during donor characterization the appropriate conclusions are drawn from the existing findings and screening tests are initiated. This statement overlaps the need to implement universal screening for a pathogen or targeted screening based on the risk that the donor has acquired the transmissible pathogen or is not as possible to identify by current methods of clinical judgment and/or specific tests.

Non-Standard Risk Donors and Risk of Donor-Derived Infections: From Evaluation to Therapeutic Management

Expected and unexpected donor-derived infections are a rare complication of solid organ transplantation, but can result in significant morbidity and mortality. Over the last years, the growing gap existing between patients on the waiting list and available organs has favored the use of organs from donors with suspected or confirmed infections, thanks to the improvement of risk mitigation strategies against transmission of well recognized and emerging infections. Given the recent developments, the particular interest of this review is to summarize data on how to maximize utilization of HIV+ donors in HIV+ recipients, the use of HCV-viremic donors and HBV positive donors. This article also covers the implications for recipient of organs from donors with bacteremia and the challenge of multidrug resistant (MDR) infections. Lastly this review describes emerging risks associated with recent Coronavirus Disease-2019 (COVID-19) pandemics.

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Solid organ transplant in recipients with ongoing SARS-CoV-2 infection: A systematic review of case reports and series

BACKGROUND

Whether solid organ transplant (SOT) can be safely performed in recipients with ongoing SARS-CoV-2 infection is still a debated question.

METHODS

A systematic review of the literature on recipients with ongoing SARS-CoV-2 infection at the time of surgery and the associated outcomes.

RESULTS

From 29 studies, we identified 54 recipients; their median age was 47.5 years, and over half (23/54, 54.85%) were affected by fewer than two comorbidities. Kidney was the most common transplanted organ (24/54, 44.4%). SOT was performed without knowing the ongoing infection in 11.1% (6/54) of patients. On average, 16.1 (SD 23.2) days elapsed between SARS-CoV-2 infection and SOT, with a mean Ct value at diagnosis and transplantation of 29 and 31.9, respectively. Most patients (25/39,64.1%) had received previous COVID-19 vaccinations. Twenty-four patients (45.3%) received an anti-SARS-CoV-2 therapy. Ten patients (18.5%) required oxygen support, while seven (13.7%) were admitted to the intensive care unit. There were two reported cases (3.7%) of all-cause death, while there were no cases of COVID-19-related death.

CONCLUSIONS

Deliberate SOT of recipients with ongoing SARS-CoV-2 is performed worldwide in candidates of nonlung transplant who are fit, immunized against the virus, and displaying a nonsevere disease course. No COVID-19-related deaths were recorded.

Minimizing risk while maximizing opportunity: The infectious disease organ offer process survey

BACKGROUND

The purpose of this study was to understand how transplant infectious disease (TID) physicians assess a potential donor with known or suspected infection and describe posttransplant management.

METHODS

We designed a survey of 10 organ offer scenarios and asked questions pertaining to organ acceptability for transplantation and management posttransplant. The survey was distributed to TID clinicians via transplant society listservs and email. Responses were recorded in REDCap, and descriptive statistics were employed.

RESULTS

One hundred thirteen infectious disease physicians responded to the survey, of whom 85 completed all cases. Respondents were generally in agreement regarding organ acceptability, although some divergence was seen when evaluating lungs from donors with influenza, tuberculosis, or multidrug-resistant Acinetobacter infection. Posttransplant management showed more variation. Areas of optimization were identified: (1) Further understanding of where risk-mitigation strategies within the donor offer process may improve donor acceptability and therefore organ utilization; (2) importance of recipient considerations in assessing degree of infectious risk; and (3) gaps in evidenced-based data regarding optimal posttransplant management of recipients.

CONCLUSION

Evaluation of donor offers by TID clinicians is a complex process. Although the survey does not itself serve to make recommendations regarding best practices, it highlights areas where generation of data to inform acceptance and management practices may allow for improved organ utilization and recipient management.

Hepatitis B Vaccine Compliance, Serologic Response, and Durability in Adult Thoracic Organ Transplant Recipients

INTRODUCTION

Hepatitis B virus (HBV) vaccination is recommended for solid organ transplant (SOT) candidates. However, there is a lack of data on the HBV vaccine compliance, serologic response, and durability of HBV seroprotection in thoracic organ transplantation recipients.

METHODS

We conducted a retrospective study of adult thoracic organ (heart and lung) transplant candidates who received HBV vaccination at Mayo Clinic sites in Minnesota, Arizona, and Florida between January 2018 and August 2023. Conventional recombinant hepatitis B vaccine (Recombivax HB) was used before 2020, and Heplisav-B was preferred after 2020. HBV seroprotection was defined as hepatitis B surface antibody (HBsAb) ≥ 10 IU/L. Furthermore, we compared characteristics between recipients who maintained HBV seroprotection and those who lost HBV seroprotection (HBsAb < 10 IU/L) at 30 days posttransplantation (D30).

RESULTS

Among 922 candidates who were eligible for HBV vaccination, 430 (47%) completed the HBV vaccine series. Patients receiving Heplisav-B were more likely to complete the series than Recombivax HB (81% vs. 60%, p < 0.001) and Heplisav-B had a higher seroprotection rate than Recombivax HB (75% vs. 64%, p = 0.023). Multivariate logistic regression analysis identified receiving Heplisav-B as an independent predictor for HBV seroprotection (adjusted odds ratio [aOR] 1.723; 95% confidence interval [CI] 1.056-2.810; p = 0.029). A total of 145 thoracic organ transplant recipients achieved HBV seroprotection at the date of transplantation. Loss of HBV seroprotection occurred in 38 (26%) patients at D30. Multivariate logistic regression analysis identified two predictors for HBV seroprotection loss at D30: age ≥ 60 years (aOR, 2.503; 95% CI 1.026-6.107; p = 0.044), and pretransplant HBsAb level between 10 and 100 IU/L (aOR, 18.575; 95% CI 5.211-66.209; p < 0.001).

CONCLUSIONS

Although less than half of thoracic organ transplant candidates completed HBV vaccine series pretransplant, Heplisav-B provided a higher vaccine completion rate and seroprotection than the 3-dose Recombivax HB. Clinicians should also be aware of the increased loss of HBV seroprotection in thoracic organ transplant recipients with age ≥ 60 years and pretransplant HBsAb between 10 and 100 IU/L. Assessment of seroprotection after HBV vaccination should be prioritized during the pretransplant period.

Donor-Derived Bartonella quintana Infection in Solid Organ Transplantation: An Emerging Public Health Issue With Diagnostic Challenges

Bartonella quintana is a louse-borne intracellular bacterium that remains a neglected cause of bacteremia, bacillary angiomatosis, and infective endocarditis among individuals experiencing poverty. In October 2023, Health Canada notified Canadian organ transplantation programs of an outbreak of donor-derived B quintana infection. From March to August 2023, 5 cases of donor-derived B quintana disease were acquired in Alberta, Canada, from 3 deceased donors who had experienced homelessness. Similar cases recently occurred in the United States. In this article, we discuss strategies to screen organ donors and monitor transplant recipients for B quintana infection using epidemiologic risk factors, physical examination signs, and laboratory diagnostic tests. We review the limitations of existing diagnostic tests for B quintana and describe how these problems may be magnified in the organ transplantation context.

The pre-transplant evaluation: Considerations for trainees and early career transplant infectious diseases clinician

Transplant infectious disease (TID) clinicians are integral to the pre-transplantation evaluation. Pre-transplant evaluations allow clinicians to assess risk factors for latent infections and relevant exposures to potential pathogens, address immunizations, and optimize patients' health and understanding of life after transplant. However, there is not a standardized approach to the pre-transplant evaluation. This article reviews the details of performing successful pre-transplant evaluations, including updated recommendations on available vaccines and contemporary opinions on marijuana use. This resource can be used for teaching with trainees or for early career TID clinicians.

Overcoming Double Jeopardy: Successful Orthotopic Heart Transplant in a Recipient With Bacterial and Fungal Infections

Although active infection is generally a contraindication before an orthotopic heart transplant, a 16-year-old man diagnosed with dilated cardiomyopathy successfully underwent an orthotopic heart transplant despite having active probable invasive pulmonary aspergillosis and bacterial pneumonia in the presence of septic and cardiogenic shock.

Risk for Donor-Derived Syphilis after Kidney Transplantation, China, 2007-2022

To evaluate the risk of acquiring syphilis from a donated kidney, we evaluated kidney transplantation pairs from West China Hospital, Sichuan, China, during 2007-2022. Donor-derived syphilis was rare. Risk may be higher if donors have active syphilis and may be reduced if recipients receive ceftriaxone.

The Cascade of Care in Management of Solid Organ Transplant Candidates With Latent Tuberculosis Infection

Background

Solid organ transplant (SOT) candidates should be screened and treated for latent tuberculosis infection (LTBI) to prevent tuberculosis (TB) reactivation after transplantation. We aimed to assess the steps from positive QuantiFERON (QFT) through LTBI treatment (cascade of care) in the SOT population.

Methods

We conducted a retrospective study of SOT recipients older than 18 y with a positive QFT during pretransplant evaluation at the Mayo Clinic from January 2010 to June 2023. We analyzed each cascade step to determine associated drop-out factors for LTBI management.

Results

Of 629 patients who had positive QFT results, 587 (93%) were evaluated by an infectious disease (ID) specialist, 478 (76%) were recommended to start LTBI treatment, 473 (75%) initiated LTBI treatment, and 457 (73%) completed LTBI treatment. LTBI treatment was not recommended in 109 patients evaluated by infectious disease, most of whom had previously received either LTBI (n = 72) or TB (n = 14) treatment. LTBI treatment was initiated before or after transplantation for 45% and 55% of patients, respectively. Isoniazid monotherapy was the most common regimen (92%), and adverse events were rare (7%). Seven patients developed active TB infection posttransplantation under various circumstances (3 without LTBI treatment, 1 during LTBI treatment, and 3 after completing LTBI treatment).

Conclusions

Our findings demonstrate the variability of LTBI management in SOT recipients with positive QFT. When recommended, most patients completed LTBI treatment successfully. Nonetheless, active TB was noted regardless of whether patients received LTBI treatment. This study highlights the importance of optimizing LTBI management in this population.

A Digital Approach to Improve Infection Screening Among Solid Organ Transplant Candidates

BACKGROUND

Pretransplant infection screening (IS) of potential organ recipients is essential to optimal outcome of solid organ transplantation (SOT).

METHODS

A pre-post study was performed during 2020-2023 to investigate the impact of the STREAM (Solid organ TRansplant stEwArdship and Multidisciplinary approach) intervention to improve IS in SOT. The intervention, performed in 2022, included the implementation of IS through educational meetings, local guidelines, and the availability of a digital screening tool. The objective of the study was the assessment of IS completion, including a list of 17 laboratory tests and the investigation of vaccination status. The reduction of unnecessary tests was also analyzed. The test of proportions and a multilevel multivariate Poisson regression model were used to compare IS completion before and after STREAM. infectious diseases (ID) consultation and urgent evaluation were investigated as predictors of IS completion.

RESULTS

A total of 171 patients were enrolled, including liver (44%), heart (32%), and kidney (24%) transplant candidates. Mean age was 56 ± 11 years, and most patients (77%) were males. Ninety-five (56%) patients were included before the intervention and 76 (44%) after STREAM. IS completion increased after STREAM (IRR 1.41, p < 0.001) with significant improvement recorded for seven (39%) IS items. Unnecessary tests decreased by 43% after the intervention. ID consultation (IRR 1.13, p = 0.02) and urgent evaluation (p = 0.68, p < 0.001) were predictors of IS improvement.

CONCLUSIONS

STREAM was successful in improving IS completion. Further research is needed to investigate the impact of this intervention on posttransplant infections.

Hepatitis B Virus Reactivation in Non-Liver Solid Organ Transplantation: Incidence and Risk Analysis

INTRODUCTION

Hepatitis B virus reactivation (HBVr) can occur in solid organ transplant (SOT) recipients with previously inactive hepatitis B virus (HBV) infection. Previous studies have reported that HBVr is generally less than 10% in nonliver SOT recipients with past HBV infection.

METHODS

We conducted a retrospective study from January 2018 to August 2023 at Mayo Clinic sites in Arizona, Florida, and Minnesota. We examined the antiviral prophylaxis strategy used and the characteristics of HBVr in hepatitis B core antibody-positive (HBcAb +) nonliver SOT adult recipients. Past HBV infection was defined as HBcAb + / hepatitis B surface antigen (HBsAg) -. Chronic HBV infection was defined as HBcAb + / HBsAg +.

RESULTS

A total of 180 nonliver SOT recipients were identified during the study period. Indefinite antiviral prophylaxis was utilized in 77 recipients, and none developed HBVr after transplantation. In 103 recipients without antiviral prophylaxis, the incidence of HBVr was 12% (12/97) and 33% (2/6) in those with past HBV infection and chronic HBV infection. The incidence of HBVr in patients with past HBV infection is 16% (8/50), 15% (3/20), and 5% (1/22) in kidney, heart, and lungs, respectively. HBVr was more frequent in those who received alemtuzumab. Among 14 recipients with HBVr, none had HBV-associated liver failure or death.

CONCLUSIONS

Our study observed a higher rate of HBVr (12%) in nonliver SOT recipients with past HBV infection compared to the previous studies. Further studies are needed to identify predictors of HBVr in nonliver SOT recipients and optimize antiviral prophylaxis guidance.

Infections in lung transplanted patients: A review

Lung transplantation can improve the survival of patients with severe chronic pulmonary disorders. However, the short- and long-term risk of infections can increase morbidity and mortality rates. A non-systematic review was performed to provide the most updated information on pathogen, host, and environment-related factors associated with the occurrence of bacterial, fungal, and viral infections as well as the most appropriate therapeutic options. Bacterial infections account for about 50% of all infectious diseases in lung transplanted patients, while viruses represent the second cause of infection accounting for one third of all infections. Almost 10% of patients develop invasive fungal infections during the first year after lung transplant. Pre-transplantation comorbidities, disruption of physical barriers during the surgery, and exposure to nosocomial pathogens during the hospital stay are directly associated with the occurrence of life-threatening infections. Empiric antimicrobial treatment after the assessment of individual risk factors, local epidemiology of drug-resistant pathogens and possible drug-drug interactions can improve the clinical outcomes.

Enhancing screening adherence for strongyloides infection in latinx inpatients with COVID-19: a local protocol implementation study

Strongyloides stercoralis hyperinfection syndrome has been observed in immunosuppressed coronavirus disease 2019 (COVID-19) patients. Detecting and treating asymptomatic Strongyloides infection in individuals from endemic areas can effectively prevent hyperinfection. Unfortunately, many clinicians are unaware of this neglected infection. Therefore, we aimed to evaluate whether including Strongyloides screening in COVID-19 management protocols would encourage this practice. To accomplish this, we conducted a retrospective single-center study at 'Hospital Universitario 12 de Octubre' in Madrid, Spain, comparing two consecutive cohorts. The first cohort comprised all Latinx patients over 18 years old who were admitted for COVID-19 between March 1st and April 30th, 2020. The second cohort consisted of Latinx patients admitted between July 1st and December 31st, 2020, following an amendment to the COVID-19 management protocol that recommended screening for strongyloidiasis in at-risk patients. We identified 559 and 795 patients in the first and second periods, respectively. The percentage of individuals screened increased significantly from 8.8% to 51.6% after the screening recommendation was included in the protocol (odds ratio [OR] 11.08, 95% confidence interval [CI] 8.01-15.33). In both periods, the screening rate was significantly higher among those receiving immunosuppression than those who did not receive steroids and/or tocilizumab. No other factors influenced the screening rate. In conclusion, including strongyloidiasis screening recommendations in COVID-19 management protocols led to its increased implementation. However, the overall screening rate remained low, emphasizing the need for further efforts to enhance screening practices.

Monocentric, Retrospective Study on Infectious Complications within One Year after Solid-Organ Transplantation at a Belgian University Hospital

The epidemiology, diagnostic methods and management of infectious complications after solid-organ transplantation (SOT) are evolving. The aim of our study is to describe current infectious complications in the year following SOT and risk factors for their development and outcome. We conducted a retrospective study in adult SOT recipients in a Belgian university hospital between 2018 and 2019. We gathered demographic characteristics, comorbidities leading to transplantation, clinical, microbiological, surgery-specific and therapeutic data concerning infectious episodes, and survival status up to one year post-transplantation. Two-hundred-and-thirty-one SOT recipients were included (90 kidneys, 79 livers, 35 lungs, 19 hearts and 8 multiple organs). We observed 381 infections in 143 (62%) patients, due to bacteria (235 (62%)), viruses (67 (18%)), and fungi (32 (8%)). Patients presented a median of two (1-5) infections, and the first infection occurred during the first six months. Nineteen (8%) patients died, eleven (58%) due to infectious causes. Protective factors identified against developing infection were obesity [OR [IC]: 0.41 [0.19-0.89]; p = 0.025] and liver transplantation [OR [IC]: 0.21 [0.07-0.66]; p = 0.007]. Risk factors identified for developing an infection were lung transplantation [OR [IC]: 6.80 [1.17-39.36]; p = 0.032], CMV mismatch [OR [IC]: 3.53 [1.45-8.64]; p = 0.006] and neutropenia [OR [IC]: 2.87 [1.27-6.47]; p = 0.011]. Risk factors identified for death were inadequate cytomegalovirus prophylaxis, infection severity and absence of pneumococcal vaccination. Post-transplant infections were common. Addressing modifiable risk factors is crucial, such as pneumococcal vaccination.

An Anatomically Complicated Living Donor Kidney Transplantation from Hepatitis B Surface Antigen-Positive Donor to Negative Recipient With Size Discrepancy

The deficiency of organ donors remains a barrier to kidney transplantation. Living donor kidney transplantation (LDKT) can overcome graft shortage, resulting in better outcomes. Many efforts are being made to expand the donor pool, such as hepatitis B surface antigen (HBsAg)-positive donors to negative recipients and anatomically complicated donor kidneys with size discrepancies. We report a case in which we overcame various problems in LDKT. The recipient was a 56-year-old, 106-kg, HBsAg negative male with diabetic nephropathy. The donor was a 63-year-old female, 56-kg, hepatitis B virus (HBV) carrier with dual renal arteries. Preoperative antiviral medication was provided to the donor for negative conversion of HBV-DNA. The recipient was given HBV vaccination (antihepatitis B antibody: 2.25-36.16 mIU/mL). Anti-HBV immunoglobulin was intraoperatively administered to prevent transmission. The donor and recipient had an absolute weight difference (50 kg). In addition, the donor's kidney had a main and an accessory artery in the upper pole, which were anastomosed to the recipient's right external iliac and inferior epigastric artery, respectively. Follow-up serum creatinine levels decreased. Doppler ultrasonography showed good vascular flow within the reference range of the resistive index. The recipient's follow-up HBV-DNA titer was negative with antiviral medication. We successfully performed LDKT from an HBV-positive donor to a negative recipient by perioperative antiviral treatment and overcame a significant size discrepancy and anatomic challenges by preserving even a small portion of the kidney graft.

Incidental lymphadenopathy in renal transplantation

INTRODUCTION

Iliac lymphadenectomy is performed to provide anastomotic access during the vascular implantation procedure in renal transplantation. Iliac lymph nodes (LNs) are often enlarged, but there are no standardised guidelines for the management of incidentally enlarged LNs during transplantation. We aimed to evaluate histological findings of LNs sent for examination at our unit.

METHODS

Patients were evaluated in two distinct date cycles. In the first cycle, lymphadenectomy and histological assessment were performed at the discretion of the transplanting surgeon. In the second cycle, all incidentally enlarged LNs were sent for histological assessment, regardless of size.

RESULTS

In the first cycle (n = 76), 11 patients (14.47%) had incidentally enlarged iliac LNs on lymphadenectomy and histology showed only reactive changes. In the second cycle (n = 165), eight patients (4.85%) had incidentally enlarged LNs on lymphadenectomy. One patient was found to have mature B cell chronic lymphocytic leukaemia. The patient was referred to haematology and a "watch and wait" approach was taken, with the patient still alive at last follow-up (511 days post-transplantation).

DISCUSSION

There are currently no published guidelines on the management of incidentally enlarged iliac LNs during transplantation. Current literature suggests that clinically significant lymphadenopathy needs to be investigated in all patients. Based on our centre's experience of a 5.26% (1 in 19) positive pathological LN sampling, we recommend that all incidental LNs with suspicious features and/or that are greater than 10mm in diameter should be considered for histological, microbiological and molecular assessment as appropriate.

Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial

Opportunistic infections are a leading cause of lung transplant recipient morbidity and mortality. Risk factors for infection include continuous exposure of the lung allograft to the external environment, high levels of immunosuppression, impaired mucociliary clearance and decreased cough reflex, and impact of the native lung microbiome in single lung transplant recipients. Infection risk is mitigated through careful pretransplant screening of recipients and donors, implementation of antimicrobial prophylaxis strategies, and routine surveillance posttransplant. This review describes common viral, fungal, and mycobacterial infectious after lung transplant and provides recommendations on prevention and treatment.

Pre-Transplantation Strategies for Infectious Disease Mitigation and Prevention

Pediatric Infectious Disease (ID) clinicians play a critical role in helping prevent and mitigate infectious risks in children peri- and post-transplantation. Prevention starts during the pre-transplant evaluation and persists throughout the solid organ transplant and hematopoietic cell transplant continuum. The pre-transplant evaluation is an opportunity to screen for latent infections, plan preventative strategies, optimize immunizations, and discuss risk mitigation practices. An ideal pre-transplant evaluation establishes a relationship with the family that further promotes post-transplant infectious risk reduction. This manuscript builds on shared pediatric ID prevention strategies, introduces updated ID testing recommendations for transplant donors/candidates, highlights emerging data, and identifies ongoing knowledge gaps that are potential areas of research.

Controlling infections in hospitalized pretransplant candidates

PURPOSE OF REVIEW

Infections in hospitalized patients awaiting solid organ transplantation can pose complicated diagnostic and therapeutic challenges. Goals of management include stabilizing the patient, treating or controlling infections, and decreasing the risk of reactivation of infection after transplant.

RECENT FINDINGS

Groups such as The Organ Procurement and Transplantation Network, American Society of Transplantation Infectious Diseases Community of Practice and the European Society of Clinical Microbiology and Infectious Diseases have updated their guidelines on screening and treatment of infection in transplant candidates. There are also recent developments in therapeutic options for tuberculosis, COVID-19, Clostridioides difficile colitis, bloodstream infections, and other common infections.

SUMMARY

Ideally, antimicrobial therapy should be complete prior to transplantation. In situations in which completion of therapy prior to transplant is not feasible, therapy may need to be prolonged or modified. In most situations, infections can be managed similarly to the general population, although some infections, particularly fungal and mycobacterial, require a different management approach. We review disease- and organ-specific management.

Identifying CNS infections in transplantation and immunomodulatory therapy

Opportunistic central nervous system (CNS) infections are a significant cause of morbidity and mortality in immunocompromized patients, including those undergoing transplantation and receiving immunomodulatory therapy. Particularly in these individuals, the clinical presentation of these infections may have atypical patterns, emphasizing the need to consider various diagnostic possibilities, including noninfectious conditions. Quick and accurate identification, along with prompt treatment, is crucial for improving patient outcomes. Therefore, understanding which pathogens are likely to cause infection based on factors such as timing post-transplantation, specific organ transplant, and the mechanism of action of immunomodulatory medications is essential. This review will provide a detailed description of the types of infections that may arise in the context of transplantation and immunomodulatory therapy.

Pre-Transplant Seroprevalence, Associated Factors, and Post-Transplant Incidence of Toxoplasma gondii Infection Among Heart Transplant Recipients in Japan

BACKGROUND

Among solid organ transplant (SOT) recipients, heart transplant (HT) recipients are at a higher risk of Toxoplasma gondii infection. As Toxoplasma seroprevalence varies by geographic location, updated local epidemiology is essential to guide preventive and therapeutic strategies. However, the Toxoplasma seroprevalence and incidence of post-transplant toxoplasmosis among SOT recipients in Japan are unknown.

METHODS

We performed a single-center retrospective observational study at an HT center in Tokyo, Japan. All HT recipients aged ≥18 years between 2006 and April 2019 were included. We reviewed patient charts and conducted a questionnaire survey to investigate the risk factors for infection.

RESULTS

Among 105 recipients included in the study, 11 (10.5%) were seropositive before transplant. Ninety-five recipients (90.5%), including all pre-transplant seropositive recipients, answered the questionnaire. The recipients who had lived in Okinawa (odds ratio [OR] 7.5 [95% CI 1.42-39.61]; P = .032) and who reported raw-meat eating habits (OR 4.64 [95% CI 1.04-23.3]; P = .021) were more likely to be seropositive. None of the patients developed symptoms of toxoplasmosis. The post-transplant incidence of other major adverse outcomes was not significantly different according to the pre-transplant serostatus.

CONCLUSIONS

About 10% of HT recipients at an HT center in Tokyo were seropositive for Toxoplasma pre-transplant, and none developed symptomatic toxoplasmosis post-transplant on trimethoprim-sulfamethoxazole. The history of raw meat consumption was associated with seropositivity; therefore, avoiding it might be recommended for HT recipient candidates.

Prevention and Management of Infections in Lung Transplant Recipients

Anti-rejection medications are essential in preventing organ rejection amongst solid organ transplant recipients; however, these agents also cause profound immunosuppression, predisposing lung transplant recipients (LTRs) to infectious complications. The timely management including prevention, diagnosis, and treatment of such infectious complications is vital to prevent significant morbidity and mortality in solid organ transplant recipients and allograft dysfunction. LTRs are inundated with microbes that may be recognized as commensals in hosts with intact immune systems. Bacterial infections are the most common ones, followed by viral pathogens. Indications of a brewing infectious process may be subtle. Hence, the importance of adapting vigilance around isolated hints through symptomatology and signs is pivotal. Signals to suggest an infectious process, such as fever and leukocytosis, may be dampened by immunosuppressive agents. One must also be vigilant about drug interactions of antibiotics and immunosuppressive agents. Treatment of infections can become challenging, as antimicrobials can interact with immunosuppressive agents, and antimicrobial resistance can surge under antimicrobial pressure. Transplant infectious disease physicians work in concert with transplant teams to obtain specimens for diagnostic testing and follow through with source control when possible. This heavily impacts medical decisions and fosters a multidisciplinary approach in management. Furthermore, the reduction of immunosuppression, although it augments the risk of allograft rejection, is as crucial as the initiation of appropriate antimicrobials when it comes to the management of infections.

Beginners guide to protocol writing in transplant infectious diseases

Creating protocols surrounding the guidance of the prevention and treatment of infections in transplantation is an integral part of being a transplant infectious disease physician. This piece outlines the key components for success in developing a protocol, with an example protocol and protocol template available for readers. Collaborating effectively within the multi-disciplinary team to develop, implement, and assess the efficacy of a protocol is a skill that enhances the relationship with our transplantation colleagues and improves patient outcomes by standardizing the care delivered.

Approach to vaccinating the pediatric solid organ transplant candidate and recipient

Solid organ transplantation (SOT) candidates and recipients are at increased risk for morbidity and mortality from vaccine-preventable infections. Children are at particular risk given that they may not have completed their primary immunization series at time of transplant or have acquired natural immunity to pathogens from community exposures. Multiple society guidelines exist for vaccination of SOT candidate and recipients, although challenges remain given limited safety and efficacy data available for pediatric SOT recipients, particularly for live-vaccines. After transplant, individual patient nuances regarding exposure risks and net state of immunosuppression will impact timing of immunizations. The purpose of this review is to provide readers with a concise, practical, expert-opinion on the approach to vaccinating the SOT candidate and recipient and to supplement existing guidelines. In addition, pediatric-specific knowledge gaps in the field and future research priorities will be highlighted.

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.

Vaccination coverage reinforced by an infectious disease consultation during pretransplant check-up in patients awaiting kidney transplantation: A randomized study

BACKGROUND

Vaccine coverage (VC) in patients awaiting kidney transplantation is insufficient.

METHODS

We performed a prospective, single-center, interventional, randomized, open-label study comparing a reinforced group (infectious disease consultation proposed) and a standard group (letter stating vaccine recommendations sent to the nephrologist) of patients in our institution awaiting renal transplantation.

FINDINGS

Out of the 58 eligible patients, 19 declined to participate. Twenty patients were randomized to the standard group and 19 to the reinforced group. Essential VC increased from. 10% to 20% in the standard group and from 15.8% to 52.6% in the reinforced group (p < 0.034). The main obstacles identified were lack of vaccination traceability, refusal of an additional consultation and the journey time between home and hospital.

CONCLUSION

While introduction of an infectious disease consultation during the pre-transplant check-up significantly improved VC in patients, it is time-consuming and failed to achieve a satisfactory rate of VC.

Executive summary consensus statement of imported diseases group (GEPI) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SETMSI), on the diagnostic and treatment of imported schistosomiasis

Schistosomiasis is a highly prevalent disease, especially in immigrant populations, and is associated with significant morbidity and diagnostic delays outside endemic areas. For these reasons, the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SEMTSI) have developed a joint consensus document to serve as a guide for the screening, diagnosis and treatment of this disease outside endemic areas. A panel of experts from both societies identified the main questions to be answered and developed recommendations based on the scientific evidence available at the time. The document was reviewed by the members from both societies for final approval.

Antimicrobial Resistance in Organ Transplant Recipients

The overall burden of the main clinically relevant bacterial multidrug-resistant organisms (MDROs) (eg, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum β-lactamase producing or extended-spectrum cephalosporin-resistant Enterobacterales, carbapenem-resistant or carbapenemase-producing Enterobacterales, MDR Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii) in solid organ transplant (SOT) populations is summarized showing prevalence/incidence, risk factors, and impact on graft/patient outcome according to the type of SOT. The role of such bacteria in donor-derived infections is also reviewed. As for the management, the main prevention strategies and treatment options are discussed. Finally, nonantibiotic-based strategies are considered as future directions for the management of MDRO in SOT setting.

Diagnosis, Prevention, and Treatment of Infections in Kidney Transplantation

Kidney transplant often is complicated by infections in the recipient from therapy-related and patient-related risk factors. Infections in kidney transplant recipients are associated with increased morbidity, mortality, and allograft dysfunction. There is a predictable timeline after kidney transplant regarding the types of pathogens causing infections, reflecting the net state of immunosuppression. In the early post-transplant period, bacterial infections comprise two thirds of all infections, followed by viral and fungal infections. Infections occurring early after kidney transplantation are generally the result of postoperative complications. In most cases, opportunistic infections occur within 6 months after kidney transplantation. They may be caused by a new infection, a donor-derived infection, or reactivation of a latent infection. Community-acquired pneumonia, upper respiratory tract infections, urinary tract infections, and gastrointestinal infections are the most common infections in the late period after transplantation when the net immunosuppression is minimal. It is crucial to seek information on the time after transplant, reflecting the net state of immunosuppression, previous history of exposure/infections, geography, and seasonal outbreaks. It is imperative that we develop regionally specific guidelines on screening, prevention, and management of infections after kidney transplantation.

South Asian Transplant Infectious Disease Guidelines for Solid Organ Transplant Candidates, Recipients, and Donors

These guidelines discuss the epidemiology, screening, diagnosis, posttransplant prophylaxis, monitoring, and management of endemic infections in solid organ transplant (SOT) candidates, recipients, and donors in South Asia. The guidelines also provide recommendations for SOT recipients traveling to this region. These guidelines are based on literature review and expert opinion by transplant physicians, surgeons, and infectious diseases specialists, mostly from South Asian countries (India, Pakistan, Bangladesh, Nepal, and Sri Lanka) as well as transplant experts from other countries. These guidelines cover relevant endemic bacterial infections (tuberculosis, leptospirosis, melioidosis, typhoid, scrub typhus), viral infections (hepatitis A, B, C, D, and E; rabies; and the arboviruses including dengue, chikungunya, Zika, Japanese encephalitis), endemic fungal infections (mucormycosis, histoplasmosis, talaromycosis, sporotrichosis), and endemic parasitic infections (malaria, leishmaniasis, toxoplasmosis, cryptosporidiosis, strongyloidiasis, and filariasis) as well as travelers' diarrhea and vaccination for SOT candidates and recipients including travelers visiting this region. These guidelines are intended to be an overview of each topic; more detailed reviews are being published as a special supplement in the Indian Journal of Transplantation .

Biofire pneumonia panel in lung donors: faster detection but limited pathogens

BACKGROUND

Culture of bronchoalveolar lavage (BAL) specimens takes time to report. We tested whether a molecular diagnostic test could accelerate donor lung assessment and treatment.

METHODS

We compared BioFire Film Array Pneumonia Panel (BFPP) with standard of care (SOC) tests on lung allograft samples at three time points: (1) donor BAL at organ recovery, (2) donor bronchial tissue and airway swab at implantation, and (3) first recipient BAL following lung implantation. Primary outcomes were the difference in time to result (Wilcoxon signed-ranked tests) and the agreement in results between BFPP and SOC assays (Gwet's agreement coefficient).

RESULTS

We enrolled 50 subjects. In donor lung BAL specimens, BFPP detected 52 infections (14 out of 26 pathogens in the panel). Viral and bacterial BFPP results were reported 2.4 h (interquartile range, IQR 2.0-6.4) following BAL versus 4.6 h (IQR 1.9-6.0, p = 0.625) for OPO BAL viral SOC results and 66 h (IQR 47-87, p < .0001) for OPO BAL bacterial SOC results. Although there was high overall agreement of results between BAL-BFPP versus OPO BAL-SOC tests (Gwet's AC p < .001 for all), the level of agreement differed among 26 pathogens designed in BFPP and differed by types of specimens. BFPP could not detect many infections identified by SOC assays.

CONCLUSIONS

BFPP decreased time to detection of lung pathogens among donated lungs, but it cannot replace SOC tests due to the limited number of pathogens in the panel.

Design and evaluation of a Mobile-Based decision support system to enhance lung transplant candidate assessment and management: knowledge translation integrated with clinical workflow

BACKGROUND

Accurate and timely decision-making in lung transplantation (LTx) programs is critical. The main objective of this study was to develop a mobile-based evidence-based clinical decision support system (CDSS) to enhance the management of lung transplant candidates.

METHOD

An iterative participatory software development process was employed to develop the ImamLTx CDSS. This study was accomplished in three phases. First, required data and standard clinical workflow were identified according to the literature review and expert consensus. Second, a rule-based knowledge-based CDSS application was developed. In the third phase, this CDSS was evaluated. The evaluation was done using the standard Post-Study System Usability Questionnaire (PSSUQ 18.3) and ten usability heuristics factors for user interface design.

RESULTS

According to expert consensus, fifty-five data items were identified as essential data sets using the Content Validity Ratio (CVR) formula. By integrating information flow in clinical practices with clinical protocols, more than 450 rules and 500 knowledge statements were extracted. This CDSS provides clinical decision support on an Android platform regarding inclusion and exclusion referral criteria, optimum transplant time based on the type of lung disease, findings of initial assessment, and the overall evaluation of lung transplant candidates. Evaluation results showed high usability ratings due to the fact provided accuracy and sensitivity of this lung transplant CDSS with the information quality domain receiving the highest score (6.305 from 7).

CONCLUSION

Through a stepwise approach, the ImamLTx CDSS was developed to provide LTx programs with timely patient data access via a mobile platform. Our results suggest integration with existing workflow to support clinical decision-making and provide patient-specific recommendations.

Transplantation and immigration: Comparing infectious complications and outcomes between foreign-born and US-born kidney transplant recipients in Minnesota

BACKGROUND

Foreign-born kidney transplant recipients (FBKTRs) are at increased risk for reactivation of latent infections that may impact outcomes. We aimed to compare the etiology of infections and outcomes between FBKTR and United States KTRs (USKTR).

METHODS

We performed a retrospective study of patients who underwent kidney transplantation between January 1, 2014 and December 31, 2018 at two transplant centers in Minnesota. Frequency and etiology of infections as well as outcomes (graft function, rejection, and patient survival) at 1-year post-transplant between FBKTR and USKTR were compared.

RESULTS

Of the 573 transplant recipients, 124 (21.6%) were foreign-born and 449 (78.4%) US-born. At least one infection occurred in 411 (71.7%) patients (38.2% bacterial, 55% viral, 9.4% fungal). Viral infections were more frequent in FBKTR, particularly BK viremia (38.7% vs. 21.2%, p < .001). No statistical differences were found for bacterial or fungal infections; no parasitic infections were identified in either group. No geographically-restricted infections were noted aside from a single case of Madura foot in a FBKTR. Rejection episodes were more common in USKTR (p = .037), but stable/improving graft function (p = .976) and mortality (p = .451) at 1-year posttransplantation were similar in both groups. After adjusting for covariates, previous transplantation was associated with a higher number of infections (IRR 1.35, 95% confidence intervals 1.05-1.73, p = .020).

CONCLUSION

Although viral infections were more frequent in FBKTR, overall frequency and etiology of most infections and outcomes were similar between FBKTR and USKTR suggesting that comprehensive transplant care is providing timely prevention, diagnosis, and treatment of latent infections in FBKTR.

Solid organ transplant recipients with tuberculosis disease in California, 2010 to 2020

Using California Tuberculosis (TB) Registry data from 2010-2020, we compared the presentation and outcomes of patients with TB aged >15 years with and without solid organ transplantation (SOT). We matched to the United Network for Organ Sharing registry for 1987-2020 and the estimated time from transplantation to the diagnosis of TB, the incidence of posttransplant TB, and the probability of death and graft failure in SOT recipients with TB, compared to those without TB. From 2010-2020, there were 148 posttransplant TB cases. Patients with posttransplant TB were more likely to have extrapulmonary disease and more than twice as likely to die as TB patients without SOT (relative risk [RR], 2.2; 95% confidence interval [CI], 1.6-2.9). The median time from transplantation to TB diagnosis was 1.2 years, with the shortest time among lung transplant recipients. The incidence of TB disease among Californians with SOT was 56.0 per 100 000 person-years. The risk of death was higher among SOT recipients with posttransplant TB than those without (adjusted hazard ratio, 2.8; 95% CI, 2.0-4.1); the risk of graft failure was higher among kidney transplant recipients with posttransplant TB than those without (adjusted hazard ratio, 3.4; 95% CI, 1.7-6.9). An increased risk of death and graft failure in SOT recipients with posttransplant TB highlights the need for enhanced pretransplant TB prevention.