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Recently a kidney transplant recipient in US died of rabies and it has been believed that he may have contracted the infection from the organ he received from a brain dead donor who had encephalitis from unknown cause. This prompted an alarm across five states in the US prompting screening and vaccination of those potentially exposed to the infection.
The demand supply gap of transplantable organs has lead to a clamour for various methods to increase the donor pool. There is an increasing tendency among surgeons to accept organs that in an earlier era would have been considered unsuitable, to benefit the increasing wait list for organs. Although with modern innovations, immunosuppression and surgical techniques, such marginal organs can be transplanted with comparable graft and patient survival, occasionally significant donor related problems can be transmitted to the patient with disastrous consequences.
Deceased donor organ donation inherently is an emergency where the process of brain death declaration, harvesting of organs and the transplant itself has to be done in a short period of time (often few hours). Although all donors are screened for common transmissible infections like HIV, hepatitis B & C, CMV as well as syphilis, there are many infections that could be potentially be in a latent period or in a window period where, there are no clinical manifestations or serological markers to indicate their presence. The results of some tests like fungal, viral or tubercular cultures may only be available after a few days....not in time to make a decision whether organ harvest should be performed or not.
Donor derived infections can be bacterial, fungal or viral. Even cancer cells can be potentially carried from donor to the recipient through the transplanted organ. Infections or tumors (low grade) of the brain that do not spill into the cerebrospinal fluid are often believed to have no risk of transmission and hence not considered a contraindication for organ harvest. Since the immunity of the recipient is suppressed after transplantation to prevent organ rejection, any infections or cancers (suppressed by intact immunity in the organ donor) can escalate leading to rapid clinical manifestation, deterioration and even death of the patient as in the rabies case.
Thankfully donor derived infections are reported in less than 10% organ recipients and in a very small number they can impact graft or patient survival. What is important is to be aware of this problem and screen for problems in the donor as far as possible. If a possible infection is suspected but not confirmed, this information should be passed on to the recipient clearly so that an informed choice regarding the small but present risk of transmission of the infection can be made by the patient and recipient team.
In the rush to accept more and more marginal organs to benefit needy recipients, transplant surgeons should not lose sight of the important doctrine....'first do no harm'.
One hopes that with introduction of rapid microbiological tests like DNA probes and the like, infections will be identifiable within few hours so that such inadvertent mishaps do not accompany what is otherwise an extremely noble exercise.
The demand supply gap of transplantable organs has lead to a clamour for various methods to increase the donor pool. There is an increasing tendency among surgeons to accept organs that in an earlier era would have been considered unsuitable, to benefit the increasing wait list for organs. Although with modern innovations, immunosuppression and surgical techniques, such marginal organs can be transplanted with comparable graft and patient survival, occasionally significant donor related problems can be transmitted to the patient with disastrous consequences.
Deceased donor organ donation inherently is an emergency where the process of brain death declaration, harvesting of organs and the transplant itself has to be done in a short period of time (often few hours). Although all donors are screened for common transmissible infections like HIV, hepatitis B & C, CMV as well as syphilis, there are many infections that could be potentially be in a latent period or in a window period where, there are no clinical manifestations or serological markers to indicate their presence. The results of some tests like fungal, viral or tubercular cultures may only be available after a few days....not in time to make a decision whether organ harvest should be performed or not.
Donor derived infections can be bacterial, fungal or viral. Even cancer cells can be potentially carried from donor to the recipient through the transplanted organ. Infections or tumors (low grade) of the brain that do not spill into the cerebrospinal fluid are often believed to have no risk of transmission and hence not considered a contraindication for organ harvest. Since the immunity of the recipient is suppressed after transplantation to prevent organ rejection, any infections or cancers (suppressed by intact immunity in the organ donor) can escalate leading to rapid clinical manifestation, deterioration and even death of the patient as in the rabies case.
Thankfully donor derived infections are reported in less than 10% organ recipients and in a very small number they can impact graft or patient survival. What is important is to be aware of this problem and screen for problems in the donor as far as possible. If a possible infection is suspected but not confirmed, this information should be passed on to the recipient clearly so that an informed choice regarding the small but present risk of transmission of the infection can be made by the patient and recipient team.
In the rush to accept more and more marginal organs to benefit needy recipients, transplant surgeons should not lose sight of the important doctrine....'first do no harm'.
One hopes that with introduction of rapid microbiological tests like DNA probes and the like, infections will be identifiable within few hours so that such inadvertent mishaps do not accompany what is otherwise an extremely noble exercise.
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