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Transmission of HIV by organ transplantation is an extraordinary event. The report by Ison et al. in this month's American Journal of Transplantation describes the second documented case of deceased donor derived HIV infection since 1987 (1,2). Although this case represents an exceptional occurrence, its impact on public policy has been far reaching, prompting a change in the consent process for recipients of organs from donors at high risk for HIV, Hepatitis C, and Hepatitis B and greater interest in the soon to be released Public Health Systems Guidelines for identifying these high risk donors. The authors suggest that this transmission event highlights the inadequacies of the current safety systems and prompts the need for the development of a system similar to the Transplantation Transmission Sentinel Network, an internet based system piloted by the Centers for Disease Control for tracking of organ donation associated disease transmission events (3).

It is critical to put this report in perspective, however. Disease transmission of infection and malignancy is a recognized risk of organ transplantation. In fact, the most commonly transmitted diseases (herpes viruses, including Cytomegalovirus) are accepted events, despite the potential association with long term complications. Moreover, much has already changed since the 1987 report of HIV transmission to improve donor safety, beginning with the Final Rule enacted in 1999 and leading up to the creation of the OPTN Ad Hoc DTAC of UNOS, initiated in 2005. Led for several years by the first author of this report, DTAC has taken a leadership role in patient safety, not simply collating reports but developing a more sophisticated reporting and communication system and a method for educating the larger transplant community about the potential risks of disease transmission associated with specific donation events. Is there room for improvement? Clearly there are several key areas that must be a focus of future initiatives to improve donor safety.

The first and potentially most pressing need is for an improved consent process. The current system has not standardized the consent process for all organ recipients and it is apparent that individual recipients have differing expectations, especially with regard to the risk of disease transmission. As we look for ways to expand our donor pool, it is impossible to maintain a supply of completely risk free organs and recipients must be alerted to the potential risk of both the known and unanticipated transmission potential for any individual donor organ. Informed consent should distinguish the common events such as CMV transmission from the extraordinary ones, including the transmission of pathogens such as HIV, Lymphocytic Choriomeningitis Virus and Rabies, in a way that is clear and comprehensible to recipients with limited medical understanding.

Second, all transplant centers must have multidisciplinary involvement in the transplant process. This should include experts in infectious diseases, malignancy and ethics who may provide input on donors both prior to and following transplantation. In this way, optimal selection of donor organs and management of them afterwards may be coordinated to develop the safest approach for the individual patient. The potential gain of organs as well as the development of safer systems for posttransplant care will ultimately be worth what might be an initial investment for the transplant center.

Our ability to assess patient historical information must also be improved. It is notable that although we focus on what is unknown about the deceased donor, our ability to assess HIV risk in the context of live donation must also be reviewed, as evidenced by a recent report in Morbidity and Mortality Weekly Reports that has been reprinted in this month's AJT (4). It is difficult to develop a uniform questionnaire for all donors, especially as historians for deceased donors may not have sufficient knowledge of the donor to provide accurate information and live donors may be motivated to limit their histories if that will increase the likelihood of being deemed an acceptable donor. Nevertheless, this should continue to be a focused effort involving all stakeholders in transplantation as accurate historical information will better inform the consent process.

Do we need to change our safety system to one such as the public health based reporting system piloted by the CDC, as suggested by Ison et al.? In the absence of such a system, the transplant community has already made tremendous strides to enhance donor safety, especially in the past 5 years. At this time, I think we need to build on what has been created, developing an enhanced and equal partnership between UNOS, the transplant community and public health authorities. This requires engagement of the entire transplant community and the public health systems, working together in order to both effectively assess transplantation issues and accurately and rapidly report them to the transplant community. This unique and collaborative partnership can and should herald a new era of safety for transplant recipients, both of deceased and live donor organs, in the years to come.

Disclosure

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  3. References

The author of this manuscript has no conflicts of interest to disclose as described by the American Journal of Transplantation.

The author is the current chair of the OPTN Ad Hoc Disease Transmission Advisory Committee (DTAC) of UNOS. The content of this editorial is the responsibility of the author alone and does not reflect the views or policies of DTAC or the Department of Health and Human Services.

References

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  2. Disclosure
  3. References
  • 1
    Ison MG, Llata E, Conover CS et al. Transmission of Human Immunodeficiency Virus and Hepatitis C from an organ donor to four transplant recipients. Am J Transplant 2011; 11: 12181225.
  • 2
    Epidemiologic Notes and Reports human immunodeficiency virus infection transmitted from an organ donor screened for HIV antibody–North Carolina. MMWR Morb Mortal Wkly Rep 1987; 36: 306308.
  • 3
    Fishman JA, Strong DM, Kuehnert MJ. Organ and tissue safety workshop 2007: Advances and challenges. Cell Tissue Bank 2009; 10: 271280.
  • 4
    HIV transmitted from a living organ donor—New York City 2009. MMWR Morb Mortal Wkly Rep 2011; 60: 297301.