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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.

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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.

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Donor-derived infection is an uncommon but potentially devastating complication of solid organ transplantation (SOT). Accurate and timely identification of unexpected infectious disease transmission events has implications not only for the recipient(s) experiencing infection, but also other recipients of organs or tissues from the same donor who may require additional testing or risk mitigation, as well as the broader organ transplant regulatory framework. This narrative review synthesizes data from published reports of symptomatic unexpected donor-derived infections in SOT recipients to provide clinicians with a systematic approach to the evaluation of undifferentiated illnesses that may be of donor origin. Key reasons to consider donor-derived infection include certain microbiologically proven infections in the recipient, especially early after transplant, characteristics of the donor or their management that suggest potential exposure to or infection with specific pathogens prior to organ procurement, and select clinical syndromes that occur in the post-transplant period. Syndromes for which expedited consideration and evaluation of donor-derived infection may be warranted include central nervous system infection, graft or perigraft complications developing in the absence of typical risk factors, and unexplained critical illness/sepsis syndrome in the early post-transplant period. When embarking on an investigation of a suspected donor-derived infection, clinicians should apply knowledge of the entire continuum of the organ procurement and transplant process to ensure unbiased and comprehensive data collection that will facilitate appropriate adjudication of these uncommon but high-consequence events.

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BACKGROUND: Hepatitis E is a potentially serious infection in organ recipients, with an estimated two-thirds of cases becoming chronic, and with a subsequent risk of cirrhosis and death. In Europe, transmission occurs most often through the consumption of raw or undercooked pork, more rarely through blood transfusion, but also after solid organ transplantation. Here we describe a case of Hepatitis E virus (HEV) infection transmitted following kidney transplantation and review the literature describing cases of HEV infection transmitted by solid organ transplantation. CASE PRESENTATION: Three weeks after kidney transplantation, the patient presented with an isolated minimal increase in GGT and hepatic cytolysis 6 months later, leading to the diagnosis of genotype 3c hepatitis E, with a plasma viral load of 6.5 log10IU/mL. In retrospect, HEV RNA was detected in the patient's serum from the onset of hepatitis, and in the donor's serum on the day of donation, with 100% identity between the viral sequences, confirming donor-derived HEV infection. Hepatitis E had a chronic course, was treated by ribavirin, and relapsed 10 months after the end of treatment. DISCUSSION: Seven cases of transmission of HEV by solid organ transplantation have been described since 2012 without systematic screening for donors, all diagnosed at the chronic infection stage; two patients died. HEV organ donor transmission may be underestimated and there is insufficient focus on immunocompromised patients in whom mild liver function test impairment is potentially related to hepatitis E. However, since HEV infection is potentially severe in these patients, and as evidence accumulates, we believe that systematic screening of organ donors should be implemented for deceased and living donors regardless of liver function abnormalities, as is already the case in the UK and Spain. In January 2024, the French regulatory agency of transplantation has implemented mandatory screening of organ donors for HEV RNA.

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While Switzerland has not yet established a systematic approach, the small size of the country and the intensive collaboration between the transplant infectious disease teams facilitate a rapid communication once a donor-derived infection is suspected. Critical information regarding donor infections is shared rapidly, and appropriate measures are discussed. The long-term observational Swiss Transplant Cohort Study, which includes >92% of all solid organ recipients collects all relevant infectious disease episodes and facilitates detection of patterns of potential donor-derived infection.

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BACKGROUND: Inconsistent data exists regarding the risk factors for bronchoalveolar lavage (BAL) positivity in lung donors, the incidence of donor-derived infections (DDI), and the effect of BAL positivity on lung transplant (LuTx) recipients' outcome. METHODS: A retrospective analysis was conducted on consecutive LuTx at a single center from January 2016 to December 2022. Donors' data, including characteristics, graft function and BAL samples were collected pre-procurement. Recipients underwent BAL before LuTx and about the 3rd, 7th and 14th day after LuTx. A DDI was defined as BAL positivity (bacterial growth ≥104 colony forming units) for identical bacterial species between donor and recipient. Recipients' pre-operative characteristics, intra-operative management, and post-operative outcomes were assessed. Two recipient cohorts were identified based on lung colonization status before undergoing LuTx. RESULTS: Out of 188 LuTx procedures performed, 169 were analyzed. Thirty-six percent of donors' BAL tested positive. Donors' characteristics and graft function at procurement were not associated with BAL positivity. Fourteen DDI were detected accounting for 23% of recipients receiving a graft with a positive BAL. Only among uncolonized recipients, receiving a graft with positive BAL is associated with higher likelihood of requiring invasive ventilation at 72 hours after LuTx on higher positive end-expiratory pressure levels having lower PaO2/FiO2, prolonged duration of mechanical ventilation and longer ICU stay. No difference in hospital length of stay was observed. CONCLUSIONS: Receiving a graft with a positive BAL, which is poorly predicted by donors' characteristics, carries the risk of developing a DDI and is associated to a worse early graft function among uncolonized recipients.

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We transplanted six solid organs from three hepatitis C virus (HCV) polymerase chain reaction (PCR)-positive donors during 2018-2023. Recipients were treated with glecaprevir/pibrentasvir or sofosbuvir/velpatasvir for 4-12 weeks, with all six achieving sustained virological response without significant adverse events. As occurs in other jurisdictions, solid organ transplants from HCR PCR-positive donors can be safely utilised in Australia.

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BACKGROUND: Current guidelines lack consensus on whether antiviral prophylaxes should be administered after kidney transplantation from HBcAb+ donors. This systematic review and meta-analysis aimed to evaluate the incidence and risk factors of de novo HBV (DNH) infection, as well as graft and patient survival. METHODS: We searched PubMed, Embase, and the Cochrane Library up to December 31, 2023. We included relevant studies that assessed clinical outcomes following transplantation utilizing HBcAb+ kidneys. Summary measures of effect and 95% confidence intervals (CI) for prevalence, risk factors, as well as graft and patient survival were estimated using random-effects meta-analysis. RESULTS: Thirteen studies were included for the final analysis. The DNH incidence was at 0.36% (9/2516) with low heterogeneity (I2 = 6%). HBsAb+ recipients (OR: 0.78, 95%CI: 0.25-2.38), HBcAb+ recipients (OR: 3.11, 95%CI: 0.91-10.66, P = 0.071), and recipients not receiving any antiviral prophylaxis (OR: 1.26, 95%CI: 0.15-10.58) were not associated with higher DNH risk. Specifically, HBsAb-/HBcAb+ recipients had the highest DNH incidence (4.65%), followed by HBsAb-/HBcAb- (0.49%), HBsAb+/HBcAb- recipients (0.45%), and HBsAb+/HBcAb+ (0%). Furthermore, recipients receiving HBcAb+ kidneys had comparable graft survival (HR: 1.06, 95%CI: 0.94-1.19, P = 0.55) and patient survival (HR:1.16, 95%CI: 0.98-1.38, P = 0.090) compared with recipients receiving HBcAb- kidneys. CONCLUSION: Kidney transplantation utilizing HBcAb+ kidneys contributed to comparable graft and patient survival with an extremely low risk of HBV transmission. Antiviral prophylaxes may only be administered in HBsAb-/HBcAb+ recipients.

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With the increasing prevalence of marijuana use in the US, many deceased organ donors have a history of marijuana use, raising concerns about infectious risks to transplant recipients. We performed a multicenter retrospective cohort study in which exposed donors were those with recent marijuana use (in the prior 12 months) and unexposed donors were those with no recent marijuana use. Primary outcomes included the following: (1) positive donor cultures for bacteria or fungi, (2) recipient infection due to bacteria or fungi within 3 months posttransplant, and (3) recipient graft failure or death within 12 months posttransplant. Multivariable regression was used to evaluate the relationship between donor marijuana use and each outcome. A total of 658 recipients who received organs from 394 donors were included. Recent marijuana use was not associated with donor culture positivity (aOR: 0.84, 95% CI: 0.39-1.81, P = .65), recipient infection (aHR: 1.02, 95% CI: 0.76-1.38, P = .90), or recipient graft failure or death (aHR: 1.65, 95% CI: 0.90-3.02, P = .11). Our data suggest that organs from donors with a history of recent marijuana use do not pose significant infectious risks in the early posttransplant period.

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Donor-derived infections (DDIs) caused by carbapenem-resistant gram-negative bacteria (CR-GNB) in solid organ transplant recipients are potentially life-threatening. In this prospective study, we evaluated the incidence, factors associated with transmission, and the outcome of recipients with unexpected CR-GNB DDIs after the implementation of our local active surveillance system (LASS). LASS provides for early detection of unexpected donor CR-GNB infections, prophylaxis of recipients at high risk, and early diagnosis and treatment of DDIs. Whole genome sequencing confirmed DDI. Among 791 recipients, 38 (4.8%) were at high risk of unexpected CR-GNB DDI: 25 for carbapenem-resistant Enterobacterales (CRE) and 13 for carbapenem-resistant Acinetobacter baumannii (CRAB). Transmission did not occur in 27 (71%) cases, whereas DDIs occurred in 9 of 25 of CRE and 2 of 13 of CRAB cases. Incidence of CR-GNB DDI was 1.4%. Recipients of organs with CR-GNB-positive preservation fluid and liver recipients from a donor with CRE infection were at the highest risk of DDI. There was no difference in length of hospital stay or survival in patients with and without CR-GNB DDI. Our LASS contains transmission and mitigates the negative impacts of CR-GNB DDI. Under well-defined conditions, organs from donors with CR-GNB may be considered after a thorough evaluation of the risk/benefit profile.

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PURPOSE: Donor-derived infection (DDI) has become an important factor affecting the prognosis of lung transplantation patients. The risks versus benefits of using donor organs infected with multidrug-resistant organisms (MDRO), especially carbapenem-resistant organisms (CRO), are frequently debated. Traditional microbial culture and antimicrobial susceptibility testing at present fail to meet the needs of quick CRO determination for donor lungs before acquisition. In this study, we explored a novel screening method by using Xpert® Carba-R assay for CRO in donor lungs in a real-time manner to reduce CRO-associated DDI mortality. METHODS: This study was registered on chictr.org.cn (ChiCTR2100053687) on November 2021. In the Xpert Carba-R screening group, donor lungs were screened for CRO infection by the Xpert Carba-R test on bronchoalveolar fluid (BALF) before acquisition. If the result was negative, donor lung acquisition and subsequent lung transplantation were performed. In the thirty-five potential donors, nine (25.71%) with positive Xpert Carba-R results in BALF were declined for lung transplantation. Twenty-six recipients and the matching CRO-negative donor lungs (74.29%) were included in the Xpert Carba-R screening group. In the control group, nineteen recipients underwent lung transplants without Xpert Carba-R screening. The incidence and mortality of CRO-associated DDI were collected and contrasted between the two groups. RESULTS: Multivariate analysis showed that CRO-related death due to DDI within 60 days was significantly lower in the Xpert Carba-R screening group than that in the control group (OR = 0.05, 95% CI 0.003-0.74, p = 0.03). CONCLUSION: Real-time CRO screening of donor lungs before transplantation at the point of care by the Xpert Carba-R helps clinicians formulate lung transplantation strategies quickly and reduces the risk of subsequent CRO infection improving the prognosis of lung transplantation.

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In the United States, there is currently no system to track donated human tissue products to individual recipients. This posed a challenge during an investigation of a nationwide tuberculosis outbreak that occurred when bone allograft contaminated with Mycobacterium tuberculosis (Lot A) was implanted into 113 patients in 18 US states, including 2 patients at 1 health care facility in Colorado. A third patient at the same facility developed spinal tuberculosis with an isolate genetically identical to the Lot A outbreak strain. However, health care records indicated this patient had received bone allograft from a different donor (Lot B). We investigated the source of this newly identified infection, including the possibilities of Lot B donor infection, product switch or contamination during manufacturing, product switch at the health care facility, person-to-person transmission, and laboratory error. The findings included gaps in tissue traceability at the health care facility, creating the possibility for a product switch at the point of care despite detailed tissue-tracking policies. Nationally, 6 (3.9%) of 155 Lot B units could not be traced to final disposition. This investigation highlights the critical need to improve tissue-tracking systems to ensure unbroken traceability, facilitating investigations of recipient adverse events and enabling timely public health responses to prevent morbidity and mortality.

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With persistent progress in donor-recipient evaluation criteria, organ procurement and preservation regimens and surgical techniques, the incidence of vascular complication after kidney transplantation has been declined, whereas it is still one of the most severe surgical complications of kidney transplantation, which may lead to graft loss and recipient death, and seriously affect the efficacy of kidney transplantation. Therefore, the occurrence, clinical manifestations, diagnosis and treatment strategies of common vascular complications after kidney transplantation, including vascular stenosis, arterial dissection, pseudoaneurysm, vascular rupture and thrombosis were reviewed in this article. In combination with the incidence, diagnosis and treatment of vascular complications after kidney transplantation in the First Affiliated Hospital of Xi'an Jiaotong University, diagnosis and treatment strategies for common vascular complications after kidney transplantation were summarized, aiming to provide reference for clinical diagnosis and treatment of vascular complications after kidney transplantation, lower the incidence of vascular complications, and improve clinical efficacy of kidney transplantation and survival rate of recipients.

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Organ transplantation has become an effective treatment for multiple end-stage diseases. However, the recipients of organ transplantation need to take immunosuppressive drugs for a long time after operation, which leads to low immune function and relatively high incidence of bacterial, viral and fungal infections. Traditional microbial detection methods, such as pathogen culture, immunological detection and polymerase chain reaction, have been widely applied in infection detection, whereas these methods may cause problems, such as long detection time and presumed pathogens. Metagenomic next-generation sequencing has been widely adopted in infection prevention and control in organ transplantation in recent years due to high detection rate and comprehensive detection of pathogen spectrum. In this article, the application of metagenomic next-generation sequencing in the prevention and control of infection in solid organ transplantation was reviewed, aiming to provide reference for the diagnosis and treatment of transplantation-related infection.

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Donor-derived infections in solid organ transplantation can be prevented by risk stratification of donors based on available information, and inquiries surrounding possible or diagnosed infection are common questions posed to transplant infectious disease subspecialists. This article outlines the five key steps in addressing a donor call from a transplant team in a systematic approach, focusing on donor and recipient-specific factors, transmissibility and treatment of possible infections, and the likelihood of a patient's future organ offers and mortality remaining on the waitlist. These principles are then applied to five donor call cases, in which we review the key takeaway points and supporting literature. These cases can be used as a resource for teaching with trainees.

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Background: There is no consensus on the optimal use of perioperative antibiotics prophylaxis after kidney transplantation, but there is a common trend to limit the duration of antibiotic use worldwide. Metagenomic next-generation sequencing (mNGS) has emerged as a novel technology for pathogen detection in clinical practice due to its noninvasive, rapid, precise and high susceptibility to detect infectious pathogens. However, data are lacking on whether mNGS analyses could be used to detect pathogens and guide anti-infection regimens in kidney transplant donors and recipients. Methods: We conducted a retrospective study to review all clinic data of mNGS and traditional laboratory methods (TMs) for pathogen detection in kidney transplant recipients and their corresponding deceased donors from August 1, 2021 to October 30, 2022 in our center. Results: A total of 57 donors and 112 of their corresponding recipients were included. The antimicrobial strategy mainly depended on mNGS results combined with traditional pathogen culture and clinical conditions. The percentages of positive pathogen detected by mNGS in blood, urine, bronchoalveolar lavage fluid (BALF) and preservation fluids (PFs) were 50.9% (29/57), 35.1% (20/57), 84.2% (48/57) and 54.4% (31/57) respectively, and were 24.6% (14/57), 15.8% (9/57), 57.9% (33/57) and 14.1% (8/57) respectively when using TMs. mNGS could detected all of pathogens which were detected by TMs. However, samples with negative TMs testing can be additionally detected as positive by mNGS (15/43 in blood, 11/48 in urine, 15/24 in BALF and 23/49 in PFs). Drug resistance genes were detected in 9 donors by mNGS,which were consistent with 6 donors by TMs. There was only one case of donor-derived infection in this study. Conclusion: This study showed that it is effective to combine mNGS with traditional pathogen detection methods and clinical features to develop optimal perioperative antimicrobial management strategies for deceased donor kidney transplantation.

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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.

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Universal Hepatitis E Virus (HEV) screening of deceased organ donors was implemented by the UK national organ procurement organisation in October 2017. Donor testing for HEV infection is done post-transplant; detection of HEV ribonucleic acid (RNA) in donor plasma is therefore not a contra-indication for organ donation, with the result being used to inform recipient management. Immediate post-transplant detection of donor HEV viraemia triggers notification to transplant centres. Follow up of liver and kidney recipients has shown that transmission through solid organs is very efficient, particularly through liver grafts, as expected; no other organ types were transplanted in this cohort. Although donors with higher plasma viral load (VL > 103 IU/mL) were invariably associated with recipient infection, transmission was also documented at lower VL levels. Knowledge of donor HEV status has led to identification of transmission of infection via solid organ grafts followed by close patient monitoring and informed clinical management decisions. The purpose of this strategy is to allow early detection of infection and recurrence and treatment to circumvent the risk of accelerated liver damage from chronic HEV infection due to undiagnosed, inadvertent donor-derived transmission of infection.

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BACKGROUND & AIMS: HBsAg-positive (HBsAg[+]) donors are rarely accepted for kidney transplantation (KT), especially when the donor is also HBV DNA-positive (HBV DNA[+]) or HBeAg-positive (HBeAg[+]) serologically. This study aimed to report kidney transplant outcomes from HBsAg(+) donors to HBsAg(-) recipients. METHODS: Consecutive cases were retrospectively identified from 1 July 2017 to 31 December 2020. KTs from HBsAg(-)/HBcAb-positive (HBcAb[+]) donors to HBcAb(-) recipients were selected as the control group. The primary outcomes were de novo HBV infection (DNH), graft and patient survival. RESULTS: We identified 105 HBsAg(-) recipients who received HBsAg(+) kidneys and 516 HBcAb(-) recipients who received HBcAb(+) kidneys. A higher DNH rate was observed after receiving HBsAg(+) kidneys than after receiving HBcAb(+) kidneys after a median follow-up of 23.0 months (4/105[3.8%] vs. 2/516[0.4%], p = .009). All four infected recipients receiving HBsAg(+) kidneys had HBsAg clearance after treatment. Graft and patient survival were comparable between the groups (p = .630, p = .910). The DNH rates were 0/22(0%), 3/70(4.3%) and 1/13(7.7%) after receiving HBsAg(+), HBV DNA(+) and HBeAg(+) kidneys, respectively (p = .455). The DNH rate was lower if the donor had received antiviral treatment (4/42[9.5%] vs. 0/63[0%], p = .023). HBsAb(-) recipients had a higher DNH incidence than HBsAb(+) recipients (3/25[12.0%] vs. 1/80[1.3%], p = .041). CONCLUSIONS: The use of HBsAg(+) donors contributed to comparable graft and patient survival, but HBV DNA(+) or HBeAg(+) donors and HBsAb(-) recipients maybe associated with a higher risk of HBV infection. These findings help expand the donor pool and emphasize the role of donor antiviral treatment and recipient HBV immunity in establishing optimal prophylactic regimens.

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