Organ Transplant Candidates Research Articles

Underimmunization of the solid organ transplant population: An urgent problem with potential digital health solutions.

Solid organ transplant recipients are at risk for potentially life-threatening infections due to lifelong immunosuppression. Vaccine-preventable infections result in graft injury, morbidity, mortality, and significantly increased medical costs. Unfortunately, the majority of transplant recipients continue to be underimmunized at the time of transplant and thereafter. Given the rising rates of vaccine hesitancy and refusal in the general population, transplant recipients can no longer rely on herd immunity to protect them from vaccine-preventable infections. Novel tools are desperately needed to overcome transplant-specific immunization barriers to improve immunization rates in this high-risk population. Digital health technologies may offer a solution by addressing transplant-specific barriers: specifically, providing accurate information about vaccine safety, efficacy, and timing in the pre- and posttransplant periods; making a complete immunization record universally available and easily accessible; enabling communication between patients and multiple providers; and providing automated vaccine reminders to both patients and providers when vaccines are due using transplant-specific immunization guidelines. Digital health has transformed health care by empowering patients with their own health information and connecting patients, their providers, and public health officials. In doing so, it offers a potential platform to address and overcome the problem of underimmunization in the transplant population.

Percutaneous Coronary Intervention Outcomes in Solid Organ Transplant Candidates

Background: As part of the pre-transplant assessment, patients with end-stage renal, liver, pancreas, or lung disease who wish to attain transplant eligibility must undergo evaluation for coronary artery disease (CAD). Any significant CAD must be treated, usually by revascularization via either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), in order to achieve transplant candidacy. PCI in these patients is inherently higher risk due to baseline comorbidities, but there are few studies reporting outcomes following PCI in this population. We sought to investigate the short- and intermediate-term outcomes in patients undergoing PCI as part of a transplant candidacy evaluation. We also aimed to assess whether these patients ultimately received the desired transplant after PCI.
 Methods: This is a retrospective study investigating all patients who underwent PCI as part of a pre-transplant evaluation between 2009 and 2017 at IU Health Methodist Hospital. Patients were identified and data variables were extracted from an institutional American College of Cardiology CathPCI database. Medical records of all patients were reviewed to determine date of initial PCI and the type of solid organ transplant each patient was being evaluated for. Primary outcomes measured included 30-day and 1-year mortality, and whether organ transplantation ultimately occurred.
 Results: A total of 497 patients were identified. Pre-transplant PCI performed in end-stage liver disease was most common (n=182), followed by renal (n=167), lung (n=74), multi-organ (n=66), pancreas (n=6), and intestinal (n=2). Combined 30-day mortality was 4.9%, 5.4%, 12.2%, 0%, 0%, and 0% for liver, renal, lung, multi-organ, pancreas, and intestinal, respectively. Combined 1-year mortality was 23.1%, 7.8%, 12.2%, 37.9%, 0%, and 0% for liver, renal, lung, multi-organ, pancreas, and intestinal, respectively. The percentage of patients ultimately receiving the desired transplant was low, with 32.4% for liver, 35.9% for renal, 32.4% for lung, 57.6% for multiorgan, 83.3% for pancreas, and 0% for intestinal.
 Conclusion: This study demonstrates that PCI in patients undergoing solid organ transplant evaluation is relatively high-risk based on the 30-day and 1-year mortality. Furthermore, the percentage of patients ultimately receiving a transplant is relatively low. These results raise the question of whether high-risk PCI is the optimal CAD treatment in this population. These results also raise the question of whether changes to the transplant care protocol should be made to improve the likelihood of receiving a transplant before continuing to subject these patients to high-risk PCI.

Exercise for Solid Organ Transplant Candidates and Recipients: A Joint Position Statement of the Canadian Society of Transplantation and CAN-RESTORE.

The objectives of this position statement were to provide evidence-based and expert-informed recommendations for exercise training in adult and children solid organ transplant (SOT) candidates and recipients and on the outcomes relevant to exercise training and physical function that should be evaluated in SOT. We identified randomized controlled trials (RCTs) and systematic reviews of exercise interventions in adult and pediatric SOT candidates and recipients. When RCTs were not available, studies of any design were reviewed. The key recommendations were based on scientific evidence and expert-informed opinion. We recommended that exercise training should be offered in the pre- and posttransplant phase for both adults and children. In adults, exercise training pretransplant was safe, but there was insufficient evidence to provide specific guidelines on the training characteristics. RCTs in adult SOT recipients demonstrated that exercise training improved exercise capacity, lower extremity muscle strength, and health-related quality of life. To obtain benefits, exercise training should be of moderate to vigorous-intensity level, 3-5 times a week for a minimum of 8 weeks. In pediatrics, there is an urgent need for high-quality multicenter clinical trials in the pre- and posttransplant phases. Due to limited evidence, specific recommendations regarding training characteristics could not be provided for pediatrics. The clinical relevance of this position statement is that it provides a key step toward raising awareness of the importance of exercise training in SOT patients among transplant professionals. It also identifies key areas for further research.

Nontuberculous mycobacteria in solid organ transplant.

Nontuberculous mycobacteria (NTM) are emerging pathogens of concern especially in solid organ transplant candidates and recipients. This review aims to address diagnostic challenges, new and emerging treatment options, and infection prevention. The incidence of NTM infections in transplant candidates and recipients is rising. The infection prevalence of these environmental pathogens varies geographically by species with a coastal predominance. Although existing guidelines from the American Thoracic Society, Infectious Diseases Society of America, and British Thoracic Society provide recommendations for diagnosis and management, they do not fully address the subtle nuances and challenges faced in managing infections in immunocompromised transplant recipients. Evolving data on new therapeutic agents and their use in combination therapy will help individualize treatment regimens while limiting adverse effects and improving compliance. Use of combination β-lactams, avibactam, tedizolid, clofazimine, bedaquiline, liposomal amikacin, and ciprofloxacin for commonly isolated species such as Mycobacterium abscessus and Mycobacterium avium complex have proven effective. Further studies are needed to determine the incidence of NTM infection in a prospective, multicentric manner and evaluate the most promising synergistic treatment combinations in transplant recipients.

Tests for latent tuberculosis in candidates for solid organ transplantation: A systematic review and meta-analysis.

Reactivation of latent tuberculosis following solid organ transplantation has serious consequences for the recipient. The most useful diagnostic test for latent TB is not clear. We conducted a systematic review and meta-analysis to assess the relative test performance of interferon gamma release assays (IGRAs) and the tuberculin skin test (TST) in people undergoing solid organ transplantation. The clinical or radiological risk factors were used as the proxy reference standard. Test performance was expressed as an odd ratio (OR). We identified 24 studies (N=7811), 12 studies compared IGRAs with TST directly, nine studies evaluated only TST and three studies only IGRAs. Direct comparison between tests and clinical risk factors indicated both tests were strongly associated with the presence of clinical risk factors for TB (TST: OR 3.17; 95%CI 1.55-6.48, IGRA: OR 2.78; 95%CI 1.55-5.01), and radiological evidence of past TB (TST: OR 3.26; 95%CI 1.85-5.73, IGRA: OR 3.85; 95%CI 2.16-6.86). Relative comparison indicated IGRAs positivity was more strongly associated with presence of radiological evidence of TB than TST (relative OR: 3.24; 95%CI 1.10-9.56). While there is no strong evidence in supporting use of IGRAs over TST for diagnosing latent TB, IGRAs positivity is more associated with the presence of radiological evidence of previous TB.

HLA alleles and haplotypes observed in 263 US families

The 17th International HLA and Immunogenetics Workshop (IHIW) conducted a project entitled “The Study of Haplotypes in Families by NGS HLA”. We investigated the HLA haplotypes of 1017 subjects in 263 nuclear families sourced from five US clinical immunogenetics laboratories, primarily as part of the evaluation of related donor candidates for hematopoietic stem cell and solid organ transplantation. The parents in these families belonged to five broad groups – African (72 parents), Asian (115), European (210), Hispanic (118) and “Other” (11). High-resolution HLA genotypes were generated for each subject using next-generation sequencing (NGS) HLA typing systems. We identified the HLA haplotypes in each family using HaplObserve, software that builds haplotypes in families by reviewing HLA allele segregation from parents to children. We calculated haplotype frequencies within each broad group, by treating the parents in each family as unrelated individuals. We also calculated standard measures of global linkage disequilibrium (LD) and conditional asymmetric LD for each ethnic group, and used untruncated and two-field allele names to investigate LD patterns. Finally we demonstrated the utility of consensus DNA sequences in identifying novel variants, confirming them using HLA allele segregation at the DNA sequence level.

Vaccination of solid organ transplant candidates and recipients: Guidelines from the American society of transplantation infectious diseases community of practice.

These updated guidelines of the AST IDCOP review vaccination of solid organ transplant candidates and recipients. General principles of vaccination as well as the use of specific vaccines in this population are discussed. Vaccination should be reviewed in the pre-transplant setting and appropriate vaccines updated. Both inactivated and live vaccines can be given pre-transplant. The timing of vaccination post-transplant should be taken into account. In the post-transplant setting, inactivated vaccines can be administered starting at 3months post-transplant with the exception of influenza which can be given as early as one month. Inactivated vaccines can be safely administered post-transplant. There is accumulating data that live-attenuated vaccines can also be given to select post-transplant patients. Close contacts of transplant patients can receive most routine live vaccines. Specific vaccines including pneumococcal, influenza, hepatitis B, HPV, and meningococcal vaccines are discussed. Newer vaccines for seasonal influenza vaccine and herpes zoster are highlighted. Live-attenuated vaccines such as measles, mumps, rubella, and varicella are also discussed. Emerging data on live-attenuated vaccines post-transplant are highlighted.

Organ donation after trauma: A 30-year review.

Over the past 30 years, the demographics, clinical characteristics, and management of trauma patients have changed dramatically. During this same period, the organ donor population has also changed. The interactions between these two demographic shifts have not been examined in a systematic way. We hypothesize that trauma victims continue to be an important source of organs. We set out to systematically examine traumatic donors in an attempt to identify opportunities to increase organ recovery and quality. In this retrospective analysis, we compared trauma donors (TDs) and non-TDs (NTDs) in the Scientific Registry of Transplant Recipients standard analysis files, a clinical data set collected by the Organ Procurement Transplant Network on all solid organ transplant candidates, donors, and recipients in the United States since 1987. Scientific Registry of Transplant Recipients contained data on 191,802 deceased donors. The percentage of TDs decreased from 55.3% in 1987 to 35.8% in 2016 (p < 0.001) primarily due to a steady increase in NTDs. Trauma donors are younger and have fewer comorbidities while the percentage of donors who were public health service high risk or who underwent donation after cardiac death were clinically similar. The TDs produce more organs/donor (3.5 vs. 2.4, p < 0.001), are more likely to yield an extrarenal organ, and exhibit lower (better) Kidney Donor Risk Index scores, a predictor of graft longevity. These better outcomes are maintained after stratifying by age. Over the past 30 years, the number of NTDs has increased much more than the number of TDs. However, TDs remain a critically important organ donor source, yielding more organs per donor, better quality kidneys, and a higher likelihood of extrarenal organs. Potential causes, such as improved resuscitation protocols, should be examined in the future. Retrospective review, level III.

CMV-specific T-cells and CD27-CD28-CD4+ T-cells for assignment of cytomegalovirus (CMV) status in adults awaiting organ transplant

Background/objectives: Determination of Cytomegalovirus (CMV) status in solid organ transplant (SOT) candidates is essential to stratify risk of post-transplant CMV disease. Passive transfusion-acquired antibodies can make serologic determination of CMV status unreliable. We evaluated 3 assays, not affected by passive antibodies (PA), in assignment of CMV status: quantification of CMV-specific CD4 + T-cells (CMV-TC) and exhausted CD27-CD28- CD4 + T-cells, and detection of CMV DNA with Nucleic Acid Amplification Testing (NAAT).Study design: We enrolled 50 adults awaiting SOT and 50 immunocompetent age-matched controls, and collected a throat swab, urine, saliva and blood sample on each. Using flow cytometry CD4 + T-cells were phenotypically analyzed for expression of CD27 and CD28 and CMV-specific CD4 + T-cells were identified by CD69 expression and intracellular IFN-γ quantification after stimulation with CMV-antigen lysate. CMV NAAT was performed on all specimens using real-time PCR. CMV serology (CMV IgG) was determined by enzyme immunoassay. Subjects were considered to have potential PA if they received blood products within 2 months of collection.Results: The CMV-TC assay discriminated between CMV-seropositive and seronegative SOT candidates without PA well (sensitivity 79%, specificity 93%) while the CD27-CD28-CD4 + T-cell assay had good sensitivity (86%) but specificity of 74%. Detection of CMV DNA was uncommon in CMV-seropositive SOT candidates (2/21).Conclusions: Given its high specificity, the CMV-TC assay is valuable in confirming true-positive CMV status in seropositive SOT candidates with PA, while use of CD27-CD28-CD4 + T-cell analysis is limited by moderate specificity. Detection of CMV DNA is of limited value in assignment of CMV status in adults.

Leveraging marginal structural modeling with Cox regression to assess the survival benefit of accepting vs declining kidney allograft offers.

Existing studies evaluating the survival benefit of kidney transplantation were unable to incorporate time-updated information on decisions related to each organ offer. We used national registry data, including organ turndown data, to evaluate the survival benefit of accepting vs turning down kidney offers in candidates waitlisted from 2007-2013. Among candidates who declined their first offer, only 43% ultimately received organ transplantations. Recipients who later underwent organ transplantation after declining their first offer had markedly longer wait times than recipients who accepted their first offer, and 56% received kidney transplants that were of similar or lower quality compared to their initial offer. In marginal structural modeling analyses accounting for time-updated offer characteristics (including Kidney Donor Profile Index, Public Health System risk status, and pumping), after 3 months posttransplant, there was a significant survival benefit of accepting an offer (adjusted hazard ratio 0.76, 95% confidence interval 0.66-0.89) that was similar among diabetics, candidates aged >65years, and candidates living in donor service areas with the longest waitlist times. After carefully accounting for the effect of donor quality, we confirm that the survival benefit of accepting an organ offer is clinically meaningful and persistent beyond 3 months post-kidney transplantation, including high-risk subgroups of organ transplantation candidates.

A preliminary investigation of sleep quality and patient-reported outcomes in pediatric solid organ transplant candidates.

The current cross-sectional, single-center study aimed to examine sleep quality in a sample of adolescents awaiting solid organ transplantation and to explore associations between sleep quality and both health-related quality of life and barriers to adherence. Thirty adolescents between the ages of 12 and 18years (M age=15.26, SD=1.89) who were awaiting transplantation participated in this study. Participants completed measures of sleep quality, health-related quality of life, and barriers to adherence. T test and correlational analyses were performed to examine study aims. Adolescents awaiting transplantation had significantly lower levels of overall sleep quality compared to published norms of healthy peers. Domains of sleep quality were positively related to emotional and psychosocial health-related quality of life. Sleep quality domains were also negatively related to adherence barriers. This study provides preliminary evidence demonstrating that sleep quality among transplant candidates is compromised, and that poor sleep quality is related to adolescents' functioning across a number of domains during the pretransplant period. Results highlight the clinical importance of assessing and targeting sleep functioning in adolescents awaiting transplantation in order to reduce the negative influence of suboptimal sleep on functioning during this vulnerable period.

Use of Hepatitis C Positive Organs: Patient Attitudes in Urban Chicago

Background: Hepatitis C virus (HCV)-infected organs are being transplanted in patients with and without HCV in the direct-acting antiviral era. Little is known about patient attitudes towards receiving an HCV-positive organ. Objectives: The aim of this study is to determine transplant candidates’ attitudes towards receiving HCV-positive organs. Methods: Adult solid organ transplant candidates were identified during a clinic visit or during outpatient hemodialysis from May to December 2017. Willing participants completed a survey. Descriptive analysis including mean and median for continuous variables and frequencies for categorical variables were calculated by the appropriate statistical method and compared across willing, unsure, and unwilling patients and between willing and unsure/unwilling patients. Results: Fifty patients were surveyed with median age 54.5 years (range 32–77). Eighty-eight percent were awaiting kidney transplant, and 12% were awaiting other organs. Median waitlist time was 39.8 months (range 1.7–203 months). Most patients (90%) had prior knowledge of HCV, but only 60% knew it was curable. Forty-six percent were willing, 30% were unsure, and 24% were unwilling to receive an HCV-positive organ. Those willing to accept an HCV-positive organ were significantly older, Caucasian, had shorter waitlist times, and had greater physician trust than those that were unsure/unwilling. Similar worries, such as HCV incurability, insurance coverage, fears over the organ not working, and post-transplant death, were expressed in both the willing and unsure/unwilling patients. Conclusions: The availability of HCV-positive organs may expand the donor pool and decrease waitlist times and mortality. These data highlight the need for patient education towards use of these organs.

Tuberculosis Screening and Treatment in Solid Organ Transplantation

Background: Tuberculosis (TB) is a common infection with challenges in diagnosis and treatment. Management of TB in solid organ transplant (SOT) candidates and recipients poses unique challenges not seen in other populations. Questions and recommendations: Latent TB infection (LTBI) is important to diagnose pre-transplant through history, physical examination, imaging, and laboratory tests. Tuberculin skin tests and interferon-gamma release assays are important tools but not sufficiently sensitive nor specific to diagnose LTBI alone. Active TB is more likely to present as a disseminated or extrapulmonary infection. Donor-derived infections occur infrequently though can be serious; these can sometimes be prevented through LTBI treatment of the donor or recipient. Treatment of active or latent TB is similar to that in other populations with particular attention to drug interactions and adverse drug reactions. Conclusions: LTBI and TB are important infections in SOT candidates and recipients with unique challenges though substantial literature and experience have emerged to guide providers.

Usefulness of a systematic approach at listing for vaccine prevention in solid organ transplant candidates.

Solid organ transplant (SOT) candidates may not be immune against potentially vaccine-preventable diseases because of insufficient immunizations and/or limited vaccine responses. We evaluated the impact on vaccine immunity at transplant of a systematic vaccinology workup at listing that included (1) pneumococcal with and without influenza immunization, (2) serology-based vaccine recommendations against measles, varicella, hepatitis B virus, hepatitis A virus, and tetanus, and (3) the documentation of vaccines and serology tests in a national electronic immunization registry (www.myvaccines.ch). Among 219 SOT candidates assessed between January 2014 and November 2015, 54 patients were transplanted during the study. Between listing and transplant, catch-up immunizations increased the patients' immunity from 70% to 87% (hepatitis A virus, P=.008), from 22% to 41% (hepatitis B virus, P=.008), from 77% to 91% (tetanus, P=.03), and from 78% to 98% (Streptococcus pneumoniae, P=.002). Their immunity at transplant was significantly higher against S. pneumoniae (P=.006) and slightly higher against hepatitis A virus (P=.07), but not against hepatitis B virus, than that of 65 SOT recipients transplanted in 2013. This demonstrates the value of a systematic multimodal serology-based approach of immunizations of SOT candidates at listing and the need for optimized strategies to increase their hepatitis B virus vaccine responses.

Genitourinary Tract Infection Due to Mycobacterium avium intracellulare Complex Infection in Pretransplant Setting With Recurrence Following Transplant: A Case Report

Genitourinary (GU) tract infection with Mycobacterium avium intracellulare complex (MAI) is very rare and, to our knowledge, has never been reported in the solid organ transplant literature. Case DescriptionA 61-year-old Somali-born woman had a history of liver cirrhosis due to chronic hepatitis C infection. She was diagnosed as having and treated for latent tuberculosis infection and GU tract infection due to MAI. She received a total of 17 months antimycobacterial therapy consisting of azithromycin, ethambutol, and moxifloxacin. Within 5 months of the initiation of antimicrobial therapy, there was documented sterilization of urine mycobacterial cultures. Liver and kidney transplant was performed 3 months after finishing the treatment course. One year following transplant, GU tract infection due to MAI recurred. She declined further diagnostic testing as well as mycobacterial therapy. She died 15 months following transplant for reasons not related to infections. ConclusionThe treatment of MAI infection in solid organ transplant candidates and recipients is challenging, and the duration of therapy in this population is not known. The recurrence of infection following transplant in this case may argue in favor of a duration that extends beyond the date of transplant. The combination of a fluoroquinolone and ethambutol may successfully prevent reactivation of tuberculosis in patients with history of latent tuberculosis infection and deserves further evaluation.

Ethical rejections of xenotransplantation? The potential and challenges of using human-pig chimeras to create organs for transplantation.

EMBO Reports (2018) 19: e46337[OpenUrl][1][FREE Full Text][2] Gene editing and stem cell biotechnologies are being applied to create chimeric animals with human organs, which could alleviate the current shortage of human organs for transplantation. While the medical benefits of xenotransplantation appear to be significant, we discuss specific ethical, medical, cultural, and financial challenges and potential solutions that need to be addressed before clinical trials using organs from human‐animal chimeras should begin. > The use of animal organs to replace defective organs in human patients dates back at least to 1838 when the first pig‐to‐human corneal transplant was performed. Organ transplantation has a long history. The use of animal organs to replace defective organs in human patients dates back at least to 1838 when the first pig‐to‐human corneal transplant was performed. The first human skin transplant was done in 1869, the first successful kidney transplant between fraternal twins took place in 1954, and the first heart transplant was performed in 1967. Aortic valve replacement with a porcine heart valve was first reported 2 years later in 1969 and continues to be used to this day. Notwithstanding, of the clinical successes, organ transplantation has been held back by a huge shortage of people willing to donate their organs. Currently, more than 115,000 people are organ transplant candidates in the USA; 75,000 of these are on the national organ waiting list (https://optn.transplant.hrsa.gov). About 25% of patients on the list die before an organ becomes available. Xenotransplantation—using organs from animals for transplantation—has great potential to alleviate this organ shortage. However, tissue rejection and infections have greatly limited the effectiveness of cross‐species transplantations. Recent advances in biotechnology, including gene editing and stem cell science, may provide the key elements needed to create animals that grow human organs for transplantation. Research is currently focusing on growing human hearts, … [1]: {openurl}?query=rft.jtitle%253DEMBO%2BReports%26rft_id%253Dinfo%253Adoi%252F10.15252%252Fembr.201846337%26rft_id%253Dinfo%253Apmid%252F29991538%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=FULL&journalCode=embor&resid=19/8/e46337&atom=%2Fembor%2F19%2F8%2Fe46337.atom

Decrease in eosinophilia as a marker of response to therapy in solid organ transplant candidates with Strongyloides infection: A single‐center experience

Decrease in eosinophilia as a marker of response to therapy in solid organ transplant candidates with <i>Strongyloides</i> infection: A single‐center experience

Seroprevalence of antibodies against the three serotypes of poliovirus and IPV vaccine response in adult solid organ transplant candidates

ObjectivesTo assess the prevalence of protective antibody titers to polioviruses in adults candidates for solid organ transplant (SOT), and to assess the immunogenic response to inactivated polio vaccine in this population. MethodsThe study included SOT candidates referred to Immunization Reference Centre of Evandro Chagas National Institute of Infectious Diseases from March 2013 to January 2016. It was conducted in 2 phases. The first one, a cross-sectional seroprevalence study, followed by an uncontrolled analysis of vaccine response among patients without protective antibody titers at baseline. Antibody titers to poliomyelitis were determined by microneutralization assay. ResultsAmong 206 SOT candidates included, 156 (76%) had protective antibody titers to all poliovirus serotypes (95% CI: 70–81%). Proven history of oral vaccination in childhood was not associated with higher seroprevalence of protective antibody. In 97% of individuals without protective antibody titers at baseline, there was adequate vaccine response with one dose of inactivated polio vaccine. ConclusionsA relevant proportion of adult candidates for SOT does not have protective titers of antibodies to one or more poliovirus serotype. One dose of inactivated vaccine elicited protective antibody titers in 97% of these subjects and should be routinely prescribed prior to SOT.

Epidemiology and outcomes of pretransplant methicillin-resistant StaphylococcusAureus screening in pediatric solid organ transplant candidates.

MRSA infection following SOT is an important cause of morbidity and mortality, but epidemiology and risk factors for colonization prior to pediatric SOT remain unclear. A retrospective cohort of SOT patients ≤21years of age from 2009 to 2014 was evaluated. Demographics, MRSA screens, timing of transplantation, and MRSA infection were abstracted. From 2013 to 2014, 130 SOT candidates were screened or had known prior MRSA infection. Seventeen patients (13%) were MRSA colonized. Liver transplant candidates were least likely to be colonized (OR 0.22, CI:0.06-0.81, P=.02); greatest risk of colonization was in lung (OR 18.7, CI:1.9-182.3, P=.03), abdominal multivisceral (OR 7.5, CI:1.5-38.6, P=.02), and cardiac patients with history of cardiothoracic surgery (OR 8.0, CI:1.7-36.0, P=.007). In univariable analysis, African American patients were more likely to be colonized (OR 7.1, CI:2.49-19.41, P=.0005). There were 3 early MRSA infections in screened patients, incidence of 3.9%; only one in a colonized patient. Thirteen percent of screened pediatric SOT candidates were MRSA colonized, with greatest risk in lung, multivisceral and cardiac patients with prior cardiothoracic surgery. Early MRSA infection occurred in 3.9% of transplanted patients. Cardiothoracic and multivisceral organ transplant candidates may benefit the most from targeted MRSA screening.

Management and diagnosis of tuberculosis in solid organ transplant candidates and recipients: Expert survey and updated review,

Background: Optimal screening and management of latent tuberculosis infection (LTBI) and active tuberculosis (TB) in solid organ transplant (SOT) candidates and recipients is necessary to prevent morbidity and mortality.Methods: We conducted a cross-sectional survey of TB and transplant experts across the United States reviewing the clinical practice preferences on key management issues related to LTBI and TB in SOT candidates and recipients.Results: Thirty TB and 13 SOT experts were surveyed (response rate = 53.8%). Both groups agreed that tuberculin skin test (TST) and chest x-ray screening in SOT candidates was useful (78.6% and 84.6%, respectively). TST after SOT was not useful for most transplant experts and TB experts (0% vs. 32.1%, respectively), but both groups were split on usefulness of interferon gamma release assays (IGRA) in SOT recipients (42.9% TB experts vs. 46.2% SOT experts). Most experts recommend LTBI treatment prior to SOT if close monitoring is assured (82.1% TB experts vs. 76.9% transplant experts). LTBI treatment with isoniazid was preferred for patients on calcineurin inhibitors. Evaluation for suspected TB in SOT recipients varied, but most TB experts favored sputum testing (88.9%) whereas most transplant experts favored bronchoscopic testing (69.2%). Preferred TB treatment regimens in SOT recipients were similar to regimens recommended for immunocompetent patients.Conclusions: Most TB and transplant experts recommend evaluation and treatment for LTBI in SOT candidates. Liver transplant candidates, however, should only be treated if close monitoring can be assured and after consulting with a hepatologist. Practice preferences varied regarding the initial diagnostic approach for suspected TB in SOT recipients; however, most experts agreed that SOT recipients should receive similar treatments as immunocompetent patients.