Solid Organ Donors Research Articles

372. Impact of Updated 2020 Public Health Service Guidelines on Deceased Organ Donors and Transplant Recipients

Abstract Background New guidelines for assessing solid organ donors and recipients for Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), and Hepatitis C (HCV) infection were published by the US Public Health Service (PHS) in 2020 and implemented into Organ Procurement and Transplantation Network (OPTN) policy on 3/1/21. Changes included a shorter risk criteria inclusionary timeframe and the removal of 4 risk criteria. Methods We analyzed OPTN deceased donor and transplant data 2 years pre-(3/1/19-2/28/21) and post-(3/1/21-3/1/23) implementation of the updated guidelines. For Kaplan-Meier survival analyses, the post- cohort included recipients transplanted before 1/1/23 to ensure recipients had at least 1 year follow-up plus a 3-month data lag. Utilization rates, defined as number of organs transplanted divided by number of available organs from donors with at least 1 organ recovered for the purpose of transplant, are shown for thoracic organs. Non-use rates, defined as number of organs recovered for the purpose of transplant but not transplanted divided by the total number of organs recovered for the purpose of transplant, are shown for abdominal organs. Results The proportion of donors considered to have PHS risk factors decreased by approximately 10% post-policy, both overall and by organ type (Fig. 1). There were no major differences pre- to post- in reported donor HIV, HCV or HBV NAT test results (Fig2. ). Post-policy, utilization rates for heart and lung for donors with risk factors were 34.9% and 17.5% respectively, compared to 34.3% and 20.0% pre-policy; while kidney and liver non-use rates for donors with risk factors were 20.3% and 8.2% respectively, compared to 17.2% and 7.9% pre-policy. There was no significant change in 1-year post-transplant patient survival for recipients who received organs from donors with PHS risk factors (Fig. 3). Conclusion Less restrictive PHS guidelines led to fewer donors being classified as having risk factors for disease transmission. Updated guidelines did not significantly affect donor infectious disease test results or post-transplant survival for recipients. Changes in donor organ utilization and non-use may be due to donor pool changes and/or overlapping policy implementations, and further investigation is warranted. Disclosures Lara A. Danziger-Isakov, MD, MPH, Aicuris: clinical research contract, paid to institutio|Ansun BioPharma: clinical research contract, paid to institution|Astellas: Advisor/Consultant|Astellas: clinical research contract, paid to institutio|Merck: clinical research contract, paid to institutio|Pfizer: Grant/Research Support|Takeda: clinical research contract, paid to institutio

P-2319. A 5-year Single Center Review of Strongyloides stercoralis Seropositivity in Cardiac Transplant Candidates in Central Texas

Abstract Background Strongyloides stercoralis is a parasitic nematode that chronically infects an estimated 30 - 100 million individuals worldwide and is mainly found in tropical, subtropical, and warm temperate regions. In solid organ transplant recipients, Strongyloides can cause disseminated disease or hyperinfection, which has an extremely high mortality rate. According to the American Society of Transplantation, all potential solid organ donors and recipients with risk factors for Strongyloides infection should undergo serologic screening. Our study aimed to identify the prevalence of Strongyloides seropositivity in patients evaluated for cardiac transplantation. We also aimed to identify demographic characteristics and risk factors associated with seropositivity, and any side effects of treatment. Table 1 Total number of Strongyloides seropositive (SSp) and seronegative (SSn), total number of patients that received cardiac transplant, demographic characteristics, and country of origin. Methods This study was a single-center, retrospective chart review of patients aged 18 or older who underwent cardiac transplant evaluation and serologic screening for Strongyloides at Baylor Scott & White Medical Center in Temple, Texas, between March 2019 and March 2024. A positive test was defined as > 1.1 Index Value (IV), negative as < 1.0 IV, and equivocal as 1.0-1.1 IV. Data was collected and managed using Research Electronic Data Capture (REDCap). Bivariate analyses were completed to test the association between the Strongyloides Seropositive (SSp) and Strongyloides Seronegative (SSn) groups. All statistical analyses were performed in SAS 9.4. Table 2 Pre-transplantation serologic results SSp and SSn. Abbreviations: Herpes Simplex Virus (HSV), Cytomegalovirus (CMV), Ebstein Bar virus (EBV), Varicella Zoster Virus (VZV), Human T-lymphotropic virus-1 (HTLV-1), human immunodeficiency virus (HIV). Results 259 patients underwent screening for cardiac transplant and Strongyloides. 11.58% tested positive or equivocal for Strongyloides. Epidemiological risk factors were not associated with seropositivity. All patients who underwent cardiac transplantation received appropriate treatment with no side effects. There were no cases of disseminated infection. Table 3 Travel history to endemic including tropic regions of Southeast Asia and the Appalachian region in the US, history of homelessness, history being barefoot, symptoms at diagnosis (Gastrointestinal, cutaneous, or respiratory symptoms), and treatment history. Conclusion Our study provides insight into the prevalence of Strongylodies in Texas. Based on our results, targeted screening may miss many seropositive patients. Given the lack of epidemiological risk factors within our SSp population and rising concern for indigenous cases within Texas, we recommend consideration of universal Strongyloides screening for solid organ transplant donors and recipients. Disclosures All Authors: No reported disclosures

Engagement With Sports After Solid Organ Transplant.

Introduction Transplant Games lend a unique opportunity not only by providing a platform for donors and recipients to engage in sports but also to counter the negativity surrounding organ donation and showcase to the world that transplant recipients can lead active lives. When the Transplant Games were held in Kochi, Kerala, India, for the first time, it provided a venue to engage with transplant recipients, donors, and the families of deceased donors. We aimed to understand the impact that engagement in sports brings on the lives of donors and recipients. Methods After obtaining permission from the organizers, we explained the objectives of the survey to the participants and encouraged them to participate. A survey, covering basic demographic information, transplantation details, and questions related to sports engagement was formulated. Participants could complete the survey electronically via a quick response code or in hard copy. They were fully informed about the objectives of the survey and had the right to withdraw at any stage without consequences. The survey was available for five hours during the games. The study received institutional ethics committee approval (ECASM-AIMS-2024-059). Results Among the approximate 150 participants, we received 78 respondents (52%). After the nine who withdrew consent were removed, we had a full response from 69 participants. Of these, 59 were males (85.5%), and 10 (14.5%) were females. The average age of the participants was 45 ± 13 years. Self-motivation was the most common factor in taking up sports for 30.4% of the responders, followed by family and friends in 23.2% and transplant doctors in 5.8%. Liver Foundation of Kerala (LIFOK), a self-help group of transplant recipients, played a major role in 4.3% of the responders. Bowling was the most popular sport with 23 mentions, followed by carroms and badminton with 27 and 20 mentions, respectively. Donors started to take an active role in sports earlier than recipients, 3.1 ± 1.89 vs. 5.7 ± 5.5 months. The most common reason cited for taking up sports was to become part of the transplant community, followed by a desire to embrace a healthier lifestyle and improve fitness levels. Although none had a personalized coach, most intensified their training and improved nutrition as part of their preparation for the games. Conclusion Our survey is limited by its small and self-selected sample size. Our study highlights the significant role of self-motivation, family support, and self-help groups in encouraging solid organ transplant recipients and donors to engage in sports after surgery. It also highlights the need for more proactive encouragement from doctors and better availability of sports facilities and support staff to help transplant recipients and donors engage in physical activities, which are crucial for their physical and emotional well-being.

Solid Organ Donation Process: Correlation between Pro!le, Learning and Course Indication

Objectives: To understand the pro!le of professionals trained in the solid organ donation process, to analyze the result of their learning before and after the course, and to correlate the pro!le and the performance of the professional with the learning and indication of the course. Methods: Retrospective, quantitative, analytical-descriptive study with participants of the course Processo de Doação de Órgãos Sólidos para Pro!ssionais de Saúde. Online questionnaires were used on professional pro!le, performance in the area of organ donation, knowledge assessment, and course indication. "e analyses and correlations were veri!ed with the McNemar test, Spearman's rank, and the bisserial point. Results: Of the 130 professionals, 62% were nurses, 38% physicians, 35% emergency physicians, 26% intensivists, and 42% had more than 10 years of training. For the pro!le of work in the area of organ donation, the professionals report having participated in up to !ve cases in each of the following stages: 44% were involved in the brain death protocol, 56% in the family interview, and 60% in the organ donation process. "e class knowledge retention rate was 26.7%, with 29.5% for physicians and 24.8% for nurses. "e indication of the course was evaluated following the Net Promoter Score (NPS), being in the promoters zone. "e correlation between the groups was positive and statistically signi!cant for those working in the emergency room, with more than 5 years since graduation and with more than !ve cases reported on the questioned stages of organ donation. No signi!cant correlation was identi!ed between these variables and the indication of the course. Conclusion: "e course contributed to the learning of professionals with more training time, greater previous experience in the stages of the organ donation process, and working in the emergency sector.

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

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. 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. 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. 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.

Does the use of double hormone replacement therapy for trauma patient organ donors improve organ recovery for transplant.

With an ongoing demand for transplantable organs, optimization of donor management protocols, specifically in trauma populations, is important for obtaining a high yield of viable organs per patient. Endocrine management of brain-dead potential organ donors (BPODs) is controversial, leading to heterogeneous clinical management approaches. Previous studies have shown that when levothyroxine was combined with other treatments, including steroids, vasopressin, and insulin, BPODs had better organ recovery and survival outcomes were increased for transplant recipients. To determine if levothyroxine use in combination with steroids in BPODs increased the number of organs donated in trauma patients. A retrospective review of adult BPODs from a single level 1 trauma center over ten years was performed. Exclusion criteria included patients who were not solid organ donors, patients who were not declared brain dead (donation after circulatory death), and patients who did not receive steroids in their hospital course. Levothyroxine and steroid administration, the number of organs donated, the types of organs donated, and demographic information were recorded. Univariate analyses were performed with P < 0.05 considered to be statistically significant. A total of 88 patients met inclusion criteria, 69 (78%) of whom received levothyroxine and steroids (ST/LT group) vs 19 (22%) receiving steroids without levothyroxine (ST group). No differences were observed between the groups for gender, race, pertinent injury factors, age, or other hormone therapies used (P > 0.05). In the ST/LT group, 68.1% (n = 47) donated a high yield (3-5) of organ types per donor compared to 42.1% (n = 8) in the ST group (P = 0.038). There was no difference in the total number of organ types donated between the groups (P = 0.068). This study suggests that combining levothyroxine and steroid administration increases high-yield organ donation per donor in BPODs in the trauma patient population. Limitations to this study include the retrospective design and the relatively small number of organ donors who met inclusion criteria. This study is unique in that it mitigates steroid administration as a confounding variable and focuses specifically on the adjunctive use of levothyroxine.

The state of paediatric deceased-organ donation at a South African tertiary public- sector hospital: A 14-year analysis.

Solid-organ transplantation (SOT) has been proven to be a highly effective and life-saving treatment modality for adults and children suffering from end-stage organ failure. However, high paediatric waiting-list mortality has been reported, and children may suffer irreversible physical and deleterious psychological effects if not transplanted timeously. To identify in-hospital barriers to organ donation and gain a better understanding of the paediatric donor landscape. A retrospective descriptive study of consecutive deceased-donor referrals at Red Cross War Memorial Children's Hospital over a 14-year period, from 1 January 2007 to 31 December 2020. During the study period, 156 in-hospital deaths were recorded in the trauma unit and 1 425 in the paediatric intensive care unit. Ninety-three of the 1 581 patients (5.9%) were referred to the on-call transplant co-ordinator as potential organ donors, of whom 69% had been involved in a traumatic accident, including 52% in road traffic collisions. The mean age of the potential donors was 7 years with 60.2% being boys. On initial assessment, 67 of the 93 potential donors (72%) were assessed as eligible for donation of at least one solid organ. The transplant co-ordinator attempted to approach all families for consent; however, five families/next of kin could not be located despite multiple attempts. Among the remaining 62 eligible donors, 44 families/next-of-kin declined consent for solid-organ donation, resulting in a consent rate of 29% (n=18). Several families refused consent for religious reasons. One of the consented donors did not proceed to procurement as there were no suitable recipients. Seventeen donors proceeded to theatre, the intention being solid-organ procurement, but in 2 donors the organs were assessed as being unsuitable for transplant. From the remaining 15 donors, a total of 46 organs were procured and successfully transplanted: 14 livers, 30 kidneys and 2 hearts. During the 14-year study period, only 15 deceased donors could be utilised for SOT, as a result of low in-hospital referral (5.9%) and consent rates (29%). The reasons for low referral and consent rates are complex and often multifactorial, which the current study was not designed to investigate in sufficient detail. Future studies should be designed to further interrogate our findings, while accommodating for nuances specific to the paediatric deceased-donor population and their families.

Organ donation after extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest in a metropolitan cardiac arrest centre in Milan, Italy

IntroductionExtracorporeal cardiopulmonary resuscitation (ECPR) may improve survival in refractory out-of-hospital cardiac arrest (OHCA) but also expand the donor pool as these patients often become eligible for organ donation. Our aim is to describe the impact of organ donation in OHCA patients treated with ECPR in a high-volume cardiac arrest centre. MethodsRate of organ donation (primary outcome), organs harvested, a composite of patient survival with favourable neurological outcome or donation of ≥1 solid organ (ECPR benefit), and the potential total number of individuals benefiting from ECPR (survivors with favourable neurological outcome and potential recipients of one solid organ) were analysed among all-rhythms refractory OHCA patients treated with ECPR between January 2013–November 2022 at San Raffaele Hospital in Milan, Italy. ResultsAmong 307 adults with refractory OHCA treated with ECPR (95% witnessed, 66% shockable, low-flow 70 [IQR 58–81] minutes), 256 (83%) died during hospital stay, 33% from brain death. Donation of at least one solid organ occurred in 58 (19%) patients, 53 (17%) after determination of brain death and 5 (1.6%) after determination of circulatory death, contributing a total of 167 solid organs (3.0 [IQR 2.5–4.0] organs/donor). Overall, 196 individuals (29 survivors with favourable neurological outcome and 167 potential recipients of 1 solid organ) possibly benefited from ECPR. ECPR benefit composite outcome was achieved in 87 (28%) patients. Solid organ donation decreased from 19% to 16% in patients with low-flow <60 min and to 11% with low-flow <60 min and initial shockable rhythm. ConclusionsWhen ECPR fails in patients with refractory OHCA, organ donation after brain or circulatory death can help a significant number of patients awaiting transplantation, enhancing the overall benefit of ECPR. ECPR selection criteria may affect the number of potential organ donors.

Transmission and Non-transmission of Melanoma From Deceased Solid Organ Donors to Transplant Recipients: Risks and Missed Opportunities.

Biovigilance concerns are in tension with the need to increase organ donation. Cancer transmission risk from donor to recipient may be overestimated, as non-transmission events are rarely reported. We sought to estimate melanoma transmission risk in deceased organ donation and identify missed opportunities for donation in an Australian cohort with high melanoma prevalence. We used a population-based approach and linked deceased organ donors, transplant recipients, and potential donors forgone, 2010-2018, with the Central Cancer Registry (CCR), 1976-2018. We identified melanomas using ICD-O-3 classification, assessed the probability of transmission, and compared suspected melanoma history in potential donors forgone with melanoma notifications in the CCR. There were 9 of 993 donors with melanoma in CCR; 4 in situ low-risk and 5 invasive high-to-unacceptable risk. Four were unrecognized before donation. Of 16 transplant recipients at risk, we found 0 of 14 transmission events (2 recipients had insufficient follow-up). Of 35 of 3588 potential donors forgone for melanoma risk alone, 17 were otherwise suitable for donation; 6 of 35 had no melanoma in CCR, 2 of 35 had in situ melanomas and 9 of 35 had thin invasive melanomas (localized, ≤0.8 mm thickness). Our findings contribute to current evidence that suggests donors with melanomas of low metastatic potential may provide an opportunity to safely increase organ donation and so access to transplantation.

Developing online communication training to request donation for vascularized composite allotransplantation (VCA): improving performance to match new US organ donation targets.

Approaching families of dying or newly deceased patients to donate organs requires specialized knowledge and a mastery of relational communication. As the transplantation field has progressed, Donation Professionals (DPs) are also leading conversations with family decision makers (FDMs) about the donation of uncommon anatomical gifts, such as face, hands, genitalia, referred to as Vascularized Composite Allotransplants (VCA) without much training or experience. To address the need for training, we adapted and beta tested an evidenced-based communication training program for donation discussions to VCA requests. The overarching goal of Communicating Effectively about Donation for Vascularized Composite Allotransplantation (CEaD-VCA) is to increase the number of VCA authorizations and to improve the socioemotional outcomes of FDMs. We developed CEaD-VCA, an online, on-demand training program based on the previously tested, evidenced-based communication skills training program designed to train DPs to have conversations about solid organ donation. The training was modified utilizing data from a national telephone survey with DPs and results of 6 focus groups conducted with members of the general public. The survey and focus groups assessed knowledge, attitudes, and barriers to VCA donation. The training was shaped by a partnership with a leading industry partner, the Gift of Life Institute.™ RESULTS: Using the results as a guide, the existing CEaD training program, consisting of interactive eLearning modules, was adapted to include technical information about VCA, foundational communication skills, and two interactive example VCA donation request scenarios to facilitate active learning. Forty-two DPs from two partner Organ Procurement Organizations (OPOs) participated in the beta test of CEaD-VCA. Pre- and post-test surveys assessed the impact of the training. The training was scored highly by DPs in effectiveness and ease of use. This project created a standardized, accessible, and comprehensive training for DPs to communicate about VCA donation. CEaD-VCA is an example of how to develop a communication skills training for difficult conversations utilizing input from stakeholders, guided by communication theory. It also demonstrates how gaps in communication skills during medical education can be filled utilizing advanced online Learning Management Systems. The training specifically addresses new CMS rules concerning OPO performance metrics.

Examination of the Brain Stem Death Approach to Defining Death in an Organ Transplant Context and its Credibility with ‘Nigerian’ Values and Beliefs

Organ donation generally consists of two modes - living (largely less-problematic), and cadaveric (largely problematic). Cadaveric donation of solid organs is simply the process of solid organ transplant after the demise of its owner (deceased). Consequently, many approaches to death have evolved in order to procure more solid organs in the medical sphere today as a result of science and technology. However, these approaches to death are not without controversies such as the credibility of the approach with the Nigerian values and beliefs. To this end, this paper, examines the some key controversies surrounding the adoption of the brain stem death approach to defining death and its credibility with the Nigerian values and beliefs with a bid to chart a way-forward for the country. In gathering and analysing data, the writer used doctrinal method of data collection relying on local statutes, cases laws, textbooks, journal articles, international treaties, conventions and covenants. The writer found that although it may appear unrealistic to have an approach to organ donation that will be devoid of criticisms, a holistic adherence to the recommendations herein may significantly address fears of critics and possibly reduce controversies and tensions surrounding the approaches to death. More so, robust sensitization of the citizenry should be done to turn the rather, organ transplantation apathy to an enviable one.

Population Characteristics and Organ Procurement Organization Performance Metrics

In 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule updating the Organ Procurement Organization (OPO) Conditions for Coverage. This rule evaluates OPO performance based on an unadjusted donation rate and an age-adjusted transplant rate; however, neither considers other underlying population differences. To evaluate whether adjusting for age and/or area deprivation index yields the same tier assignments as the cause, age, and location consistent (CALC) tier used by CMS. This retrospective cross-sectional study examined the performance of 58 OPOs from 2018 to 2020 across the entire US. A total of 12 041 778 death records were examined from the 2017 to 2020 National Center for Health Statistics' Restricted Vital Statistics Detailed Multiple Cause of Death files; 399 530 of these met the definition of potential deceased donor. Information about 42 572 solid organ donors from the Scientific Registry of Transplant Recipients was also used. Statistical analysis was performed from January 2017 to December 2020. Area deprivation of donation service areas and age of potential donors. OPO performance as measured by donation and transplant rates. A total of 399 530 potential deceased donors and 42 572 actual solid donor organs were assigned to 1 of 58 OPOs. Age and ADI adjustment resulted in 19.0% (11 of 58) to 31.0% (18 of 58) reclassification of tier ratings for the OPOs, with 46.6% of OPOs (27 of 58) changing tier ranking at least once during the 3-year period. Between 6.9% (4 of 58) and 12.1% (7 of 58) moved into tier 1 and up to 8.6% (5 of 58) moved into tier 3. This cross-sectional study of population characteristics and OPO performance metrics found that adjusting for area deprivation and age significantly changed OPO measured performance and tier classifications. These findings suggest that underlying population characteristics may alter processes of care and characterize donation and transplant rates independent of OPO performance. Risk adjustment accounting for population characteristics warrants consideration in prospective policy and further evaluation of quality metrics.

P601 Stem cell recipient becomes solid organ donor: Whose HLA is this?

P601 Stem cell recipient becomes solid organ donor: Whose HLA is this?

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 .

Nomenclature for factors of the HLA system, update January, February, and March 2023.

Nomenclature for factors of the HLA system, update January, February, and March 2023.

An Operational Burden Issue: Deciding on a Corneal Recipient From the Corneal Transplant Wait List for Elective Corneal Transplant

The cornea is the outermost tissue of the eye and must be transparent to maintain good visual function. Diseases with loss of corneal transparency (ie, corneal blindness) account for 10% of blindness worldwide. The treatment of this condition is only possible with corneal transplant from corneal tissue obtained from deceased donors. More than 10 million people worldwide have corneal blindness, but the annual number of available corneal transplants is only 185 000. Accordingly, it is obvious that the quantity of available donor tissue does not meet the need, with nearly 70 candidates on the wait list for each available corneal transplant. Rapid identification of appropriate recipients has become a crucial element in the field of corneal transplantation. There is a similar urgency (and scarcity) in other solid-organ donation programs, most of which have an established set of selection parameters (such as blood enzyme levels) that are easily defined and measurable. However, in the case of corneal transplant, there is presently no worldwide consensus on such selection criteria. The corneal transplant wait lists are long. The selection of appropriate recipients from these wait list candidates is managed by a designated authority (the authorized recipient selection operator) informed by the literature and the characteristics of the recipient within a framework of generally accepted, but variable, guidelines. The decision process is encumbered to a degree proportionate to the length of the wait list. In this review, we focus on solutions documented in the literature for selection of appropriate corneal recipients from transplant wait lists.

Investigation of donor-derived Strongyloides stercoralis infection in multiple solid organ transplant recipients-California, Michigan, Ohio, 2022.

The Centers for Disease Control and Prevention led an investigation to determine if Strongyloides infection in a right kidney recipient was an existing chronic infection, or if the infection was transmitted from an infected organ donor. Evidence regarding the organ donor and organ recipients Strongyloides testing, treatment, and risk factors were gathered and evaluated. The case classification algorithm created by the Disease Transmission Advisory Committee was utilized. The organ donor had risk factors for Strongyloides infection; the banked donor specimen, submitted for serology testing 112 days post-donor death, was positive. The right kidney recipient was negative for Strongyloides infection pretransplant. Strongyloides infection was diagnosed via small bowel and stomach biopsies. The left kidney recipient had risk factors for Strongyloides infection. Two posttransplant Strongyloides antibody tests were negative at 59 and 116 days posttransplant; repeat antibody tests returned positive at 158 and 190 days posttransplant. Examination of bronchial alveolar lavage fluid collected 110 days posttransplant from the heart recipient showed a parasite morphologically consistent with Strongyloides species. She subsequently developed complications from Strongyloides infection, including hyperinfection syndrome and disseminated strongyloidiasis. Based on the evidence from our investigation, donor-derived strongyloidiasis was suspected in one recipient and proven in two recipients. The results of this investigation support the importance of preventing donor-derived Strongyloides infections by laboratory-based serology testing of solid organ donors. Donor positive testing results would direct the monitoring and treatment of recipients to avoid severe complications.

C3d-binding assay for the detection of complement activating HLA antibodies: A useful tool for allocation to highly sensitised recipients in the post-CDC era?

The CDC crossmatch test is being phased out in solid organ donor allocation, and standard luminex single antigen bead assays do not differentiate complement activating function of HLA antibodies. The current study investigated the LIFECODES C3d-binding assay to determine if it could accurately predict actual T and B cell CDC results in a cohort of highly sensitised patients. Nineteen serum samples from different highly sensitised solid organ patients were crossmatched against cells from 62 unique donors, with 174 total T and B cell crossmatches performed. The sera also underwent SAB assay using OLI and LC platforms, and C3d-binding assay. Complement activating ability of each unique HLA antibody specificity detected using SAB was assigned based on the actual CDC results, which was then used to determine the accuracy of the C3d-binding assay. The C3d-binding assay was found to be highly accurate, with sensitivity of 95%, specificity 89% and negative predictive value 97% for class I DSA and the T cell CDC crossmatch results. Furthermore, we found 100% accuracy for prediction of the complement activating function of HLA-C antibodies. Negative predictive value of above 90% was also found for HLA class II DSA. C3d-binding proved more accurate than virtual crossmatch alone to predict CDC results. This study confirms that the C3d-binding assay predicts actual CDC crossmatch results accurately. In particular, the high negative predictive value of the C3d-binding assay may be extremely useful to define HLA antibodies that do not activate complement in highly sensitised recipients.

Vulnerability, Autonomy, and the Living Organ Donor

AbstractThe Living Organ Donor as Patient: Theory and Practice, by Lainie Friedman Ross and J. Richard Thistlethwaite, Jr. (Oxford University Press, 2021), offers a stimulating opportunity to consider the ethics of living solid organ donation in more depth. Ross and Thistlethwaite detail a framework of five principles—respect for persons, beneficence, justice, vulnerability, and responsibility—that positions prospective living donors as patients. The authors engage readers by applying these principles across a series of examples, issues, and possibilities, the “practice.” Readers may wish to reflect further on the framework's implications, including those related to vulnerability, power, and social justice (to name a few), particularly as these relate to the “theory” of this book. The book is well worth the read for clinicians, ethicists, and others involved in organ donation and transplantation.

HLA diversity in ethnic populations can affect detection of donor-specific antibodies by single antigen beads.

In solid-organ transplantation, human leukocyte antigen (HLA) donor-specific antibodies (DSA) are strongly associated with graft rejection, graft loss, and patient death. The predominant tests used for detecting HLA DSA before and after solid-organ transplantation are HLA single antigen bead (SAB) assays. However, SAB assays may not detect antibodies directed against HLA epitopes that are not represented in the SAB. The prevalence and potential impact of unrepresented HLA epitopes are expected to vary by ethnicity, but have not been thoroughly investigated. To address this knowledge gap, HLA allele frequencies from seven ethnic populations were compared with HLA proteins present in SAB products from two manufacturers to determine unrepresented HLA proteins. Allele frequencies were obtained from the Common, Intermediate, and Well Documented HLA catalog v3.0, and frequencies of unrepresented HLA types were calculated. Next-generation sequencing was used to determine HLA types of 60 deceased solid-organ donors, and results were used to determine if their HLA-A, -B, -C, and -DRB1 proteins were not present in SAB reagents from two vendors. Unrepresented HLA proteins were compared with the most similar protein in SAB assays from either vendor and then visualized using modeling software to assess potential HLA epitopes. For the seven ethnic populations, 0.5% to 11.8% of each population had HLA proteins not included in SAB assays from one vendor. Non-European populations had greater numbers of unrepresented alleles. Among the deceased donors, 26.7% (16/60) had at least one unrepresented HLA-A, -B, -C, or -DRB1 protein. Structural modeling demonstrated that a subset of these had potential HLA epitopes that are solvent accessible amino acid mismatches and are likely to be accessible to B cell receptors. In conclusion, SAB assays cannot completely rule out the presence of HLA DSA. HLA epitopes not represented in those assays vary by ethnicity and should not be overlooked, especially in non-European populations. Allele-level HLA typing can help determine the potential for HLA antibodies that could evade detection.