Solid Organ Donors Research Articles

P106 LinkSēq for ABO, a molecular based typing solution for the ABO blood group

Aim ABO-incompatible (ABOi) organs have been successfully transplanted from A2 donors into B recipients, especially when the recipient’s anti-A titers are reduced. Laboratories typically use serological methods to perform ABO typing. However, serology has significant limitations including (i) recently transfused patients may exhibit mixed field agglutination and (ii) both forward and reverse typing must be performed, but may yield discordant results. These limitations are most problematic with phenotypes involving weakly expressed antigens and ABO subgroups (i.e. A2). However, current ABO subgrouping methods using anti-A1 lectin have limitations: they only indirectly determine A2, and typically include a gray zone reactivity range for which subgroups cannot be reliably called. A combination of genotyping solutions (SSP, sequencing, etc) can be used for ABO subgrouping, but these methods are time- and labor-consuming, and require interpretation by subject matter experts. Methods The Thermo Fisher Scientific solution is based on its LinkSēq real-time PCR technology, which was developed over 10 years ago for genotyping the complex Human Leukocyte Antigen (HLA) system. LinkSēq ABO analyzes 19 reactions that identify multiple relevant SNPs located within the ABO gene. We evaluated this solution by analyzing 40 archived DNA samples, including blood blank samples for which serotyping failed or produced discordant results, and samples from deceased solid organ donors for comparison with A1 lectin testing. Results Genotyping results generated by LinkSēq were 100% concordant with typing obtained by traditional methodologies. In two cases, serology couldn’t provide conclusive results and typing had to be reflexed to lectin tests or SBT. LinkSēq overcomes the major challenges of molecular typing by providing a robust, automated approach that increases laboratory productivity and reduces turn-around time. With less than 10 min of hands-on set-up, no further operator intervention with reagents, and SureTyper software fully automating all analysis, LinkSēq delivers genotyping and predicted phenotyping results in approximately 90 min. Conclusions We conclude that LinkSēq can provide a simple, effective and robust method for ABO typing including accurate A2 subgrouping.

Solid organ transplantation following allogeneic haematopoietic cell transplantation: experience from a referral organ transplantation center and systematic review of literature.

Solid organ transplantation (SOT) following haematopoietic cell transplantation (HCT) is a rare event. Uncertainty exists whether such recipients are at higher risk of relapse of underlying haematological disease or at increased risk of developing infectious or immunological complications and malignancies following SOT. The experience at our referral organ transplantation center and the present literature of SOT (n = 198) in recipients following previous HCT was systematically reviewed. Outcome analysis of 206 SOT recipients following HCT challenges the validity of the frequently stated comparable outcome with recipients without prior HCT. SOT recipients after HCT are younger and have a higher mortality and morbidity in comparison with “standard” recipients. Rejection rates for SOT recipients following HCT appear to be lower for all organs, except for liver transplantation. In the setting of liver transplantation following HCT, mortality for recipients of deceased donor grafts appears to be exceptionally high, although experience with grafts of living donors are favourable. Morbidity was mostly associated with infectious and malignant complications. Of note some SOT recipients who received solid organ donation from the same HCT donor were able to achieve successful withdrawal of immune suppression. Despite limited follow-up, recipients with prior HCT show a different course after SOT, necessitating attention and closer follow-up.

Risk acceptance of human T-lymphotropic virus infection in solid organ transplantation-A survey of Atlantic Canadian ambulatory patients.

Human T-lymphotropic virus (HTLV) has an estimated prevalence of 12 per 100000 in the general Canadian population (with higher rates in distinct groups) and is most commonly transmitted by breast feeding, sexual intercourse, sharing injection tools, and blood transfusions. A minority of those infected will develop severe disease. Health Canada mandates that people who are positive for HTLV are not suitable to be solid organ donors. Given the apparent low-disease burden of HTLV in Canada, we explored HTLV risk tolerance among patients, in the context of organ transplantations. Using telephone, and in-person questionnaires, we assessed willingness of patients to accept the risk of HTLV infection in hypothetical scenarios in which they required an organ transplant for survival. Seventy-four outpatients attending various medical clinics participated in the survey. In a standard gamble scenario, 37.5% of respondents would have accepted a solid organ transplant regardless of HTLV risk, as compared to 27.3% and 24.6% accepting organ transplantation if there was a risk of human immunodeficiency virus (HIV) or of human virus Y (HVY; a fictitious virus describing HTLV in terms of neurological outcomes), respectively. Similarly, the median longevity traded to ensure a virus-free organ was 4-5years regarding all viruses, except for HVY, for which the median time exchanged to ensure a virus-free organ was 10 (out of a possible 20) years. These data suggest that patients, though willing to accept some risk of viral infection, would not be willing to forgo HTLV screening of solid organs.

Pesticide-Poisoned Patients: Can They Be Used as Potential Organ Donors?

The gap between the number of patients on transplant waiting lists and patients receiving transplants is growing. Use of organs from donors who have died following pesticide exposure remains controversial. This study reviews the literature related to transplantation from this group. A literature search was undertaken on PubMed using the following keywords: 'insecticide', 'pesticide', 'rodenticide', 'organophosphate', 'carbamate', 'paraquat', 'poisoning', 'toxicity', 'overdose', 'intoxication', 'ingestion', 'organ donation or procurement', 'transplant', 'allograft transplant', and 'expanded criteria organ donation'; 21 specific pesticides/insecticides were also added to the search; the indexes for EAPCCT/NACCT meeting abstracts 2008-2017 were also searched. Identified publications were reviewed and if described human donation/transplantation of ≥ 1 solid organ(s), the following was extracted: (i) compound(s) ingested; (ii) donor demographics; (iii) organ(s) transplanted; and (iv) graft function at follow-up. Ten papers were identified describing 20 fatalities (1999-2017) related to the following pesticide exposures: organophosphate, 8 cases; aldicarb, 4; paraquat, 3; parathion, 1; malathion, 1; carbofuran/carbamate, 1; carbamate, 1; and brodifacoum, 1 and no further cases were identified from EAPCCT/NACCT abstracts. Donors were aged 12-50 (25.9 ± 11.9)years. Forty-four organs were transplanted: 28 kidneys, 7 livers, 6 corneas, and 3 hearts. Forty recipients had outcome reported: 3 (7.5%) patients died, 3 (7.5%) had graft failure/dysfunction and 34 (85.0%) had good graft function. Overall survival with good function was 96%, 71%, 83%, and 67% for kidneys, livers, corneas and hearts respectively. Review of the published literature suggests that solid organ donation following exposure to a pesticide is associated with good short-to-medium-term graft organ function following transplantation, particularly for transplanted kidneys and corneas.

Recent Progress in Pig to Non-Human Primate(NHP) Solid Organ Xenotransplantation in Korea

Extreme shortage of solid organ donors comparing to the transplant-needed patients is most critical problem now and only probable solution seems to be xenotransplantation. However, results of preclinical trials of solid organ xenotransplantation of pig to NHP are not sufficient to start the clinical trials yet. In Korea, although GalTKO pigs are developed already in the middle of 2000th, trials of solid organ xenotransplantation of pig to NHP are only begun from 2011. From then, 6 cases of kidney xenotransplantation and 20 cases of heart xenotransplantation have been done in our research team until now. We have used the cynomolgus monkey as recipient animal and pigs of several types of transforming just like GTKO only, GTKO.hCD46 and GTKO.hCD39 as donor animal. We have used the immunosuppressants of CD154 ab, rituximab, ATG, Tacrolimus, MMF and steroid. The longest survival of kidney and heart is 32 and 61 days for each. And among heart and kidney recipients, nearly 40% survive more than 3 weeks and longer survivals are recent cases. For the kidney transplantation, functioning graft was confirmed. There are no signs of hyper-acute rejection for the transplanted graft and even for the more than 1-month survivors, acute rejection is the cause of death. This survival results are relatively poor yet, but longest cases of survival are recent cases and so results are improving. Although solid organ xenotransplantation in Korea is just beginning and we are only team with insufficient resources and results, with the supports of governmental fund and volunteering activities of clinical experts of heart and kidney, we expect the continuing experiments and studies to make comparative good results and contribute the beginning of clinical trials of solid organ xenotransplantation Korean Rural Development Administration.

Systematic review on the treatment of deceased organ donors.

Currently, there is no consensus on which treatments should be a part of standard deceased-donor management to improve graft quality and transplantation outcomes. The objective of this systematic review was to evaluate the effects of treatments of the deceased, solid-organ donor on graft function and survival after transplantation. Pubmed, Embase, Cochrane, and Clinicaltrials.gov were systematically searched for randomized controlled trials that compared deceased-donor treatment versus placebo or no treatment. A total of 33 studies were selected for this systematic review. Eleven studies were included for meta-analyses on three different treatment strategies. The meta-analysis on methylprednisolone treatment in liver donors (two studies, 183 participants) showed no effect of the treatment on rates of acute rejection. The meta-analysis on antidiuretic hormone treatment in kidney donors (two studies, 222 participants) indicates no benefit in the prevention of delayed graft function. The remaining meta-analyses (seven studies, 334 participants) compared the effects of 10 min of ischaemic preconditioning on outcomes after liver transplantation and showed that ischaemic preconditioning improved short-term liver function, but not long-term transplant outcomes. There is currently insufficient evidence to conclude that any particular drug treatment or any intervention in the deceased donor improves long-term graft or patient survival after transplantation.

Prevalence and Distribution of Potential Vascularized Composite Allotransplant Donors, Implications for Optimizing the Donor-recipient Match.

Background:Vascularized composite allotransplantation (VCA) is an emerging and growing field. Little is known about the prevalence and distribution of the adult potential donor population in the United States now that it falls under the oversight of the United Network for Organ Sharing (UNOS).Methods:We assessed the UNOS database from 2008 to 2015 to estimate the prevalence and distribution of adult potential vascularized composite allograft donors. Donor inclusion and exclusion criteria were developed in a way to minimize risk to recipients and were applied to the dataset. Donors were categorized by factors that influence vascularized composite allograft matching including ABO blood type, cytomegalovirus status, and ethnicity (correlate for skin color) and sorted by UNOS region.Results:Just under half of all brain dead donors met the inclusion/exclusion criteria. Blood type O, cytomegalovirus+, White donors represented the most frequent donor profile while blood type AB, cytomegalovirus-, Asian donors were the least common. UNOS region 3 had the most and region 1 had the least potential VCA donors per year. Nearly all potential VCA donors were solid organ donors with the liver being the most commonly donated solid organ in this population.Conclusions:A large portion of the solid organ donor pool would qualify as adult vascularized composite allograft donors in the current UNOS system. These data will assist transplant teams in determining the prevalence and distribution of vascularized composite allograft donors for their individual patients awaiting composite allografts based on relevant matching characteristics in addition to standard transplant criteria.

P098: Solid organ donation from the emergency department - a systematic review

Introduction: There is a significant gap between the number of organ donors and people awaiting an organ transplant; therefore it is essential that all potential donors are identified. Given the nature of Emergency Medicine it is a potential source of organ donors. The purpose of this study is to determine what percent of successful donors come from the Emergency Department (ED) and whether there are any missed potential donors. Methods: Electronic searches of EMBASE, MEDLINE, and CINAHL were performed July 7, 2017 using PRISMA guidelines. Primary literature in human adults were included if they described identification of patients in the ED who went on to become successful solid organ donors, or described missed potential donors in the ED. Data on the total population of actual or missed donors was required to allow calculation of a percentage. Studies describing non-solid organ donation, consent, ethics, survey of attitudes, teaching curricula, procurement techniques, donation outside the ED, and recipient factors were excluded. 2 authors independently screened articles for inclusion and discrepancies were resolved through consensus. Quality was assessed using STROBE for observational studies. Heterogeneity of patient populations precluded pooling of the data to conduct a meta-analysis. Results: 1058 articles were identified, 17 duplicates were removed, 800 articles were excluded based on title and abstract, and 217 full text articles were excluded, yielding 24 articles for the systematic review. For neurologic determination of death (NDD), ED patients comprised 4 44% of successful donors. ED death reviews revealed 0 84% of patients dying in the ED are missed as potential donors and hospital-wide death reviews revealed 13 80.9% of missed donors die in the ED. For donation after cardiac death (DCD), 4 20% of successful donors came from the ED and studies investigating potential donors suggest 2 36% of patients dying the in the ED could be potential DCD donors. The most common population of successful DCD organ donors was in traumatic cardiopulmonary arrest (TCPA), with 3.6 8.9% of TCPA patients presenting to the ED becoming successful donors. Conclusion: Patients dying in the Emergency Department are a significant source of both successful organ donors and missed potential donors. Emergency physicians should be familiar with their local organ donation protocol to ensure potential organ donors are not missed.

Visceral and Cutaneous Leishmaniasis Recommendations for Solid Organ Transplant Recipients and Donors.

Visceral and Cutaneous Leishmaniasis Recommendations for Solid Organ Transplant Recipients and Donors.

Malaria Disease Recommendations for Solid Organ Transplant Recipients and Donors.

Malaria Disease Recommendations for Solid Organ Transplant Recipients and Donors.

Tuberculosis Recommendations for Solid Organ Transplant Recipients and Donors.

Tuberculosis Recommendations for Solid Organ Transplant Recipients and Donors.

Traveler's Diarrhea Recommendations for Solid Organ Transplant Recipients and Donors.

Diarrhea is the most common illness in people traveling from resource-rich to resource-limited regions of the world.1 Most episodes of traveler’s diarrhea (TD) are benign and self-limited, but may require extra care in immunosuppressed patients.2,3 The major associated problem is dehydration, which can be exacerbated by immunosuppressive agents. TD refers to diarrhea that develops during or within 10 days of returning from travel to resource-limited countries or regions. For epidemiological purposes, it is traditionally categorized into 3 forms: severe, moderate, and mild.4 Severe TD refers to the passage of 6 or more unformed stools in a 24-hour period irrespective of the presence of at least 1 of these other symptoms: nausea, vomiting, abdominal pain or cramps, fever, or blood in stools. Moderate TD is defined as the passage of 1 or 2 unformed stools in 24 hours, plus at least 1 of the above symptoms or 3 to 5 unformed stools in 24 hours without other symptoms. Passage of 1 or 2 unformed stools in 24 hours without other symptoms is considered mild. Recently, a more functional classification has been proposed, taking into account the tolerability of the diarrheal illness and functional impairment of the patient that it causes

Viral Hepatitis Recommendations for Solid-Organ Transplant Recipients and Donors.

Viral Hepatitis Recommendations for Solid-Organ Transplant Recipients and Donors.

Incentivizing Organ Donation Through a Non-Monetary Posthumous Award

Since 2013, The Order of St John Award for Organ Donation is offered to the families of deceased solid organ donors in the United Kingdom to honor the donors and inspire others to donate. We evaluate the effects of this award using a difference-in-differences approach that builds on the fact that solid organ donors are eligible for the award, while cornea-only donors are not. We find that the introduction of the award led to an increase in the number of deceased solid organ donors, as well as in the general willingness to register as solid organ donors when alive.

Authorization of tissues from deceased patients for genetic research.

Tissues from deceased donors provide important data for genomic research and Organ Procurement Organizations (OPOs) play a significant role. To understand the decisions of families who donated for transplantation and made decisions about donation to the Genotype-Tissue Expression Project (GTEx), we examined donation decisions of family decision makers (FDMs). 413 families were interviewed by telephone. The OPO staff who made the transplant and research requests completed self-administered surveys; a total of 309 matching surveys from 99 OPO staff were obtained. 76.8% of families donated to the GTEx project. Logistic regression analysis found that FDM consent to GTEx donation was associated with endorsement of policies to promote biobanking (OR=1.35), positive attitudes about medical research (OR=1.1), lack of concern regarding a breach of confidentiality (OR=1.54), comfort with tissue donation (OR=1.24), and prior authorization to solid organ donation (OR=3.17). OPO staff characteristics associated with GTEx donation included being female (OR=3.57), White (OR=4.97), comfort with hospital staff role in donation (OR=1.61), and number of topics discussed with families (OR=57.9). Donor type, FDM attitudes, OPO staff sociodemographics, OPO comfort with the GTEx authorization process, and intensity of discussing research-specific issues were significantly associated with GTEx donation decisions.

Multiple Solid Organ Donations from Live Donors in the United States: What Do We Know?

Holscher, Courtenay MD; DiBrito, Sandra MD; Thomas, Alvin G.; Massie, Allan B. PhD; Wang, Jacqueline Garonzik MD, PhD; Lentine, Krista MD, PhD; Segev, Dorry L. MD, FACS; Henderson, Macey L. JD, PhD Author Information

P166 Validation of a next generation sequencing based HLA typing system

Aim Very high resolution typing of HLA genes by Next Generation Sequencing (NGS) methods is becoming mainstream in histocompatibility laboratories for the workup of haematopoietic stem cell and solid organ transplant patients and donors. Determining the full sequence for class I and extended exon coverage for class II genes produces HLA types with far fewer ambiguities than traditional Sanger sequencing based typing (SBT) and other lower resolution typing methods. In addition NGS brings benefits of higher throughput and lower cost. Methods We have validated the Illumina TruSight HLAv2 typing kit for HLA-A, B, C, DRB1/3/4/5, DQA1, DQB1, DPA1 and DPB1. A total of 151 samples were tested following the method described by the vendor. All method steps were carried out manually. Testing comprised 6 batches of 24 samples and 1 batch of 12 samples, which were made up of 73 local DNA samples typed previously by a combination of SBT, SSP and SSO, 54 DNA samples from the UCLA reference panel and 24 samples from the 17th International HLA Workshop Study blinded proficiency panel. Reference types for all eleven loci were not available for all local samples, four digit types were available for all eleven loci for the UCLA samples. Sequence analysis and genotype calling was performed using Illumina Assign for Trusight HLA v2.1 and GenDX NGSEngine. HLA type concordance rate, ambiguity rate and accuracy were examined. Results Total percent concordance between the reference type (n = 130) and genotype determined by Assign was as follows: A: 100; B: 99.2; C: 99.2; DRB1: 97.6.5; DRB345: 98.4; DQA1: 99.2; DQB1: 100; DPA1: 100; and DPB1: 97.6. No allele (1st, 2nd and 3rd field) or genotype ambiguity was found for HLA-A, B, C, DRB345 DQB1 or DPA1. An ambiguous type was determined in 4 cases for DRB1, 3 cases for DQA1 and 29 cases for DPB1. In the case of DRB1 and DPB1 this was due to lack of part of the gene sequence and for DQA1 it was due to poor read depth in those samples. Average read depth across all loci was 223. Repeat rates varied between 1.3% (A & B) and 10.9% (DPA1). Conclusions The Illumina TruSight HLAv2 typing kit provides a suitable first pass high resolution typing system for stem cell and solid organ transplant patients and donors. Accuracy is excellent and the ambiguity levels are very low. We intend to introduce this method for routine HLA typing.

P200 High-resolution HLA typing of deceased donors enables accurate identification of allle_specific DSA

HLA typing of donors for solid organ transplantation is performed with the primary goal of avoiding hyperacute antibody-mediated rejection (AMR) caused by recipient antibodies against donor antigens. Given the need for rapid testing of deceased donors, SSP or SSO methods are used to enable timely HLA typing at the serologic split antigen level. However, these methods do not provide unambiguous allele-level genotyping. This ambiguity can be problematic in patients with allele-specific anti-HLA antibodies. We report a case of suspected AMR following deceased donor kidney transplantation as an example of high-resolution HLA genotyping enabling identification of donor-specific antibodies (DSA). The patient was transplanted in 2010 with a flow cytometric crossmatch negative deceased donor kidney. History was remarkable for biopsy-proven C4d positive acute AMR in 2012 successfully treated by IVIG and rituximab. In late 2016, the patient developed increased proteinuria. Biopsy demonstrated changes consistent with both active and chronic AMR, but without presence of C4d. Solid-phase anti-HLA antibody testing did not demonstrate identifiable DSA, though there was evidence of allele-specific antibodies (Table 1). To investigate whether these represented DSA, donor DNA was re-typed for HLA-A, -B, -C, -DRB1, -DRB3/4/5, -DQA1, -DQB1, -DPA1,and -DPB1 by next-generation DNA sequencing (NGS). High-resolution HLA typing identified DSA against DQA1∗05:05 and DRB3∗03:01. Reactivity against DR52 or DQA05 would not have been called based upon average group reactivity. Identification of DSA supported diagnosis of AMR and enabled tracking of DSA as an objective measure of the efficacy of therapy. The increasing frequency of allele-specific DSA has led us to implement routine re-testing of solid organ donors for high-resolution HLA typing to promote accurate and efficient evaluation of potential allele-specific DSA. Download : Download high-res image (123KB) Download : Download full-size image

P004 Retrospective analysis of deceased donor samples for ZIKA virus infection in high-risk population, a three-year study

Aim The recent epidemic of Zika Virus in the United States has necessitated screening for the presence of this agent in high-risk transplant solid organ donors to avoid the transmission to potential recipients. In this study, we performed a retrospective analysis of Cadaver Donors from Auxilio Mutuo Hospital (HAM) in Puerto Rico. Methods One hundred fifty-six (156) serum samples from Deceased Donors were obtained from Puerto Rico. Aliquots of serum, were maintained at −20 °C since collection. There were 38 samples from 2014, 62 from 2015, and 56 from 2016. These samples were tested with the RealStar® Zika Virus RT-PCR Kit U.S.® kit (Altona Diagnostics), and Anti-Zika Virus ELISA IgG and IgM kits (EUROIMMUN). These assays were validated with a separate group of freshly obtained Zika-positive samples from an ambulatory clinic at HAM. Results Of the 156 total deceased donor specimens retrospectively tested, none were positive for PCR, 2 were positive for IgM, and 22 were positive or borderline for IgG. The breakdown over the 3-year period indicated an increase in long-term exposure, as indicated by the increase in IgG positive samples. In 2014, only 5.2% were positive. However, by 2015 19.4% of the samples were positive. This indicates that almost 20% of the Deceased Donors tested had some contact with the Zika Virus (or a related Flavivirus , such as Dengue or West Nile). Of the positive IgG samples, only 2 were positive for IgM, indicating the exposure was likely more than 3 months prior. The results of the PCR study were not surprising, as we have seen in our laboratory, the long-term storage of serum for later RNA-based PCR testing has been unsuccessful. Conclusions Zika testing utilizing PCR-based assays in conjunction with serological assays in areas of known infection is essential, especially when servicing solid organ transplant programs. The use of donors potentially infected with Zika virus could have a significant impact in transplant success as there are some indications that immunocompromised individuals may develop more severe symptoms or illnesses. The correct storage of serum samples is crucial to obtain reliable results of this test.

Multicenter Prospective Study for Laboratory Diagnosis of HHV8 Infection in Solid Organ Donors and Transplant Recipients and Evaluation of the Clinical Impact After Transplantation.

We performed serological and molecular pretransplant screening in solid organ transplant (SOT) donors and recipients in north central Italy and a surveillance program for human herpesvirus 8 (HHV8) infection after transplant, aiming to establish an optimal management of HHV8 infection in SOT recipients. For pretransplant HHV8 screening in both donors and recipients, 6 serological (4 indirect immunofluorescent assays [IFA] and 2 enzyme-linked immunosorbent assays-both HHV8 lytic and latent antigen based) and 2 molecular assays were used. A reference standard to identify HHV8-positive patients was defined by at least 2 positive assays. All transplant patients at risk to develop HHV8-related disease underwent virological posttransplant monitoring by quantitative real-time polymerase chain reaction (PCR) assay. Human herpesvirus 8 seroprevalence was 4% (10/249) in donors and 18% (93/517) in organ recipients. The best performance was obtained by 2 lytic antigen-based IFAs that showed almost perfect agreement to the reference standard (0.943 and 0.931 Cohen kappa). Human herpesvirus 8-DNA was detected in 6.8% and 2.9% of HHV8-seropositive donor samples by in-house nested PCR and quantitative real-time PCR assays, respectively. After transplant, 3 (25%) of 12 HHV8-mismatch patients (seropositive donor/seronegative recipient) developed a primary infection, one of whom developed a lethal nonmalignant illness. Two of 93 HHV8-seropositive recipients (2.1%) had viral replication in posttransplant period, one of whom developed Kaposi sarcoma. Serological assays, specifically lytic IFAs, were the best methodological approach to identify HHV8-infected SOT donors and recipients. A very low incidence (1.9%) of posttransplant HHV8-related disease was observed.