HIV Transmitted from a Living Organ Donor --- New York City, 2009

HIV Transmitted from a Living Organ Donor --- New York City, 2009
Weekly
March 18, 2011 / 60(10);297-301

Routine screening of organ donors for human immunodeficiency virus (HIV) infection has made transmission of HIV through organ transplantation rare in the United States. However, despite routine screening, transmission of HIV can be an uncommon complication of organ transplantation and is a public health concern. In 2010, the New York City (NYC) Department of Health and Mental Hygiene (NYC DOHMH) was notified of a potential transplant-related HIV infection. This report summarizes the results of the subsequent public health investigation, which confirmed HIV transmission through transplantation of an organ from a living donor. To reduce the risk for transmission of HIV through living-donor organ transplantation, transplant centers should screen living donors for HIV as close to the time of organ recovery and transplantation as possible, using sensitive tests for both chronic and acute infections, namely, serology and nucleic acid testing (NAT). Furthermore, clinicians should inform transplant candidates of the potential risks for disease transmission and advise donors during evaluation of their obligation to avoid behaviors that would put them at risk for acquiring HIV before organ donation.

Recipient Illness

An adult with hemodialysis-dependent renal failure received a kidney transplant from a living donor at hospital A in NYC in 2009. The recipient did not have any history of sexually transmitted infections (STIs), injection drug use, sex with injection drug users, or other high-risk sexual activity. The recipient received blood transfusions in 2006, but none previously. The recipient tested negative for HIV infection by enzyme immunoassay (EIA) 12 days before the transplant (Figure). The posttransplant clinical course was complicated by multiple hospitalizations for febrile illness, episodes of renal insufficiency, and evaluation for possible rejection of the transplanted kidney. During the year after kidney transplantation, the recipient did not engage in any behaviors that would increase the risk for acquiring HIV. One year after transplant, the recipient was hospitalized with refractory oral and esophageal candidiasis; screening for HIV infection by EIA was positive, and HIV infection was confirmed with a positive Western blot. The recipient's initial CD4 cell count was <100 cells/µL. The advanced immunosuppression was attributed, in part, to the recipient's induction with antithymocyte globulins (an immunomodulator that depletes T-lymphocytes to prevent graft-versus-host disease) and use of mycophenolic acid (a drug that suppresses lymphocyte proliferation, prescribed to prevent rejection of a transplanted kidney). Donor Illness The donor was an adult male who underwent evaluation as a potential living donor for kidney transplantation at hospital A in 2009. Consistent with the hospital's protocol, a multidisciplinary team (consisting of a living donor coordinator, nephrologist, transplant surgeon, psychiatrist, social worker, and nutritionist) determined the donor's eligibility by assessing his immunologic compatibility with the recipient, his general health, his psychosocial status, and his willingness to donate. His evaluation revealed a previous diagnosis of syphilis and a history of sex with male partners. Laboratory testing conducted during the initial evaluation 79 days before transplant showed no evidence of infection with HIV by EIA, hepatitis B virus (HBV) by HBV surface antigen testing, or hepatitis C virus (HCV) by anti-HCV serology; a rapid plasma reagin test for syphilis was reactive undiluted (1:1) with a fluorescent treponemal antibody absorption test, also positive, consistent with previously treated syphilis. The donor's kidney was removed without complication; no blood products were administered around the time of transplant. Routine medical evaluation by the transplant team 6 months after the transplant was unremarkable. Approximately 1 year after the transplant, the donor visited his primary-care physician requesting repeat screening for STIs. Serologic testing for HIV antibody by EIA with confirmatory Western blot was positive. The transplant team learned of the living donor's new HIV diagnosis during his follow-up visit 1 year after the transplant. The diagnosis of HIV in both the donor and recipient raised the possibility of transplant-transmitted HIV infection. NYC DOHMH was notified of the possible transmission, and a public health investigation was initiated. Public Health Investigation The donor and recipient each were interviewed in person using a standardized case interview form. Medical records were reviewed, focusing on relevant medical history before and after kidney transplantation, history of HIV testing and evidence of infection, pretransplant evaluation, posttransplant course, blood product transfusion history, other past medical history, history of substance use, sexual history, and other risk factors for HIV infection. The recipient's transplant coordinator, nephrologist, and HIV physician were interviewed separately to review the transplant evaluation and medical course. The donor's primary-care physician and transplant nephrologist also were interviewed. During the public health investigation, the donor reported unprotected sex with one male partner during the 1 year before the transplant, including the time between his initial evaluation and organ recovery. He did not know his partner's HIV status. He did not report any history of injection drug use, tattoos, or blood transfusions. Two samples of frozen leukocyte specimens collected from the organ donor 57 and 11 days pretransplant and two frozen serum specimens collected from the recipient 11 days pretransplant and 12 days posttransplant were sent to CDC for HIV testing. HIV NAT on the donor leukocytes collected 57 days pretransplant was negative; however, DNA sequences for three HIV genes (envelope gp41, polymerase, and group-specific antigen p17) were amplified from donor leukocytes collected 11 days pretransplant and sequenced at CDC. Recipient serum collected 11 days pretransplant was nonreactive for HIV-1 RNA by Aptima (Gen-Probe). Recipient serum collected 12 days post transplant was reactive for HIV RNA by Aptima. On posttransplant day 404, whole blood specimens were obtained from the donor and recipient for phylogenetic analysis at CDC (Figure). The donor had initiated antiretroviral therapy 2 weeks before the specimen was obtained, whereas the recipient had not yet initiated antiretroviral therapy. HIV DNA sequences from donor and recipient peripheral blood lymphocytes collected on day 404 were amplified and sequenced. Sequences from these two specimens were analyzed phylogenetically together with HIV sequences obtained from the donor's frozen leukocyte specimen collected 11 days pretransplant. The gp41, polymerase, and p17 sequences from the donor and recipient were nearly identical, with greater than 98% identity and tight phylogenetic clustering, suggesting that the two viruses are highly related. Reported by
MA Bernard, MD, J Eavey, MSPH, HW Gortakowski, MPH, C Sabharwal, MD, C Shepard, MD, L Torian, PhD, New York City Dept of Health and Mental Hygiene; L McMurdo, LC Smith, MD, K Valente, New York State Dept of Health. JT Brooks, MD, WM Heneine, PhD, MP Joyce, MD, SM Owen, PhD, A Shankar, MS, W Switzer, MPH, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; E Farnon, MD, M Kuehnert, MD, D Seem, Div of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infections; T Al-Samarrai, MD, P Gounder, MD, CK Kwan, MD, EIS officers, CDC.


full-text:
HIV Transmitted from a Living Organ Donor --- New York City, 2009