Page 1592 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 116: Care of the Multiorgan Donor 1111

positive for antibody to HCV did not appear to cause increased 1- Fortunately, the use of trimethoprim-sulfamethoxazole as prophylaxis for
or 5-year mortality. But a more recent report with a large cohort Pneumocystis carinii infection prevents transmission of T gondii. 39
34
(>36,000 cases) has shown that kidney transplantation from HCV- Regional directives will need to be implemented as necessary with
donors does increase posttransplant mortality even in the subgroup of regard to novel infectious agents carrying alarming epidemic/pandemic
HCV-seropositive recipients. Transplantation of an HCV-positive lung life-threatening potential. Regions of North America have been faced
35
40
or heart-lung allograft when a HCV-negative recipient’s life is in danger with a relatively new entity, West Nile virus and more recently, H1N1
40
may be the only alternative to immediate death because an HCV anti- influenza virus infection. Organ donors should be tested for evidence
41
body–positive donor is an independent poor prognostic indicator for of West Nile virus viremia by polymerase chain reaction (PCR), nucleic
1- and 5-year survivals. 34,36 Table 116-1 shows the relative risk of viral acid amplification, or early antibody response (IgM) to West Nile virus.
42
transmission for hepatitis B and C viruses. Influenza virus can be reliably detected by PCR. The donor’s clinical
Transplantation of an organ from a CMV-positive donor can result in history relative to the last 10 days prior to donor assessment with regard
subsequent reactivation of latent virus and replication in the immuno- to signs or symptoms associated with such viral infections, and epi-
suppressed host. The specific CMV serological status of the donor and demiologic links related to direct contact with patients with SARS or
37
recipient has implications for prophylaxis, the highest-risk group being influenza virus should be carefully assessed for further investigations. 41
CMV-seronegative recipients of CMV-seropositive donor organs (ie, the ■
so-called primary mismatch group). DONOR-RELATED MALIGNANCIES
Nevertheless, transplantation of organs from CMV-seropositive Transmission of donor malignancies is a rare event although published
donors has not been considered an absolute contraindication for data were largely based on voluntary reporting. There is no consensus
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transplantation, because the high sero-prevalence of the virus among protocol worldwide; however, great efforts have been made to prevent
the general population makes it impractical to rule out such donors. potential cancer transmission from donors while optimizing the use of
Regardless of donor CMV status, seronegative recipients should receive extended or aged donors. Donors with past histories of certain types of
44
prophylaxis longer than CMV-seropositive recipients to prevent CMV cancers may be considered as donors, including certain types of primary
disease after transplant. 32 central nervous system (CNS) tumors. Risks of cancer transmission
Serological screening of organ donors for EBV is commonly performed from donors with a history of nonmelanoma skin cancer and selected
because primary EBV infection (ie, transplantation of an organ from an cancers of the CNS appear to be small. When considering organ
43
EBV-seropositive donor to an EBV-seronegative recipient) is associated use from donors suffering from intracranial malignancies, there are a
with an increased risk of posttransplant lymphoproliferative disease number of general guidelines. Most important is to consider the known
(PTLD). Therefore, recognition of this mismatch in a potential allograft biologic behavior of various CNS neoplasms and their propensity to
38
recipient known to be EBV-negative is important prognostic information. spread outside of the cranial vault. Repeated craniotomies as well as
The detection of antibody to treponemal antigen is not a contraindica- ventriculoperitoneal or ventriculojugular shunts have been associated
tion to organ procurement, but it is a contraindication to tissue procure- with increased risk of metastasis. 45,46
ment. A standard course of penicillin therapy would provide sufficient Risks of tumor transmission with certain other types of cancer may
antibiotic coverage to prevent syphilitic complications in an allograft be acceptable, particularly if the donor has a long cancer-free interval
recipient. The possible transmission of the protozoan Toxoplasma prior to organ procurement, while certain other cancers pose a high
32
gondii is a concern, especially for heart allograft recipients, because of transmission risk. Tumors that pose a high transmission risk include
the predilection of this parasite for muscle tissue. Organ procurement choriocarcinoma, melanoma, lymphoma, and carcinoma of the lung,
from seropositive donors is not contraindicated; however, the detection colon, breast, kidney, and thyroid. A list has been developed outlining
of seropositivity means that the recipient may be placed at high risk. the relative risks of CNS tumor transmission from deceased donor to
allograft recipient (Table 116-2).
TABLE 116-1 Risk of Hepatitis Viral Transmission ■
−
+
Donor serology HBsAb recipient HBsAb recipient CARDIAC EVALUATION
An initial electrocardiogram (ECG) should be obtained on every
HBsAg + Liver: insufficient data Liver: high
potential cardiac donor, and additional ECGs should be obtained when
Nonliver: insufficient data Nonliver: high changes in heart rhythm occur. ECG changes may be temporary and
HBcAb + Liver: low to moderate a Liver: moderate to high related to alterations in sympathetic output. Nonspecific ST-segment
and T-wave changes, prolonged QT intervals, and T-wave inversion
Nonliver: very low Nonliver: low are common. Tachycardia is common and may be caused by diabetes
HCVAb + HCVAb recipient HCVAb recipient insipidus, diuresis, hemorrhage, vasopressor therapy, or electrolyte
+
−
Liver: high b Liver: high disturbances. ECGs are evaluated for signs of acute myocardial injury.
Nonliver: insufficient data c Nonliver: high Troponin I or T can be measured every 12 hours whenever necessary. 47
A transthoracic or transesophageal echocardiogram is obtained to
a Data indicate that the risk of viral transmission may be lower for recipients who are immune from previous HBV evaluate motion of the heart wall and valve function, estimate ejection
+
−
infection (HBsAb /HBcAb ) compared to recipients who are immune from vaccination (HBsAb /HBcAb ).
+
+
fraction, and to detect a pericardial effusion. Transient changes that do
b Although there is evidence that the donor virus is transmitted to the recipient, repopulation after liver not preclude heart donation include a stunned myocardium or myocar-
transplantation occurs with approximately even frequency by donor or recipient strain. Available data indicate dial depression related to acidosis and hypoxemia. If the causes of the
no increase in short (1-year) and medium (5-year) term mortality and morbidity (incidence, timing, or severity changes are reversible, the heart may still be successfully transplanted;
of liver disease) is associated with transplantation of a liver from a HCVAb donor versus a liver from an therefore repeat echocardiogram should be considered after fluid and
+
HCVAb donor into a hepatitis C recipient.
−
+
hemodynamic resuscitation. A pulmonary artery catheter to guide the
c There are insufficient data regarding persistence of donor versus recipient virus strains after transplantation physiologic assessment and management of fluid status and ventricular
to determine the true incidence of viral transmission. Available data indicate that transplantation of a function has been used with success.
kidney from an HCVAb donor has no adverse impact on graft and patient survival (5 years) or the recipient’s Assessment and management of donor left ventricular dysfunc-
+
HCV disease compared to a kidney from an HCVAb donor. tion offers the greatest potential to increase heart donor utilization.
−
HBcAb, hepatitis B core antibody; HBsAb, hepatitis B surface antibody; HBsAg, hepatitis B surface Evidence indicates that younger hearts with left ventricular dysfunction
antigen; HCV, hepatitis C virus; HCVAb, hepatitis C virus antibody. can recover normal function over time in the donor and after trans-
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Reproduced with permission from Rosengard BR, Feng S, Alfrey EJ, et al. Report of the Crystal City meeting to plantation into a recipient. Metabolic abnormalities, anemia, and
maximize the use of organs recovered from the cadaver donor. Am J Transplant. September 2002;2(8):701-711. excessive doses of inotropes should be corrected prior to obtaining an
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