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Screening of Donor and Recipient Prior to Solid Organ Transplantation

2009; Elsevier BV; Volume: 9; Linguagem: Inglês

10.1111/j.1600-6143.2009.02888.x

1600-6143

Staci A. Fischer, Robin K. Avery,

Polyomavirus and related diseases

Pretransplant screening of potential organ donors and recipients is essential to the success of solid organ transplantation (1Avery RK Recipient screening prior to solid-organ transplantation.Clin Infect Dis. 2002; 35: 1513-1519Crossref PubMed Scopus (45) Google Scholar, 2Avery RK Prophylactic strategies before solid-organ transplantation.Curr Opin Infect Dis. 2004; 17: 353-356Crossref PubMed Scopus (26) Google Scholar, 3Delmonico FL Cadaver donor screening for infectious agents in solid organ transplantation.Clin Infect Dis. 2000; 31: 781-786Crossref PubMed Scopus (67) Google Scholar, 4Delmonico FL Snydman DR Organ donor screening for infectious diseases: Review of practice and implications for transplantation.Transplantation. 1998; 65: 603-610Crossref PubMed Scopus (73) Google Scholar). The goals of pretransplant infectious disease screening are: (1) to identify conditions which may disqualify either donor or recipient, (2) to identify and treat active infection pretransplant, (3) to define the risk of infection and determine strategies for preventing and mitigating posttransplant infection and (4) to implement preventative interventions, such as updating of vaccination status. Although there is general agreement on the major infections for which screening is performed, there is some variation between centers in the types of screening used and actions taken as a result. In the course of pretransplant evaluation, recipients should be evaluated for infection risk by obtaining a thorough infection and travel history, as well as history of animal and environmental exposures. The pretransplant period is an ideal time for detailed counseling of the recipient and his/her family about safe food handling and the risk of infection associated with pets, travel, and hobbies such as gardening and woodworking. Infection prevention approaches including hand hygiene, prophylactic antimicrobials, postexposure prophylaxis, and updating of immunizations should be addressed as well. A variety of pathogens may be transmitted by transplantation (5Gottesdiener KM Transplanted infections: Donor-to-host transmission with the allograft.Ann Intern Med. 1989; 110: 1001-1016Crossref PubMed Scopus (162) Google Scholar) (Table 1). Guidelines for pretransplant screening have been the subject of several publications including a consensus conference of the Immunocompromised Host Society (ICHS) (6Avery RK Ljungman P Prophylactic measures in the solid-organ recipient before transplantation.Clin Infect Dis. 2001; 33: S15-21Crossref PubMed Scopus (69) Google Scholar, 7Schaffner A Pretransplant evaluation for infections in donors and recipients of solid organs.Clin Infect Dis. 2001; 33: S9-14Crossref PubMed Scopus (54) Google Scholar), the American Society for Transplantation (AST) Clinical Practice Guidelines on the evaluation of renal transplant candidates (8Kasiske BL Cangro CB Hariharan S et al.The evaluation of renal transplantation candidates: Clinical practice guidelines.Am J Transplant. 2001; 1: 3-95PubMed Google Scholar), and the ASTP Clinical Practice Guidelines on the evaluation of living renal transplant donors (9Kasiske BL Ravenscraft M Ramos EL Gaston RS Bia MJ Danovitch GM The evaluation of living renal transplant donors: Clinical practice guidelines. Ad Hoc Clinical Practice Guidelines Subcommittee of the Patient Care and Education Committee of the American Society of Transplant Physicians.J Am Soc Nephrol. 1996; 7: 2288-2313Crossref PubMed Google Scholar). Recommendations regarding hepatitis status of the donor have been summarized in the March 2001 Crystal City Meeting (10Rosengard BR Feng S Alfrey EJ et al.Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor.Am J Transplant. 2002; 2: 701-711Crossref PubMed Scopus (275) Google Scholar) and in a review by Chung, Feng and Delmonico (11Chung RT Feng S Delmonico FL Approach to the management of allograft recipients following the detection of hepatitis B virus in the prospective organ donor.Am J Transplant. 2001; 1: 185-191Crossref PubMed Scopus (69) Google Scholar). In addition, the Centers for Disease Control and Prevention (CDC), the Infectious Diseases Society of America (IDSA) and the American Society for Blood and Marrow Transplantation (ASBMT) have published guidelines in 2000 for prevention of infection in hematopoietic stem cell transplant recipients (12Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients.MMWR Recomm Rep. 2000; 49 (CE121–127): 1-125Google Scholar), and the CDC has published guidelines for the prevention of HIV transmission through transplantation (13Guidelines for preventing transmission of human immunodeficiency virus through transplantation of human tissue and organs. Centers for Disease Control and Prevention.MMWR Recomm Rep. 1994; 43: 1-17Google Scholar).Table 1Pathogens transmitted with solid organ transplantationBacteriaMycobacteriaStaphylococcus aureusMycobacterium tuberculosisKlebsiella speciesNontuberculous mycobacteriaBacteroides fragilisPseudomonas aeruginosaParasites/ProtozoaEscherichia coliToxoplasma gondiiSalmonella speciesStrongyloides stercoralisYersinia enterocoliticaPlasmodium speciesTreponema pallidumTrypanosoma cruziBrucella speciesBartonella speciesVirusesEnterobacter speciesCytomegalovirusAcinetobacter speciesEpstein-Barr virusHerpes simplex virusFungiVaricella-zoster virusAspergillus speciesHuman herpesvirus-6Candida speciesHuman herpesvirus-7Histoplasma capsulatumHuman herpesvirus-8Cryptococcus neoformansHepatitis B, DCocciodioides immitisHepatitis CScedosporium apiospermumHuman immunodeficiency virusPrototheca speciesParvovirus B19RabiesLymphocytic choriomeningitis virusWest Nile virusBK virus Open table in a new tab While traditional screening strategies are very effective in most cases, they are not a guarantee against donor-derived infections. There have been a number of high-profile donor-derived transmission incidents over the last several years, including rabies (14Srinivasan A Burton EC Kuehnert MJ et al.Transmission of rabies virus from an organ donor to four transplant recipients.N Engl J Med. 2005; 352: 1103-1111Crossref PubMed Scopus (368) Google Scholar), lymphocytic choriomeningitis virus (15Fischer SA Graham MB Kuehnert MJ et al.Transmission of lymphocytic choriomeningitis virus by organ transplantation.N Engl J Med. 2006; 354: 2235-2249Crossref PubMed Scopus (423) Google Scholar), West Nile virus (WNV, 16Iwamoto M Jernigan DB Guasch A et al.Transmission of West Nile virus from an organ donor to four transplant recipients.N Engl J Med. 2003; 348: 2196-2203Crossref PubMed Scopus (574) Google Scholar), HIV (17Simonds RJ Holmberg SD Hurwitz RL et al.Transmission of human immunodeficiency virus type 1 from a seronegative organ and tissue donor.N Engl J Med. 1992; 326: 726-732Crossref PubMed Scopus (575) Google Scholar, 18Halpern SD Shaked A Hasz RD Caplan AL Informing candidates for solid-organ transplantation about donor risk factors.N Engl J Med. 2008; 358: 2832-2837Crossref PubMed Scopus (75) Google Scholar, 19Ahn J Cohen SM Transmission of human immunodeficiency virus and hepatitis C virus through liver transplantation.Liver Transpl. 2008; 14: 1603-1608Crossref PubMed Scopus (61) Google Scholar) and hepatitis C (HCV) (18Halpern SD Shaked A Hasz RD Caplan AL Informing candidates for solid-organ transplantation about donor risk factors.N Engl J Med. 2008; 358: 2832-2837Crossref PubMed Scopus (75) Google Scholar, 19Ahn J Cohen SM Transmission of human immunodeficiency virus and hepatitis C virus through liver transplantation.Liver Transpl. 2008; 14: 1603-1608Crossref PubMed Scopus (61) Google Scholar, 20Tugwell BD Patel PR Williams IT et al.Transmission of hepatitis C virus to several organ and tissue recipients from an antibody-negative donor.Ann Intern Med. 2005; 143: 648-654Crossref PubMed Scopus (122) Google Scholar), which have renewed discussion of the issues surrounding donor screening. The recently formed United Network for Organ Sharing (UNOS) Donor Transmission Advisory Group (DTAG), the Transplantation Transmission Sentinel Network of the CDC (21Fishman JA Strong DM Kuehnert MJ Organ and tissue safety workshop 2007: Advances and challenges.Cell Tissue Bank. 2008; 10: 271-280Crossref PubMed Scopus (36) Google Scholar) and other new initiatives have been formed to address donor-transmitted infection and current screening practices (21Fishman JA Strong DM Kuehnert MJ Organ and tissue safety workshop 2007: Advances and challenges.Cell Tissue Bank. 2008; 10: 271-280Crossref PubMed Scopus (36) Google Scholar, 22Fishman JA Greenwald MA Kuehnert MJ Enhancing transplant safety: A new era in the microbiologic evaluation of organ donors?.Am J Transplant. 2007; 7: 2652-2654Crossref PubMed Scopus (29) Google Scholar, 23Humar A Fishman JA Donor-derived infection: Old problem, new solutions?.Am J Transplant. 2008; 8: 1087-1088Crossref PubMed Scopus (16) Google Scholar). After a discussion of the differences in screening between living and deceased donors, this review will summarize current opinion on screening for bacterial, mycobacterial, fungal, parasitic and viral infections in the donor and recipient (Table 2). More detailed discussions of these infections, posttransplant monitoring, prophylaxis, and treatment are found in other sections of these guidelines. Because issues concerning the viral serologies of donor and recipient are intertwined, these will be discussed together.Table 2Frequently utilized serologic tests for screening of donor and recipient prior to transplantationTests Commonly Obtained in Both Donor and RecipientHuman immunodeficiency virus (HIV) antibodyHuman T-cell lymphotropic virus (HTLV)-I/II antibodyHSV (herpes simplex) IgG antibody (at some centers)Cytomegalovirus (CMV) IgG antibodyHepatitis C (HCV) antibodyHepatitis B (HBV) surface antigen (HBsAg)Hepatitis B core antibody (HBcAb IgM and IgG, or total core)Hepatitis B surface antibody (HBsAb) at some centersRapid plasma reagin (RPR)Toxoplasma antibody (especially in heart recipients)Epstein-Barr virus (EBV) antibody (EBV VCA IgG, IgM)Varicella-zoster virus (VZV) antibodyOther Screening Measures for Infectious DiseasesPPD or interferon gamma release assay (IGRA) for latent TB infection in recipients and living donorsStrongyloides serology (for recipients from endemic areas)Coccidioides serology (for recipients from endemic areas)Trypanosoma cruzi serology (for donors and recipients from endemic areas)Serologies for tetanus, diphtheria, measles, mumps and pneumococcal titers as an aid to pretransplant immunization (at some centers)Optional Screening MeasuresWest Nile virus serology or NAATHHV-8 serology (KSHV)Nucleic acid amplification testing (NAAT) for HIV, HCV, HBV, particularly in donors with high-risk social histories Open table in a new tab Given the limited pool of donors, it has become necessary to consider marginal candidates, including those with infection at the time of donation, higher-risk serologic profiles, or a social history indicating potential exposures to blood-borne pathogens such as HIV or HCV. The nature of any potential donor infection, the severity of end-stage organ disease in the recipient, and the likelihood of another organ offer for the patient on the transplant waiting list are important considerations when determining the acceptability of the potentially infected donor. The differences in screening of the living donor and the deceased donor are largely based on the different time frames during which the evaluation must take place. For the living donor, it is often possible to treat active infection and delay transplantation until the infection resolves. If there is a significant delay between donor evaluation and transplantation, interim evaluation may be indicated to rule out recently acquired infection. Clinical reassessment of the prospective living donor is indicated if clinical signs or symptoms of possible infection occur, particularly any unexplained febrile illness between the time of initial screening and the planned date of transplantation. Repeat serologic testing and nucleic acid amplification testing (NAAT) for HIV, hepatitis B virus (HBV) and/or hepatitis C virus (HCV) may be indicated, since antibody seroconversion may not yet have occurred with recent exposures. The screening of a prospective living donor takes place in the transplant center and includes a thorough medical and social history, physical examination, laboratory studies including serologic testing (Table 2) and radiographic studies as indicated by history or the procedure to be performed. The medical history should include an assessment of previous infections, vaccinations, travel and occupational exposures, as well as the presence of risky behaviors (e.g. drug use, sexual practices and incarceration). Living donors should be screened for syphilis, HIV, hepatitis B and C and tuberculosis via a tuberculin PPD skin test or interferon-gamma release assay (IGRA) (II-2). If there is a suspicious donor history, additional testing may be warranted. By contrast, the time frame for deceased donor evaluation is typically hours. Serologies are performed in laboratories associated with organ procurement organizations (OPOs) or other reference laboratories, which operate on a 24-hour basis to generate the data needed to determine donor suitability. Because of time constraints and the extensive geographic areas covered by some OPOs, testing is often limited to serologic methods that are rapid and routinely available. Because more sensitive testing may not be available, some infections, such as HIV and HCV, may be difficult to diagnose at an early stage, before the development of specific antibody (17Simonds RJ Holmberg SD Hurwitz RL et al.Transmission of human immunodeficiency virus type 1 from a seronegative organ and tissue donor.N Engl J Med. 1992; 326: 726-732Crossref PubMed Scopus (575) Google Scholar, 20Tugwell BD Patel PR Williams IT et al.Transmission of hepatitis C virus to several organ and tissue recipients from an antibody-negative donor.Ann Intern Med. 2005; 143: 648-654Crossref PubMed Scopus (122) Google Scholar). Thus, a detailed social and medical history on the donor is required to identify potential infections that might not be detected by serologic testing. Furthermore, certain infections may come to light only after the transplant has been performed, when results of routine procurement cultures of blood, urine, and sputum become available. Increasingly, some OPO's are utilizing rapid molecular testing, particularly in high-risk potential donors, for rapid detection of viral genetic material (NAAT), particularly for viral infections such as HCV, HBV and HIV. Testing for certain pathogens with particular geographic significance such as Trypanosoma cruzi (Chagas disease) and WNV may be performed by some OPOs. If a deceased donor with uncertain infection risk is to be used, informed consent of the recipient should include the risk for infection transmission. The evaluation detailed above will reveal most active bacterial infections present in the living donor. Infections of the respiratory tract, urinary tract or other focal sites should be thoroughly treated with documentation of resolution of infection prior to donation. The potential kidney donor with urinary tract infection should be investigated to rule out upper tract involvement. In the potential donor with a history or suspicion of prior bloodstream infection, a thorough investigation should be performed to insure that the target organ has not been seeded. Syphilis may be latent and asymptomatic and requires therapy if time permits. Syphilis has rarely been transmitted by transplantation, but it is not a contraindication to organ donation if the recipient is treated posttransplant with an appropriate course of benzathine penicillin (24Caballero F Domingo P Rabella N Lopez-Navidad A Successful transplantation of organs retrieved from a donor with syphilis.Transplantation. 1998; 65: 598-599Crossref PubMed Scopus (26) Google Scholar) (II-3). Standard regimens for late latent syphilis would be appropriate in this situation (e.g. three weekly doses of 2.4 million units of intramuscular benzathine penicillin). Deceased donors may harbor known or unsuspected bacterial infections (5Gottesdiener KM Transplanted infections: Donor-to-host transmission with the allograft.Ann Intern Med. 1989; 110: 1001-1016Crossref PubMed Scopus (162) Google Scholar, 25Doig RL Boyd PJ Eykyn S Staphylococcus aureus transmitted in transplanted kidneys.Lancet. 1975; 2: 243-245Abstract PubMed Scopus (59) Google Scholar, 26Kumar D Cattral MS Robicsek A Gaudreau C Humar A Outbreak of pseudomonas aeruginosa by multiple organ transplantation from a common donor.Transplantation. 2003; 75: 1053-1055Crossref PubMed Scopus (24) Google Scholar). They should be evaluated for these by review of medical records, detailed history from the donor family, temperature chart, radiography, and cultures when available. Blood cultures should be obtained to rule out occult donor bacteremia. Bacteremia with virulent organisms such as Staphylococcus aureus and Pseudomonas aeruginosa may result in early posttransplant sepsis or mycotic aneurysm formation at the site of vascular anastomoses in the recipient (27Fernando ON Higgins AF Moorhead JF Letter: Secondary haemorrhage after renal transplantation.Lancet. 1976; 2: 368Abstract PubMed Scopus (12) Google Scholar, 28Nelson PW Delmonico FL Tolkoff-Rubin NE et al.Unsuspected donor pseudomonas infection causing arterial disruption after renal transplantation.Transplantation. 1984; 37: 313-314Crossref PubMed Scopus (58) Google Scholar). Although a review of 95 bacteremic donors found no evidence of transmission when recipients were given antimicrobial therapy for a mean of 3.8 days posttransplant (29Freeman RB Giatras I Falagas ME et al.Outcome of transplantation of organs procured from bacteremic donors.Transplantation. 1999; 68: 1107-1111Crossref PubMed Scopus (154) Google Scholar), it is prudent to employ longer courses of therapy in the recipient (e.g. 2–4 weeks) if the donor is known to have been bacteremic with a virulent organism (II-2). In general, there is no reason to treat the recipient of an allograft from a deceased donor with nonbacteremic, localized infection not involving the transplanted organ, with the exception of meningitis, in which occult bacteremia frequently occurs (III). Organs have been successfully transplanted from donors with bacterial meningitis when appropriate antimicrobial therapy was administered to both the donor and recipients (30Lopez-Navidad A Domingo P Caballero F Gonzalez C Santiago C Successful transplantation of organs retrieved from donors with bacterial meningitis.Transplantation. 1997; 64: 365-368Crossref PubMed Scopus (72) Google Scholar). Lung transplantation deserves special attention (31Ruiz I Gavalda J Monforte V et al.Donor-to-host transmission of bacterial and fungal infections in lung transplantation.Am J Transplant. 2006; 6: 178-182Crossref PubMed Scopus (101) Google Scholar). Donor bacterial colonization is common, as the lungs are in contact with the external environment, and the mouth and upper airways are a site for colonization with multiple organisms. Donor bronchoscopy with cultures performed at the time of evaluation and/or procurement allows for the administration of antibiotics directed at these colonizing organisms, and can prevent invasive infection in the recipient (III) (31Ruiz I Gavalda J Monforte V et al.Donor-to-host transmission of bacterial and fungal infections in lung transplantation.Am J Transplant. 2006; 6: 178-182Crossref PubMed Scopus (101) Google Scholar). Allograft contamination may occur during procurement or processing (32McCoy GC Loening S Braun WE Magnusson MO Banowsky LH McHenry MC The fate of cadaver renal allografts contaminated before transplantation.Transplantation. 1975; 20: 467-472Crossref PubMed Scopus (41) Google Scholar). Rubin recommends treatment of the recipient if organisms are isolated in perfusates or organ transplant medium, citing the risk of mycotic aneurysm formation (28Nelson PW Delmonico FL Tolkoff-Rubin NE et al.Unsuspected donor pseudomonas infection causing arterial disruption after renal transplantation.Transplantation. 1984; 37: 313-314Crossref PubMed Scopus (58) Google Scholar), although culture contamination must be considered as well (33Mossad SB Avery RK Goormastic M Hobbs RE Stewart RW Significance of positive cultures from donor left atrium and postpreservation fluid in heart transplantation.Transplantation. 1997; 64: 1209-1210Crossref PubMed Google Scholar). Antibiotics should be administered for at least 14 days for Gram-negative bacilli, S. aureus or Candida species (II-3). A shorter course of therapy may be considered for less virulent organisms (III). A more recent study of kidney preservation fluid contamination with Candida species in eight recipients demonstrated that the risks of mycotic aneurysm rupture can be mitigated with appropriate antifungal therapy (34Matignon M Botterel F Audard V et al.Outcome of renal transplantation in eight patients with Candida sp. contamination of preservation fluid.Am J Transplant. 2008; 8: 697-700Crossref PubMed Scopus (52) Google Scholar). Mycobacterium tuberculosis has been transmitted by transplantation; donor transmission accounted for approximately 4% of reported posttransplant TB cases in a review of 511 patients by Singh and Paterson (35Singh N Paterson DL Mycobacterium tuberculosis infection in solid-organ transplant recipients: Impact and implications for management.Clin Infect Dis. 1998; 27: 1266-1277Crossref PubMed Scopus (502) Google Scholar). Potential living donors should have PPD testing performed (a two-stage tuberculin skin test if from an endemic area) or TB IGRA testing (36Manuel O Humar A Preiksaitis J et al.Comparison of quantiferon-TB gold with tuberculin skin test for detecting latent tuberculosis infection prior to liver transplantation.Am J Transplant. 2007; 7: 2797-2801Crossref PubMed Scopus (104) Google Scholar); if either test is positive, additional testing should be performed to rule out active infection (III). If there are symptoms or chest radiograph findings suggestive of active disease, sputum AFB cultures should be performed; chest computed tomography (CT) may be helpful in assessing adenopathy. Urine microscopy and AFB cultures, excretory urogram and abdominal CT scanning may be useful in PPD-positive prospective kidney donors. If there are no signs or symptoms of active disease and the chest radiograph is normal, sputum AFB cultures are very low-yield. Management of the prospective living donor with latent TB infection (LTBI) differs in areas of differing endemicity. Delay of transplant until the living donor is treated for LTBI (with isoniazid for 9 months or rifampin for 3 months) is appropriate, should another suitable donor not be available. In TB endemic areas, where as many as 30–40% of donors have LTBI, it may be difficult to avoid the use of infected donors. One cohort study from an endemic area demonstrated no benefit to treating the prospective living donor with LTBI prior to transplantation (37Hernandez-Hernandez E Alberu J Gonzalez-Michaca L et al.Screening for tuberculosis in the study of the living renal donor in a developing country.Transplantation. 2006; 81: 290-292Crossref PubMed Scopus (25) Google Scholar). Isoniazid prophylaxis of the recipient is an option but controlled studies are needed to determine the efficacy of this practice. In deceased donors, time does not allow for tuberculin skin testing, and the IGRA is not yet logistically practical in this situation. Donors in whom active tuberculosis is a clinical possibility should not be utilized (II-2). In cases where a potential donor is known to have a recent PPD skin test conversion, transplantation should be approached with caution due to the risk of dissemination in the recipient. Donors with a history of a positive PPD but without evidence of active disease are acceptable, but warrant consideration of treatment of the recipient with isoniazid (INH) (III) (35Singh N Paterson DL Mycobacterium tuberculosis infection in solid-organ transplant recipients: Impact and implications for management.Clin Infect Dis. 1998; 27: 1266-1277Crossref PubMed Scopus (502) Google Scholar, 38Antony SJ Ynares C Dummer JS Isoniazid hepatotoxicity in renal transplant recipients.Clin Transplant. 1997; 11: 34-37PubMed Google Scholar). Active systemic fungal infection in the donor is a contraindication to transplantation. The endemic mycoses in particular may be present in dormant form. Transmission of histoplasmosis by transplantation has been described (39Limaye AP Connolly PA Sagar M et al.Transmission of Histoplasma capsulatum by organ transplantation.N Engl J Med. 2000; 343: 1163-1166Crossref PubMed Scopus (114) Google Scholar), but most cases appear to be the result of reactivation of past infection in the recipient. In many individuals from the Midwestern United States, calcified pulmonary, hilar and splenic granulomata on X-ray may be the visible residua of old Histoplasma infection, but such radiographic signs have not traditionally been considered a contraindication to donation (III). Transmission of coccidioidomycosis by lung transplantation has been reported in the Southwestern United States (40Tripathy U Yung GL Kriett JM Thistlethwaite PA Kapelanski DP Jamieson SW Donor transfer of pulmonary coccidioidomycosis in lung transplantation.Ann Thorac Surg. 2002; 73: 306-308Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar), although reactivation of coccidioidomycosis in the recipient appears to be far more common (41Blair JE Logan JL Coccidioidomycosis in solid organ transplantation.Clin Infect Dis. 2001; 33: 1536-1544Crossref PubMed Scopus (171) Google Scholar). As yet, uniform recommendations for donor screening for endemic mycoses have not emerged. Toxoplasmosis is a major concern particularly in heart transplantation, where the Toxoplasma-seronegative recipient of a Toxoplasma-seropositive heart is at highest risk for developing active toxoplasmosis posttransplant (42Wreghitt TG Gray JJ Pavel P et al.Efficacy of pyrimethamine for the prevention of donor-acquired Toxoplasma gondii infection in heart and heart-lung transplant patients.Transpl Int. 1992; 5: 197-200Crossref PubMed Google Scholar). Toxoplasmosis has also rarely been transmitted to liver and kidney recipients (43Rogers NM Peh CA Faull R Pannell M Cooper J Russ GR Transmission of toxoplasmosis in two renal allograft recipients receiving an organ from the same donor.Transpl Infect Dis. 2008; 10: 71-74Crossref PubMed Scopus (40) Google Scholar). Donor seropositivity is not a contraindication to heart donation but allows for appropriate prophylaxis to be administered to the recipient; routine trimethoprim-sulfamethoxazole prophylaxis against Pneumocystis jiroveci is effective in preventing toxoplasmosis and may negate the need for serologic testing in areas of low prevalence (44Gourishankar S Doucette K Fenton J Purych D Kowalewska-Grochowska K Preiksaitis J The use of donor and recipient screening for toxoplasma in the era of universal trimethoprim sulfamethoxazole prophylaxis.Transplantation. 2008; 85: 980-985Crossref PubMed Scopus (47) Google Scholar). Screening of donors for Toxoplasma is not routinely performed for noncardiac donors but may be part of the screening panel at some centers. Transmission of Chagas disease (T. cruzi) by transplantation is a significant problem in endemic areas (South and Latin America) but has rarely been reported in the United States (45Chagas disease after organ transplantation–Los Angeles, California, 2006.MMWR Morb Mortal Wkly Rep. 2006; 55: 798-800PubMed Google Scholar). Routine screening is not yet mandated in the United States. Further discussion of these issues is found in the Parasitology section of these Guidelines. The following sections will discuss both donor and recipient screening for viral infections as the serologic status of both donor and recipient is often crucial in determining the risk of infection (Table 3). Each of the viruses mentioned here are discussed in more detail in other sections of these Guidelines.Table 3Interventions related to donor screening resultsSerologic findingActionAntibody to HIVExclude from organ donationAntibody to HTLV I/IIGenerally exclude from organ donation (may be used in life-threatening situations, with informed consent)Antibody to HCVIf used, usually reserve organ for recipient with antibody to HCV or severely ill recipientAntibody to CMVUse information to determine prophylaxis (in conjunction with recipient serology)Antibody to EBVConsider PCR monitoring posttransplant if donor seropositive, recipient seronegativeHepatitis B surface antigen (HBsAg+) or HBcAb IgM+Exclude from organ donation (possible use in life-threatening situations with preemptive treatment of the recipient)Hepatitis B surface antibody (HBsAb+)Generally safe for organ donationHepatitis B core antibody IgG (HBsAg-, HBcAb IgG+)High-risk for transmission if liver used for donation, but used at some centers with intensive prophylaxis; nonhepatic organs carry a small risk of transmission of HBV and are used for vaccinated recipients or with prophylaxisRPR +Not a contraindication to donation. Recipient should receive benzathine penicillinAntibody to ToxoplasmaNot a contraindication to donation. Sulfa-allergic, seronegative heart transplant recipients with a seropositive donor should receive pyrimethamine prophylaxisAny donor with evidence of active rabies, lymphocytic choriomeningitis virus, West Nile virus or other encephal