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Kidney transplants from infected donors: our experience
Kidney Transplants From Infected Donors: Our Experience M. Battaglia, P. Ditonno, O. Selvaggio, L. Garofalo, S. Palazzo, A. Schena, G. Stallone, E. D’Orazio, and F.P. Selvaggi ABSTRACT Organ procurement from infected donors may transmit a disease to the recipient that could cause a graft loss and/or recipient morbidity. Retrospectively, all kidney transplants from infected donors at our center in the last 4 years were reviewed. A donor was considered infected in the presence of at least one positive culture before procurement. From January 1999 to 2003, 23 of 160 donors (14.5%) were infected: in 10 donors a positive blood culture; in 3, a urine culture; and in 13, a bronchial culture. In a further 12 (7%) donors, only the preservation solution was contaminated. Organisms isolated were: Staphylococcus coagulase.neg. (n ⫽ 7); Staphylococcus epidermidis (n ⫽ 3); Staphylococcus aureus (n ⫽ 6); Klebsiella pneumoniae (n ⫽ 3); Pseudomonas aeruginosa (n ⫽ 4); Acinetobacter (n ⫽ 1); Candida albicans (n ⫽ 13); Aspergillus (n ⫽ 1); and Escherichia coli (n ⫽ 1). All except 2 kidneys were transplanted with positivity in all cultures. All recipients received general, nonspecific, antibacterial and antifungal prophylaxis until the antibiotic and antifungal spectrum was ready. Patient and graft survival rates at 6 months were 94% and 93%, respectively. Two deaths occurred due to bacterial arteritis (P aeruginosa), and 2 acute graft losses due to fungal arteritis. Kidneys from infected donors seem suitable for transplants. Only grafts infected by vasculotropic agents (S aureus, P aeruginosa, and C albicans) should be discarded.
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N THE ERA of donor shortage, several strategies have been developed to expand the pool. The use of marginal donors, including the use of infected organs, is becoming widespread.1 Usually kidneys from infected donors are discarded, because of the risk of transmission of an infectious disease to the recipient that may cause graft loss and/or recipient morbidity or mortality. We have reviewed our experience with this kind of donor, evaluating patient survival rate, main postoperative complications, and graft outcome.
MATERIAL AND METHODS A donor was considered infected in presence of at least one positive culture before procurement. From January 1999 to 2003, 23 of 160 donors (14.5%) were infected. Among the 23 infected donors, 10 were positive in a blood culture; in 3, a urine culture; and in 13 in a bronchial culture. A further 12 (7%) donors had only a contaminated preservation solution. The isolated organisms included Staphylococcus coagulase negative (7); Staphylococcus epidermidis (3); Staphylococcus aureus (6); Klebsiella pneumoniae (3); Pseudomonas aeruginosa (4); Acinetobacter (1); Candida albicans (13); Aspergillus (1); and Escherichia coli (1). © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 491⫺492 (2004)
RESULTS
Kidneys procured from these donors were all transplanted except 2 that showed the presence of P aeruginosa, K pneumoniae, and C. albicans organisms in all cultures (blood, urine, and preservation solution). All the recipients were treated with a nonspecific antibacterial and antifungal regimen until an antibiotic and antifungal spectrum was obtained. The therapy lasted for 15 and 21 days in bacterial and fungal infections, respectively. The immunosuppressive regimen included basiliximab, calcineurin inhibitor, mycophenolate mofetil, and steroids. After 6 months, patient and graft survival rates were 94% and 93%, respectively. Delayed graft function occurred in 23% of the cases, and primary nonfunction in 2 cases. No From the Department of Urology and Kidney Transplant, Department of Nephrology, Dyalisis and Transplantation, and Department of Intensive Care, University of Bari, Bari, Italy. Address reprint requests to Michele Battaglia, Dipartimento Emergenze e Trapianti d’ organo, sez. Nefr.chir.e Trapianto rene, P.zza Giulio Cesare,12-70124 Bari, Italy. E-mail: battaglia@ urologia.uniba.it 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.009 491
492
acute rejection episodes were observed. Four patients displayed a septic complication due to the same organism as that recovered from donor cultures. In 2 patients, infection by P aeruginosa caused arterial anastomosis dehiscence due to bacterial arteritis on the 15th and 20th postoperative day, with patient death. In the 2 fungal infections caused by C albicans, graft loss occurred on the 30th and the 60th postoperative day. The first patient underwent nephrectomy for complete arterial anastomosis dehiscence that required 6 vascular procedures to control hemorrhage. In the second case, a primary nonfunction with pseudoaneurysm of the arterial anastomosis required nephrectomy after 2 months. DISCUSSION
A literature review showed a variety of definitions of an “infected organ,” making it difficult to compare data and to define the rate of transmission of infectious diseases from donors to recipients, ranging from none to 6.2%.2 Our experience suggests that, even if procured kidneys are contaminated by bacterial or fungal infections, a specific and prolonged chemotherapeutic regimen avoids major
BATTAGLIA, DITONNO, SELVAGGIO ET AL
infectious complications in recipients. In fact, major complications were observed in 4 patients who did not receive a specific, prolonged prophylaxis regimen.1,3 Therefore, kidneys procured from donors with positive urine or blood cultures may be suitable for transplant, provided that there is not an history of septicemia. However, kidneys infected with vasculotropic microorganisms, such as P aeruginosa and C albicans, because of the high virulence and the capacity to show blood-borne spread to other sites, should be discarded.4
REFERENCES 1. The US Scientific Registry of Transplant Recipients and the Organ Procurement and Transplantation Network: 1998 Annual Report. Transplant Data 1988 –1996 2. Zibari JB, Lipka J, Zizzi H, et al: The use of contaminated donor organs in transplantation. Clin Transplant 14:397, 2000 3. Freeman R, Giatras I, Falagas ME, et al: Outcome of transplantation of organs procured from bacteremic donors. Transplantation 68:1107, 1999 4. Rubin RH: Expanding the envelope: can we increase the organ donor pool through the appropriate application of infectious disease principles? Transplant Infec Dis 4:115, 2002
I
N THE ERA of donor shortage, several strategies have been developed to expand the pool. The use of marginal donors, including the use of infected organs, is becoming widespread.1 Usually kidneys from infected donors are discarded, because of the risk of transmission of an infectious disease to the recipient that may cause graft loss and/or recipient morbidity or mortality. We have reviewed our experience with this kind of donor, evaluating patient survival rate, main postoperative complications, and graft outcome.
MATERIAL AND METHODS A donor was considered infected in presence of at least one positive culture before procurement. From January 1999 to 2003, 23 of 160 donors (14.5%) were infected. Among the 23 infected donors, 10 were positive in a blood culture; in 3, a urine culture; and in 13 in a bronchial culture. A further 12 (7%) donors had only a contaminated preservation solution. The isolated organisms included Staphylococcus coagulase negative (7); Staphylococcus epidermidis (3); Staphylococcus aureus (6); Klebsiella pneumoniae (3); Pseudomonas aeruginosa (4); Acinetobacter (1); Candida albicans (13); Aspergillus (1); and Escherichia coli (1). © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 491⫺492 (2004)
RESULTS
Kidneys procured from these donors were all transplanted except 2 that showed the presence of P aeruginosa, K pneumoniae, and C. albicans organisms in all cultures (blood, urine, and preservation solution). All the recipients were treated with a nonspecific antibacterial and antifungal regimen until an antibiotic and antifungal spectrum was obtained. The therapy lasted for 15 and 21 days in bacterial and fungal infections, respectively. The immunosuppressive regimen included basiliximab, calcineurin inhibitor, mycophenolate mofetil, and steroids. After 6 months, patient and graft survival rates were 94% and 93%, respectively. Delayed graft function occurred in 23% of the cases, and primary nonfunction in 2 cases. No From the Department of Urology and Kidney Transplant, Department of Nephrology, Dyalisis and Transplantation, and Department of Intensive Care, University of Bari, Bari, Italy. Address reprint requests to Michele Battaglia, Dipartimento Emergenze e Trapianti d’ organo, sez. Nefr.chir.e Trapianto rene, P.zza Giulio Cesare,12-70124 Bari, Italy. E-mail: battaglia@ urologia.uniba.it 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.009 491
492
acute rejection episodes were observed. Four patients displayed a septic complication due to the same organism as that recovered from donor cultures. In 2 patients, infection by P aeruginosa caused arterial anastomosis dehiscence due to bacterial arteritis on the 15th and 20th postoperative day, with patient death. In the 2 fungal infections caused by C albicans, graft loss occurred on the 30th and the 60th postoperative day. The first patient underwent nephrectomy for complete arterial anastomosis dehiscence that required 6 vascular procedures to control hemorrhage. In the second case, a primary nonfunction with pseudoaneurysm of the arterial anastomosis required nephrectomy after 2 months. DISCUSSION
A literature review showed a variety of definitions of an “infected organ,” making it difficult to compare data and to define the rate of transmission of infectious diseases from donors to recipients, ranging from none to 6.2%.2 Our experience suggests that, even if procured kidneys are contaminated by bacterial or fungal infections, a specific and prolonged chemotherapeutic regimen avoids major
BATTAGLIA, DITONNO, SELVAGGIO ET AL
infectious complications in recipients. In fact, major complications were observed in 4 patients who did not receive a specific, prolonged prophylaxis regimen.1,3 Therefore, kidneys procured from donors with positive urine or blood cultures may be suitable for transplant, provided that there is not an history of septicemia. However, kidneys infected with vasculotropic microorganisms, such as P aeruginosa and C albicans, because of the high virulence and the capacity to show blood-borne spread to other sites, should be discarded.4
REFERENCES 1. The US Scientific Registry of Transplant Recipients and the Organ Procurement and Transplantation Network: 1998 Annual Report. Transplant Data 1988 –1996 2. Zibari JB, Lipka J, Zizzi H, et al: The use of contaminated donor organs in transplantation. Clin Transplant 14:397, 2000 3. Freeman R, Giatras I, Falagas ME, et al: Outcome of transplantation of organs procured from bacteremic donors. Transplantation 68:1107, 1999 4. Rubin RH: Expanding the envelope: can we increase the organ donor pool through the appropriate application of infectious disease principles? Transplant Infec Dis 4:115, 2002