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TRENDS

  • The demand for liver transplantation continues to expand and to outstrip the number of organs available for transplantation.

  • As a result, there is an increasing use of livers from donors with a wide range of risks, including an increased risk of infectious disease transmission.

  • Discard rates are higher for these donors despite the fact they may be high-quality donors.

  • One risk of using a broader array of donors is that there is approximately 0.2% transmissions of infections from donors to recipients.1

RISK ASSESMENT

  • To reduce the risk of disease transmission through liver transplantation, donors are generally screened for the following categories:

    • Behavioral assessment

    • Screening donor testing (Table 47-2)

    • Physical examination by both the organ procurement organization and the transplant surgical team

TABLE 47-2OPTN-Defined Increased Risk Donors1-4

Behavioral Categories

  • A careful review of the donor’s medical and social history to identify evidence of preexisting transmissible conditions or risk factors for transmissible infections.

  • Individuals within any of the categories listed in Table 47-1 are considered high-risk donors.2

  • Defined by the Organ Procurement and Transplantation Network (OPTN) with U.S. Public Health Service guidelines.

  • OPTN-defined Increased Risk Donors

    • The major screening donor testing methods available (Table 47-2) are:

      • Enzyme-linked immunosorbent assay (ELISA) for antibody testing

      • Nucleic acid testing (NAT)

    • The use of NAT should be considered when evaluating seronegative donors with high-risk behavioral characteristics.

    • NAT is not required by the OPTN and sometimes may not available in organ procurement organizations (OPOs).

    • The cost of NAT is variable among OPOs. Median cost is US$460 in addition to the cost of transportation of the sample to the laboratory.3

    • Routine use of NAT may lead to unnecessary loss of uninfected organs because of false-positives.4 The false-positive rate from initially reactive false positive using NAT in tissue and blood donors is estimated to be 0.1% to 0.85%.3

    • The window period is the time between acquisition of the infection and serologic detectability.4

    • NAT narrows the window periods in HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) when compared to serology alone (Table 47-4).5

      • HIV: 12 days reduction

      • HCV: 30 days reduction

      • HBV: 12 days reduction

    • Seropositive/NAT-negative donors can result from either:

      • False-positive serology

      • Naturally cleared ...

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