Long-term (10-year) results of kidney transplantation have been analyzed from this center with respect to several variables. In this report the influence of viral disease was added in studying the effect of cadaver versus living-related donor, recipient race, and compliance. Over all, 10-year actuarial patient and graft survival were 68% and 48%, respectively. Cytomegalovirus, hepatitis B and C, and HIV-1 were studied for their effects, and survival curves analyzed statistically. Although cadaver and living-related donor, recipient race, and compliance were 3 main variables influencing graft survival, these 4 viruses were not selective in their effects on any of them. Hepatitis B surface antigen positivity and hepatitis C antibody positivity did not influence overall mortality or graft survival. Only cytomegalovirus seronegative status was important (as opposed to seropositive status, which was not). Of seronegative patients only those receiving a kidney from a seropositive donor were adversely affected. The presence of HIV-1 antibody had an adverse effect on graft survival, but the question remains as to whether overall mortality in HIV seropositive patients is any worse than those receiving dialysis therapy.
▪Objective: To determine the prevalence of antibodies to hepatitis C virus (anti-HCV) and HCV RNA among cadaver organ donors and to correlate these results with donor liver histologic abnormalities and evidence for transmission of disease through organ transplantation. ▪Design: Retrospective testing of stored serum samples from cadaver organ donors for anti-HCV and HCV RNA. ▪Setting: Transplantation service of the University of Miami/Jackson Memorial Medical Center and other cooperative medical centers furnishing follow-up data. ▪Subjects: Of 1096 cadaver organ donors harvested between 1 January 1979 and 28 February 1991,484 had stored serum samples available for analysis. Recipients of organs from recombinant immunoblot assay (RIBA)-positive donors for whom adequate follow-up was available were also included in the analysis. ▪Measurements: Samples were tested for anti-HCV by enzyme-linked immunosorbent assay (ELISA). Confirmatory testing was done using a second-generation RIBA. Hepatitis C viral RNA was detected in serum using the polymerase chain reaction. Liver biopsies were obtained from the organ donor and interpreted blindly by a pathologist unaware of the clinical data. Liver chemistry profiles and serum sample analysis for HCV RNA were done for transplant recipients. ▪Results: From the 484 cadaver organ donors, 89 samples (18%; 95% Cl, 15% to 21%) were reactive by ELISA. Of these, 33 (6.8%; Cl, 4.6% to 9%) were RIBA seropositive. Hepatitis C viral RNA sequences were detected in 50% of the RIBA-positive serum samples tested. Liver tissue was available from 24 of the 33 RIBA-positive donors and showed chronic active hepatitis in 16, chronic persistent hepatitis in 2, and no abnormality in 6. Among the 46 recipients of a kidney from a RIBA-positive donor, 13 (28%; Cl, 15% to 41%) developed post-transplant liver disease, of which only 4 cases were highly suggestive of viral transmission from the donor. Little morbidity and no mortality could be attributed to liver disease in this cohort of recipients. ▪Conclusions: These data suggest that HCV transmission by organ transplantation is low and that the consequences of infection are small. If the medical condition of the potential recipient is so serious that other options no longer exist, the use of an organ from an anti-HCV-seropositive donor should be considered.
Hepatitis B virus (HBV) is a virulent infectious agent that affects millions of people throughout the world as the causative agent of acute and chronic liver disease. Orthotopic liver transplantation is one therapy for end-stage hepatitis B liver disease. HBV is a blood-borne pathogen transmitted primarily through blood or blood products (i.e., transfusions, hemodialysis, etc.) (1). HBV may also reappear after solid organ transplantation and immunosuppressive drug therapy are initiated (2). The typical serological profile of an infected individual begins with an incubation period that ranges from days to months. Following this phase, there is a release of HBV surface antigen (HBVsAg), followed by HBV surface antibody (HBVsAb) and HBV core antibody (HBVcAb) generation. The release of antibodies directed against the virus usually results in elimination of the surface antigen and viral DNA from the periphery (3, 4), thus neutralizing the infection. However, there is a variable sequence to the induction of resistance to the virus that has resulted in windows of uncertainty as to when transmission via sera or organ transplantation from previously infected individuals is still possible. In addition, with newer molecular techniques, viral DNA has been detected in the livers long after individuals have been cleared of the infection. These subjects have been totally asymptomatic, with the presence of resistance marker in their blood (HBVsAg negative, but HBVsAb positive and HBVcAb positive) (5). In order to investigate the possibility of transmission of HBV by kidney transplantation, we tested (prospectively) for the presence of viral DNA, using the polymerase chain reaction (PCR), in the serum and tissue biopsies of cadaveric donors that were HBVsAg negative, but HBVcAb positive and either HBVsAb positive or negative. We hoped to determine whether these molecular and serological markers might indicate whether an individual who has had an HBV infection in the past would be currently noninfectious (via blood-borne transmission), i.e., a safe candidate for organ donation. In a retrospective follow-up study, the recipients of kidneys from these donors were monitored monthly for antibody and molecular markers for HBV viral DNA. It was proposed that sequential PCR analysis for viral DNA in the serum of the recipients of these organs performed over time would demonstrate whether infection was transmitted. In addition, clinical follow-up for symptomatology and liver enzyme abnormalities was performed. Sera from cadaveric organ donors that exhibited evidence of past HBV infection, as demonstrated by HBVsAg-negative, HBVcAb-positive, and HBVsAb-positive serology, were collected and either tested immediately or stored sterilely at -70°C (n=43). Sera from recipients of kidneys and livers from these cadaveric donors were collected and stored at -70°C and followed between 1 month and 40 months after transplantation. For the molecular detection of the HBV genome, DNA was prepared from 100 μl of serum incubated with 100 μl of K buffer (6) containing 5 μg of proteinase K at 56°C for 1 hr, followed by inactivation of the proteinase K by incubation at 95°C for 20 min. This procedure was also used for tissue biopsies from the cadaver donors. DNA-Stat (Tel-test, Friendswood, TX) was used to purify the DNA according to the manufacturer's instructions. Upon lyophilization, the resulting pellet was resuspended in 50 μl of water and either tested immediately in the PCR reaction or stored at -70°C. Oligonucleotide primers were synthesized for the surface antigen coding sequence of the HBV genome (6). Primer sequences P1 and P2 were used. Amplification was performed with taq polymerase (Perkin Elmer Applied Biosystems/Roche Molecular, Branchberg, NJ) according to a modification of the procedure described by Saki et al. (7). An amplification profile utilizing 42 cycles was performed. The resulting DNA amplicon was analyzed by gel electrophoresis on an ethidium bromide-stained 3% Nusieve agarose gel (FMC Bioproducts, Rockville, MD). Each set of patient samples contained a positive and a negative serum control. A positive sample generated a 425-basepair band upon electrophoresis. The kidney transplant recipient group was composed of hemodialysis patients with first cadaveric grafts. These patients were treated with OKT3 induction therapy and either tacrolimus or cyclosporine immunosuppression, along with steroids. Forty-three cadaver donors who were HBVsAg-negative, HBVcAb-positive and either HBVsAb-positive or HBVsAb-negative were tested by PCR for the presence of HBV viral DNA in their sera. All serum samples were negative by HBV PCR. Kidney (n=9), liver (n=7), pancreas (n=3), bone marrow (n=3), lymph node (n=2), heart (n=1), and lung (n=1) tissue were tested in these donors (based on what tissue specimens were made available by the procurement agency). Except for three of seven cadaver donor livers demonstrating PCR positivity, no other tissues were positive. Twenty-two of these donor organs were used locally (2 livers and 20 kidneys). Of the 20 kidney recipients, two are deceased (one due to aspergillosis and the other due to aplastic anemia and sepsis), one had previous HBV infection, and one could not be followed (at another center). Sera obtained from the remaining 16 recipients were serially tested by HBV PCR with an average posttransplant time of 19±7.6 months. Of the two hepatitis C virus core antibody-positive cadaveric liver recipients tested and given transplants at our center, one became PCR positive 12 months after transplantation. In contrast, none of the kidney recipients of the HBVcAb-positive donors, who were either HBVsAb-positive or HBVsAb-negative, has become HBV PCR positive at this time. In addition, the donor that transmitted HBV to the liver recipient did not transmit HBV to either of the two kidney recipients. Subsequent serological testing of the kidney recipient sera confirmed the PCR results, in that these patients demonstrated no detectable HBVsAg, lack of antibody response to HBV, and “normal” liver function as detected by liver enzyme assays (n=16). The paucity of organ donation, in view of demand, makes each additional available organ important. Some transplant centers are reluctant to use organs from HBVcAb-positive donors. This rationale does not appear to be valid for organs that do not support replication of HBV. Viral transmission by organ transplantation could be reduced or eliminated with the development of rapid viral diagnostic testing, such as PCR (6). Ascher (2) has shown that when livers from these HBVsAg-negative/HBVcAb-positive donors are used, recurrence of HBV can occur. This was confirmed by our studies demonstrating HBV viral DNA in sera of one out of the two liver recipients who received such an organ. This latent virus in the liver has been reported to reactivate upon transplantation and/or immunosuppression (2). The negative results of HBV PCR testing of kidney recipients supports the notion that HBV infection is not transmitted by these HBV PCR-negative/HBVcAb-positive cadaveric kidneys. In a somewhat tangential argument, it might also be contended that although the HBV core antibody serological test is a more recent addition to diagnostic detection, the HBV surface antibody assay has been used by organ donor programs for over 20 years. During this time (17 years at our center), we have not seen HBV surface antigen-positive serology occur in transplant recipients as a result of receiving kidneys from either HBVsAg-negative or HBVsAb-positive donors. Although Douglas et al. (8) have shown that HBV may be transmitted in the blood, by their work with blood donors who were HBVcAb-positive, this test was found to be inefficient and PCR was then used to identify infected subjects with no serological markers. All kidneys transplanted from HBVcAb-positive and HBVsAg-negative donors are currently tested by kidney tissue biopsy PCR and serum PCR, as well as serology; the results are available before transplantation is performed on recipients who have been informed of this issue. In this way, it is proposed that it will be possible to scrutinize and demonstrate that these organs are safe so that the shortage of suitable organs for transplantation might be relieved. These studies also point to the need for a comprehensive and rapid viral diagnosis that is available by a combination of serological and molecular methods, such as PCR. Robert Cirocco1; Keith Zucker; Nancy Contreras; Les Olson; Jason Cravero; Mike Markou; Sharon Babischkin; Eliana Fernandez; George W. Burke, III; Violet Esquenazi; Andreas Tzakis; Joshua Miller Division of Transplantation; Department of Surgery; University of Miami School of Medicine; The Miami Veterans Administration Medical Center; Miami, Florida
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)
