Epidemiologic Notes and Reports Human Immunodeficiency Virus Infection Transmitted From on Organ Donor Screened for HIV Antibody - North Carolina

In August 1986, a cadaveric organ donor was found positive for antibody to the human immunodeficiency virus (HIV) by both enzyme immunoassay (EIA) and Western blot methods after some of the donated organs had been transplanted. A blood sample, which was taken after the donor had received a large number of blood transfusions, had been negative for HIV antibody. Two days later, when the organs were removed, more blood samples were collected. These were forwarded with the donated organs to the various transplantation centers. At one of these centers, one of these later samples was found to be seropositive.

Three persons received organs from this donor. Two of them were subsequently found to be seropositive for HIV antibody. The third, who had received the donors heart, did not survive the transplant procedure. This is the first report of HIV transmission by organ transplantation from a donor screened for HIV antibody. A summary of the investigation of the donor and the two surviving recipients follows.

Donor. A 30-year-old man who was involved in a motor vehicle accident was admitted, while in a coma, to a North Carolina hospital. He was hypotensive because of bleeding from multiple head and neck lacerations. On admission, a blood sample was collected for type- and cross-matching, and blood transfusions were started within 1 hour. The donor's bleeding persisted despite surgery to improve hemostasis. Approximately 11 hours after admission, he had received a total of 56 units of blood and blood components (1 unit of whole blood, 28 units of packed red blood cells, 7 units of fresh frozen plasma, and 20 units of platelets). At this time, another blood sample was collected and tested for HIV antibody. The specimen was negative by EIA (Abbott Laboratories, North Chicago, Illinois; optical density ratio, sample/control = .103/.131). The donor's condition did not improve, and he was declared brain-dead 2 days after testing for HIV antibody. Family members consented to organ donation and denied any knowledge of the donor's having a risk factor for HIV infection.

The donor's kidneys, heart, and liver were removed and transported to other medical centers for transplantation. Samples of the donor's blood, which were collected when the organs were removed, were sent with each organ. As part of one center's routine procedure, one of these blood samples was tested for HIV antibody and was found positive by EIA (Genetic Systems, Seattle, Washington; optical density ratio =.95/<.30) and was subsequently found positive by Western blot assay. The transplantation teams were notified of the test result, but the heart, liver, and one kidney had already been transplanted.

Personnel from the hospital where the organs had been removed were contacted. They located both the serum sample collected on admission and the serum sample previously found negative for HIV antibody. The serum collected at the time of admission, before any transfusions were administered, was highly reactive on the Abbott EIAs performed at the hospital (optical density ratios =

766/.126, .556/.126) and at the North Carolina State Laboratory of Public Health (optical density ratios =.842/108, 698/.137) and was also positive by Western blot assay at the state laboratory. When testing was repeated, the serum collected after the blood transfusions was again seronegative by EIA at the hospital and by both EIA and Western blot methods at the state laboratory.

Recipient 1. A man with end-stage renal disease received the donated kidney that was transplanted. The recipient is married and denied risk factors for HIV infection. He was negative for HIV antibody 3 days after transplantation. A blood specimen collected 10 weeks after transplantation was positive for HIV antibody by EIA, and a specimen collected 1 week later was positive by both EIA and Western blot assay. The recipient had a fever 8 days after receiving the renal allograft, and a biopsy of it showed acute rejection. He improved with additional immunosuppressive therapy. To date, he has not developed any opportunistic illness and continues to feel well.

Recipient 2. A man with sclerosis of the bilary ducts and progressive liver failure received the donated liver. He is married and denied risk factors for HIV infection. He was tested 4 days after transplantation and was negative for HIV antibody. Twelve weeks after the procedure, he was positive for HIV antibody by EIA, and a specimen collected 4 weeks later was positive by both the conventional EIA and an EIA using recombinant viral proteins (ENVACORE, Abbott Laboratories). Four months after transplantation, the recipient developed fever and malaise. A liver biopsy showed moderate allograft rejection. The recipient's condition improved with an adjustment in immunosuppressive therapy, and he returned home the following month.

Reported by: TW Lane, MD, Univ of North Carolina, Chapel Hill, and Moses H Cone Memorial Hospital, Greensboro; R Meriwether MD, FV Crout, PhD, JN MacConnack MD, MPH, State Epidemiologist, North Carolina Dept of Human Resources. L Makowka, MD, Univ of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. SA Lobel, PhD, PA Bowen, MD, RJ Caruana, MD, Medical College of Georgia, Augusta, Georgia. AIDS Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Previous reports have linked kidney-transplant recipients who have subsequently become HIV-seropositive with donors who were later found to have risks for HIV infection (1-4). However, this is the first report of transplantation-associated HIV transmission from a cadaveric organ donor screened for HIV antibody. This donor appears to have been false-negative for HIV antibody by EIA as a result of the large number of transfusions he received before serum was collected for testing.

The Public Health Service recommended in May 1985 that potential organ donors be screened for HIV antibody (5). In January 1986, CDC conducted an anonymous survey of representatives from 44 transplantation programs attending a meeting of the Southeastern Organ Procurement Foundation. All of the 26 representatives who responded reported that their centers screened donors for HIV antibody. Three of these representatives (12%) also reported identifying at least one potential organ donor who was positive for HIV antibody by EIA and Western blot methods.

Organs from donors who are HIV-seropositive should not be used for transplantation except in very unusual circumstances. If an urgent need requires considering transplantation of an organ from a seropositive donor, the potential recipient or the appropriate family members should be informed of the risks of acquiring HIV infection. Such transplantation should not take place without the consent of either the potential recipient or the appropriate family members. When donors have been transfused before their organs are removed, testing for HIV antibody should be conducted on serum collected at the time of admission rather than on serum obtained after multiple transfusions. If donor serum collected at the time of admission is not available from other sources, a pretransfusion sample may be available from the blood bank since many blood banks hold specimens collected for compatibility testing for at least 7 days (6).

References

1. Prompt CA, Reis MM, Grillo FM, et al. Transmission of AIDS virus at renal transplantation (Letter). Lancet 1985;2:672.

2. L'age-Stehr J, Schwarz A, Offermann G, et al. HTLV-III infection in kidney transplant recipients (Letter). Lancet 1985;2:1361-2.

3. Margreiter R, Fuchs D, Hansen A, et al. HIV infection in renal allograft recipients. Lancet 1986;2:398.

4. Kumar P, Pearson JE, Martin DH, et al. Transmission of human immunodeficiency virus by transplantation of a renal allograft, with development of the acquired immunodeficiency syndrome. Ann Intern Med 1987;106:244-5.

5. CDC. Testing donors of organs, tissues, and semen for antibody to human T-lymphotropic virus type III/lymphadenopathy-associated virus. MMWR 1985;34:294.

6. American Association of Blood Banks. Standards for blood banks and transfusion services. 12th ed. Washington, DC: American Association of Blood Banks, 1987:31.

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