By: Alisha Kumar, PharmD Candidate c/o 2012
HIV transmission via organ transplantation is rare in the United States. However, after a public health investigation in 2010, a case of HIV transmission via kidney transplantation was confirmed.
The kidney recipient had no history of sexually transmitted infections (STIs), injection drug use, sex with injection drug users, or other high-risk sexual activity. The recipient tested negative for HIV infection via serum enzyme immunoassay (EIA) pre-transplant day 12 and negative via serum nucleic acid test (NAT) pre-transplant day 11.
The donor underwent evaluation consistent with hospital protocol for determination of eligibility with immunologic compatibility with the recipient. His evaluation revealed a previous diagnosis of syphilis and history of intercourse with male partners. He tested negative for HIV infection via serum EIA pre-transplant day 79. He also tested negative for Hepatitis B infection by HBV surface antigen testing and negative for Hepatitis C via anti-HCV serology. A rapid plasma regain (RPR) test for syphilis was positive with a fluorescent treponemal antibody absorption (FTA-ABS) test, consistent with previous syphilis episode.
Post-transplantation, the recipient experienced complications including multiple hospitalizations for fevers, renal insufficiency, and evaluation for possible kidney transplant rejection. One year after the transplant, this patient was hospitalized for refractory oral and esophageal Candidiasis and was positive for HIV infection via EIA test. The donor was also tested one year after revealing positive HIV results via EIA confirmed by Western blot.
During the investigation, the donor reported unprotected sex with one male partner during the one year before the transplant. This time included the time between the initial evaluation and organ recovery period; therefore, it is unclear when the transmission took place. Moreover, post-transplant day 404, whole blood specimens were obtained from both donor and recipient for phylogenetic analysis at the CDC. The results revealed the two viruses as being highly related.
In conclusion, this documented case implicates a repeat test for HIV should be as close to the time of organ donation as possible, but no longer than 7 days. NAT availability now permits detection of HIV infection prior to antibody development and detectable by serology. The window with NAT (or the ―eclipse period‖ for time from infection to detection of virus in blood) is estimated to be 8-10 days. Meanwhile, the window between time of HIV infection and time of development of detectable HIV-specific antibodies ranges from 3 to 8 weeks.
Therefore, the best option would be donor screening using a combination of HIV serology and NAT to rule out acute or recent HIV infection.
- MA Bernard, et al. HIV Transmitted from a Living Organ Donor—New York City, 2009. Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report. March 18, 2011. Vol 60:10; 297-301.